ELEMENTS OF SURGERY: FOR THE USE OF STUDENTS; WITH PLATES. BY JOHN SYNG HORSEY, M. D. ADJUNCT PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, ONE OF THE SURGEONS OF THE PENNSYLVANIA HOSPI<^L, K:c. JJV TWO VOLVMES. VOL. II. .................... for want of timely care Millions have died of medicable wound£ '•■» •*'/''■ Armstrong. ■uhyji tj •■wngtcniv PHILADELPHIA: i PUBLISHED BY EDWARD PARKER, NO. 178, Js* KIMBER 55* CONRAD, NO. 93, MARKET STREET. W. Brown, Printer, Church Alley. 1813 ANNEX CONTENTS OF VOL. II. Page CHAPTER I. Of'hernia, . - - - - 1 CHAPTER II. Symptoms of reducible hernia, - - - 7 CHAPTER III. Symptoms of strangulated hernia, - - - 10 CHAPTER IV. Treatment of reducible hernia, - - - 17 CHAPTER V. Treatment of irreducible hernia, - - - 23 CHAPTER VI. Treatment of strangulated hernia, 25 1. Of the taxis, - - - ib. 2. Of blood-letting, - - 28 3. The warm bath, - - - ib. 4. The tobacco clyster, - - 29 5. Cold applications, - - 30 6. Opium, - - - - ib. 7. Cathartics, - - ib. VOL. II. A 11 CONTENTS. CHAPTER VII. Of inguinal hernia, Operation, CHAPTER VIII. Of mortified intestine, CHAPTER IX. Artificial anus, - CHAPTER X. Of femoral hernia, - - - Operation, CHAPTER XI. Exomphalos, or umbilical hernia, Operation, CHAPTER XII. Of ventral hernia, - - - CHAPTER XIII. Of hernia congenita, CHAPTER XIV. Of hydrocele, - Treatment, Of the palliative cure, Of the radical cure, CHAPTER XV. Of hematocele, CHAPTER XVI. Of varicocele and circocele, •CHAPTER XVII. Of strictures in the urethra, Treatment, CONTENTS. ill CHAPTER XVIII. PagC 'if fistula in perineo, - - . - 126 CHAPTER XIX. Of retention of urine, - _ . - 130 CHAPTER XX. Of tapping the bladder, - _ . - 141 Of the puncture above the pubes. - ib. Of the puncture through the rectum, - 143 CHAPTER XXI. Of stone in the bladder, - . . - 145 Operation, - - . - 151 CHAPTER XXII. Of fistula in ano, - - . . - 160 Treatment, - - . - 161 CHAPTER XXIII. Of hemorrhoids, - - - _ - 165 CHAPTER XXIV. Of prolapsus ani, - - _ . - 168 t CHAPTER XXV. Of aneurism, - - _ . - 171 Treatment of true aneurism, - . 175 Popliteal aneurism, - . - 178 Femoral und inguinal aneurism, - - 180 Aneurism of the carotid artery, - - 186 Aneurism of the axillary artery, - 196 CHAPTER XXVI. Of false aneurisms, - 200 CHAPTER XXVII. Of mammary abscess, - - - - 213 IV CONTENTS. Page CHAPTER XXVIII. Abscess of the hip joint, - - - - 215 Treatment, - - - - 217 CHAPTER XXIX. Lumbar, or psoas abscess, - - - - 219 Treatment, - - - - 220 CHAPTER XXX. Of curved spine, - - - - - 223 CHAPTER XXXI. Of paronychia, or whitlow, - - - - 241 Treatment, - 242 CHAPTER XXXII. Of amputation of the limbs, - 244 CHAPTER XXXIII. Amputation of the thigh, . - - 248 CHAPTER XXXIV. Amputation of the leg, - - - - 253 CHAPTER XXXV. Amputation of the arm, - 256 CHAPTER XXXVI Of amputation at the shoulder joint, - - 257 CHAPTER XXXVII. Amputation at the hip joint, - - - 260 CHAPTER XXXVIII. Amputation of the fingers and toes, - - 262 CHAPTER XXXIX. Of hemorrhage after amputation, - - - 263 CONTTENS. CHAPTER XL. Of spasms of the stump, CHAPTER XLI. Extirpation of tumours, CHAPTER XLII. Of warts and corns, CHAPTER XLIII. Of the inverted toe nail, CHAPTER XLIV. Of paracentesis abdominis, - CHAPTER XLV. Paracentesis thoracis, CHAPTER XLVI. Of blood letting, Plebotomy, Arteriotomy, Cupping, Leeching, CHAPTER XLVII. Of ulcers, - CHAPTER XLVIII. Of inflamed ulcers, CHAPTER XLIX. The fungous ulcer, CHAPTER L. Of ulcers in edematous limbs, CHAPTER LI. The sloughing ulcer. VI CONTENTS. Page CHAPTER LII. Of indolent ulcers, - CHAPTER LIII. The carious ulcer, - - - - CHAPTER LIV. Ulcers attended with varicose veins, - - 309 CHAPTER LV. Ulcers attended with specific diseased actions, - 317 1 Of those ulcers which yield to mercury, ib. 2. Of ulcers which yield to the different preparations of the conium maculatum, or hemlock, - - - - 319 3. Ofu'cers which yield to the application of salt water, - - - - 321 4. Of ulcers which yield to the use of the argentum nitratum, ... 322 5. Of ulcers that yield to the use of arsenic, 326 CHAPTER LVI. Of caries, - "^ 3o4 Treatment, - 335 CHAPTER LVII. Of necrosis, ' - 340 Treatment, - - - 347 CHAPTER LVIII. Of setons and issues, - - - - 351 CHAPTER LIX. Of malformations, - - - - - j5j Club foot, ib. CHAPTER LX. Of sfiina bifida. - - - - - 360 CONTENTS. yii t Page CHAPTER LXI. Of imperforate anus, - 362 CHAPTER LXII. Of imperforate vagina, - 357 CHAPTER LXIII. Of the Cesarean operation, - 369 CHAPTER LXIV. On the division of the symphysis pubis, - - 374 CHAPTER LXV. Of prolapsus uteri, - 377 Treatment, - - - - 378 CHAPTER LXVI. Of bandages, - - - . - 380 CHAPTER LXVII. Of opening dead bodies, - 384 ELEMENTS OF SURGERY. CHAPTER I. Of Hernia. JL HE large proportion of mankind who are afflicted with this complaint;—the great variety of forms in which it appears;—the fatality which results from its improper treatment, and the ample resources of surgery in prevent- ing its evil consequences, are circumstances which com- bine to render the investigation of hernia peculiarly in- teresting. It has been estimated that nearly one fifteenth part of the inhabitants of Great Britain, of Spain, and of Italy, are affected with hernia, and one thirtieth of the popula- tion in the north of Europe. The proportion in America, I am persuaded, is by no means so great; but it is never- theless a very frequent disease, occurring in both sexes, at every age, and in every rank of society. A hernia, or rupture, signifies a protrusion of any of the contents of the abdomen, through the parietes of that cavity.* The parts at which this protrusion occurs, * Dr, Monro in order to include every species of hernia in a definition, calls it " a tumour unconnected with a wound, and produced by a bowel, or part of VOL. II. B 'Z ELEMENTS OF SURGERY. and the particular viscera which are thus displaced, are various. The peritoneum which lines the cavity of the abdomen is generally pushed out together with the viscera, form- ing a bag called the hernial sac, which is a cavity con- tinued from that of the abdomen and lined by the same membrane. In general the bowels are protruded at some natural opening, as the abdominal ring, or crural arch ; by the term opening, in this place, is not meant any absolute hole or aperture, because in* a natural state these parts are filled up with cellular texture, but this texture being less dense and resisting than the neighbouring parts, yields more readily. Sometimes the hernia occurs at a prceternatural opening, in some part of the abdomen. The hernial sac, after passing out at the aperture through which it has been forced, gradually enlarges, in consequence of the action of the muscles of the abdomen, which augments its contents, aud of other causes. The cellular membrane in the vicinity gives but little resis- tauce to this enlargement; the part of the sac, however, which is surrounded by the firm parietes of the abdomen, is prevented from yielding, and remains of a smaller diameter than the rest of the sac, forming what is called its neck;—the extremity most distant from the neck is called the fundus of the sac. This sac varies greatly in density, not so much from an alteration in the thickness of the peritoneum itself, as from the layers of condensed cellular texture which are connected with it. In very old ruptures the hernial sac is sometimes very dense, it has been known half an inch in lluckness; but, in other cases, a contrary state of the sac is found, and it appears to be almost entirely de- a bowel, which is not situated in its natural place, and the tumour may be either external or internal." It is useless to be fastidious respecting definitions ; thev are very seldom perfect. ELEMENTS OF SURGERY. 3 stroyed. In old umbilical hernise it is often extremely thin, and cases are recorded in which no sac could be found; in these cases it had probably been absorbed, in consequence of pressure, which we know sometimes oc- casions an absorption, and sometimes a thickening of the compressed parts.* " We should hardly have supposed, a priori, that the peritoneum is susceptible of such considerable extension as it frequently suifers in cases of hernia. Scrotal rup- tures often descend to various distances on the thigh, sometimes indeed even to the knee ; yet the whole inner surface of the bag, in which all the loose viscera of the abdomen may be contained, is liued by a continuation of peritoneum ; indeed, the hernial sac is generally thicker and stronger in proportion to the size of the tumour, and to the duration of the complaint. Yet, occasionally, in- stead of an increased thickness, we observe the opposite process of absorption or thinning, in large ruptures : in some cases the coverings are so reduced, that the con- volutions and vermicular motions of the intestines may be distinguished through the skin; hence it may appear, that the sac is entirely wanting; but it will be possible to trace it in the neighbourhood of the opening. The contents of a rupture may be found immediately under the skin, when the hernial sac has been burst by a blow ; but this is an unfrequent occurrence. "The exterior covering is every where closely con- nected by cellular substance to the proper peritoneal sac. Hence the latter part is not returned into the abdomen, when the contents of the swelling are replaced ; but re- mains behind, ready to receive any future protrusion. At the first moment of the occurrence of a hernia, the protruded peritoneum must of course be unconnected to • The sternum is absorbed from the pressure of an aneurism of the aorta, and the soles of the feet are covered with a very thick skin, in consequence of compression from the weight of the body. 1 ELEMENTS OF SURGERY. the parts among which it lies. But adhesions take place so quickly that we find the sac universally connected to the contiguous parts, even in a rupture of a few days standing: and these connections become afterwards so strong and general, that we might suppose the hernial sac to have been originally formed in its unnatural situa- tion. The difficulty, which this structure would occa- sion, in separating the hernial sac from the surrounding parts, and particularly from the spermatic cord, con- stitutes an insuperable objection to any proposal for re- turning the sac into the abdomen, and must have been a source of great danger in some of the old methods of at- tempting the radical cure of ruptures." (Lawrence.) All abdominal herniae are to be considered as having sacs, except those which are consequent to wounds or preternatural openings in the parietes of the abdo- men, and those in which the sac has been absorbed. Hernia of the bladder has no sac, because its situation is exterior to the peritoneum. " The contents of a hernial sac arc some part or parts ordinarily contained in the abdomen; and commonly the omentum or intestines. These are the most moveable viscera, and occupy the front and lower part of the belly : their relative-position explains, why, in a mixed case, the latter are covered by the former. The small intes- tine, from the greater looseness of its connection, is more frequently protruded than the large; and the ileum more frequently than the jejunum, in consequence of its great- er proximity to the ring and crural arch. A part only of the diameter of the tube is sometimes included in a hernia; any larger quantity may descend from a sin- gle fold to the whole moveable portion of the canal. Adipous matter is generally deposited in large quanti- ties in the omentum of fat and elderly persons ; and in this state it escapes very readily from the cavity. Pro- trusion of the large intestines consists, generally, either ELEMENTS of surgery. 5 of the ccecum, or sigmoid flexure of the colon; as these are the least fixed portions of the canal. When the for- mer part descends, it is ordinarily, as we should expect, on the right side ; when the latter, on the left. Yet the coecum and vermiform appendix have been seen in rup- tures of the left side; and when we consider that the in- testines may descend to the knees, dragging even the sto- mach to the pubes, we shall be convinced that the natural position of an organ cannot, of itself, enable us to de- termine at which opening it may be protruded. " Other abdominal viscera, besides the intestines and omentum, may be protruded in hernia. The urinary bladder sometimes passes through the abdominal ring. The ovaries, and uterus, the spleen and stomach, have been very rarely seen in ruptures." (Lawrence.) Herniae derive different appellations from the part at which the intestines protrude, from the situation in which they make their external appearance, and from the parts contained within the hernial sac. Inguinal hernia denotes a protrusion at the abdominal ring, forming a tumour in the groin, this hernia is also called bubono- cele. Iii the male the tumour extending down into the scrotum is called oscheocele or scrotal hernia. In femoral or crural hernia (sometimes called mero- cele) the protrusion takes place under the crural arch. Exomphalos, omphalocele, or umbilical hernia, is that rupture which takes place at the navel. In any other part of the abdominal parietes, herniae are called VENTRAL. Hernia congenita is that in which the tunica vagi- nalis testis, forms the hernial sac, tho testis and intestine being in contact. In addition to these more common cases of hernia, there are some rare species which deserve to be mention- ed, as hernia of the perineum, where the parts are protruded by the side of the bladder or vagina, or, a 6 ELEMENTS OF SURGERY. tumour may be formed in any part of the vagina, forming vaginal hernia. The ischiatic rupture, and that of the foramen ovale, take place through these respective open- ings of the pelvis. When the sac contains omentum, the case is called epiplocele, or omental hernia; when intestine, entero- cele or intestinal hernia ; when both these parts are contained in the sac, it constitutes entero-epiplocele. A protrusion of the urinary bladder forms cystocele, or hernia vesicae. Herniae are reducible when the parts can be passed up into the abdomen. W^hen from having contracted adhe- sion, or being greatly enlarged, they cannot be returned, they are said to be irreducible. When they are irre- ducible in consequence of a stricture formed at the orifice through which the viscera protruded, the hernia is said to be strangulated, or incarcerated. The causes of hernia, are, predisposing debility of any particular part of the parietes of the abdomen, whether natural, or the consequence of morbid affections—and violent efforts by which the muscles of the abdomen are made to contract forcibly upon their contents—lifting heavy weights,—jumping,—running—violent coughing, parturition-vomiting—straining at stool, and many other analogous exertions of the muscles; these are the occa- sional causes of hernias. ELEMENTS OF SURGERY. 7 CHAPTER II. Symptoms of Reducible Hernia. A tumour is observed at the place of protrusion, free from pain, and generally soft, the colour of the skin be- ing unaltered. This swelling varies in size, being smal- ler in a recumbent, than in an erect posture, and the patient is generally able by lying down to return the parts into the belly, the tumour entirely subsiding. The swelling increases when the patient is flatulent; some- times a rumbling sensation is perceived in it, occasioned by wind. Coughing, sneezing, or any effort of the ab- dominal muscle produces an increase and tension of the swelling. These symptoms are more or less evident in different cases, they are not all observable in every in- stance. " The symptoms of the case will sometimes inform us what are the contained parts. This discrimination, in- deed, is often difficult, and even impossible, when the hernia is old, large, and very tense. For the viscera in such ruptures experience considerable changes in their figure and state, while the thickened hernial sac prevents an accurate examination by the hand. Again it is fre- quently hard to determine the contents of a very small hernia. " If the surface of the tumour be uniform ; if it be elastic to the touch; if it become tense and enlarged when the patient is troubled with wind, holds his breath, or coughs ; if in the latter case, the tumour feel as if it were inflated; if the part return with a peculiar noise, and pass through the opening at once, the contents of the swelling are intestine. If the tumour be compres<-i- 8 ELEMENTS OF SURGERY. ble; if it feel flabby and uneven on the surface ; if it be free from tension, under the circumstances just enume- rated ; if it return without any noise, and pass up very gradually, the case may be considered an epiplocele. "The smooth and slippery surface of the intestine makes its reduction easier; and the mixture of air with the intestinal contents, causes, when they are pressed up, a peculiar guggling noise, (Gargouillement of the French.) The reduction of the omentum is more diffi- cult, since it is soft and uneven, and its surface becomes moulded by the surrounding parts. If a portion of the contents slip up quickly, and with noise, leaving behind something which is less easily reduced, the case is pro- bably an entero-epiplocele." (Lawrence.) This, however, is only probable evidence, and should not be depended on with too much confidence. The symptoms enumerated are, however, amply sufficient to enable us to discriminate between hernia and all other diseases, except in very particular cases where the tu- mour is small and deeply seated, has arisen very gra- dually, is connected with other tumours, and contains much fluid, &c. In a fat patient the difficulty of discri- mination is considerably augmented. " A reducible hernia, though attended with no imme- diate danger, occasions much trouble to the patient, par- ticularly if it be allowed to proceed unrestrained by sur- gical treatment: and the inconvenience increases con- stantly with the size of the tumour. The portion of in- testine or omentum, which has left the abdomen, pro- duces various complaints, from its connection with the parts within. From this source of irritation proceed nausea and vomiting, indigestion and colic. As the vis- cera become accustomed to their unnatural situation, these symptoms gradually wear away. Still, as the tu- mour constantly increases in size, a large part of the vis- elements of surgery. 9 cera is deprived of that pressure and support, which, it naturally derives from the respiratory muscles; the pas- sage of the food through the alimentary canal becomes difficult and protracted; and hence large ruptures are al- most invariably attended with flatulency and constipa- tion. The patient is precluded from all active and la- borious employments, and from all considerable exer- tions, which necessarily augment the tumour, and are attended with great risk of more immediate danger, by forcing down fresh parts, so as to cause strangulation. The opening through which the viscera pass out, must subject them to more or less pressure; which will enable us to account for that effusion of fluid into the cavity of the sac, which is generally observed in old ruptures; and for the formation of those adhesions of the parts to each other, and to the hernial sac, which change the case from a reducible swelling to one which will no longer admit of reduction. Since the opening becomes enlarged by the protruded parts, and the pressure on the viscera, which causes the descent, is frequently renewed, addi- tions to the tumour take place very readily. In situa- tions where position is favourable, and the surrounding parts offer no obstacle, as in the scrotum, the only limit to the possible bulk of a rupture arises from the con- nexions of the parts within. Instances are not uncom- mon, where all the moveable viscera have been contain- ed in such a swelling; and even those which are more fixed may be gradually displaced, by the constant drag- ging of organs connected with them." (Lawrence) vol. n. c 10 elements of surgery. CHAPTER 111. Symptoms of Strangulated Hernia. " The first and most immediate effects of such a degree of pressure, as prevents the return of the protruded parts, are an obstruction to the passage of the intestinal contents, and consequent want of fecal evacuations; and a more or less violent inflammation in the strangulated part. The former symptom may not be so clearly marked where a part only of the diameter of the gut is strangulated, but it will often occur to as great a degree in that case, and will be equally insuperable by purgative medicines, as where a complete fold of intestine is included: it even happens occasionally in a mere epiplocele, where no intestine at all is protruded. Hence it must be referred rather to that inflammatory affection of the intestines, which sub- sists in this complaint, than to the mechanical obstruction of the canal: and must be considered as analogous to the constipation which prevails in ileus, when produced by other causes. The action of clysters on the bowels below the stricture often produces a stool after the stran- gulation has taken place. But when these have beeu once emptied, the most irritating clysters produce no ef- fect. The inflammation of the protruded viscera causes a thickening of their coats, an effusion of fluid into the hernial sac, and adhesions of the parts to each other. and to the containing bag. When it is particularlv vio- lent a layer of coagulating lymph is sometimes thrown out on the surface of the intestine. A manifest impres- sion is often made on the intestine by the stricture, and this may proceed so far as to cause a considerable con ELEMENTS OF SURGERY. 11 siriction of the canal. It terminates at last, unless the stricture be previously removed, in gangrene. These, which we may call the primary effects of the incarcera- tion, are accompanied by other symptoms, arising from disorder of the parts which sympathize with the hernia. "In an incarcerated intestinal rupture, the tumour which was before indolent, becomes painful; the pain is most acute at the strictured portion, and extends from that situation over the rest of the swelling and abdomen; these parts becoming at the same time swollen and tense. A feeling of tightness, as if from a chord drawn across the upper part of the belly, is often one of the earliest symptoms of strangulation. The pain, which at first is not constant, becomes in the sequel fixed; and is aug- mented by external pressure, coughing, sneezing, or other agitations of the body. The evacuations per anum are entirely suppressed, and nausea and vomiting ensue: all the contents of the stomach, and afterwards those of the intestine, down to the stricture, being rejected. These symptoms, which often remit for a considerable period, are accompanied with a proportionate derange- ment of the whole system. There is a great anxiety and restlessness, with a small, quick and hard pulse, and coldness of the extremities. The pulse cannot be at all depended on, as indicatiug the degree of general fever. It may be even slower than in health, when the patient is in the greatest danger. Neither does the degree of heat, as ascertained by our examination, or indicated by the patients sensations, correspond to fevers in general: on the contrary there is a disposition to cold sweats, and a cold state of the extremities. After a time hiccough su- pervenes, the pulse becomes so small as hardly to be sensible, the respiration is weak, and the whole body is covered by a cold and clammy sweat. Mortification now takes place; it begins in the contents of the rupture, and extends to the containing and neighbouring parts. The 12 ELEMENTS OF SURGERY. degree and intensity of the symptoms arc modified by various circumstances, as the age and strength of the pa- tient, the nature of the strangulation, &c. The duration of the complaint, from its first commencement to the ter- mination in mortification or death, is also extremely various. " An epiplocele is much less liable to strangulation than an intestinal rupture, and its symptoms are milder and slower in their progress. In this variety of the com- plaint, stools may generally be procured by purgative medicines or clysters. The connexion of the omentum with the stomach induces hiccough and sickness, and although the latter symptom seldom proceeds to stercora- ceous vomiting, it exists to a most distressing degree, and particularly characterizes the complaint. The symptoms are often influenced by the position of the body, being mitigated by bending, and aggravated by straight- ening the trunk. An epiplocele is occasionally accom- panied wTith all the dangerous and alarming symptoms of an intestinal rupture, as insuperable constipation, fecal vomiting, &c. ((The examination of a patient, who dies while la- bouring under a strangulated hernia, discloses such a state of parts as the symptoms just enumerated would naturally lead us to expect. The whole surface of the peritoneum is inflamed, and the intestines participate in this disorder, particularly that portion of the canal which is above the stricture, which is distended considerably beyond its natural diameter. From the constricted part downwards, the intestine is generally smaller than usual, and not inflamed. The convolutions of the intestinal canal are agglutinated by a recent deposition of coagu- lating lymph; and a turbid puriform fluid, with coagu- lated flakes, is effused into the abdomen; streaks of a bright and red colour, consisting of an aggregation of minute vessels, cross the intestines in different directions; ELEMENTS OF SURGERY. 13 and spots of gangrene are not unfrequently observed. All these circumstances show us most decidedly that the effects caused by strangulation are of the most active in- flammatory kind. We must regard the stricture, which the protruded parts experience, as the immediate cause of this disorder. " The distinction of strangulation, from affections which may resemble it more or less nearly, requires con- siderable attention and judgment. The intestine in- cluded in a large hernia may be affected with cholic, and ihus giving rise to constipation and vomiting. This may the more easily be mistaken for strangulation, if the parts are adherent, and incapable of reduction. Such an attack may render a reducible hernia incapable of being replaced ; particularly if the bowels are much in- flated. Clysters and oily purgatives will produce stools under these circumstauces, and thereby throw light on the real nature of the case. " The first appearance of a rupture may occasion hic- cough, vomiting, and the same symptoms may be exhi- bited in an old case, after the patient has taken much ex- ercise, or remained long in the erect posture, in conse- quence of irritation, excited by the protruded viscera in the contents of the abdomen. Here too stools may be ea- sily procured by purgatives." "The most important case, however, is where a pa- tient with a rupture has an attack of ileus from some other cause, in which the original complaint is not at all concerned. The operation, performed on the supposi- tion that the symptoms arise from the hernia, would here be not only useless, but even injurious ; and the surgeon would neglect those means, which the inflammation of the bowels so urgently demands. "• Whenever we see a patient labouring under the {symptoms of ileus, we should suspect the existence of a rupture, and make those inquiries and examinations, 14 ELEMENTS OF SURGERY which such a suspicion would naturally suggest, par ticularly in females, who are often led to concealment by motives of false delicacy. A superficial examination is not sufficient on these occasions; as a very small por- tion of intestine, not forming an external tumour, may, by its incarceration, cause the symptoms. If the latter have appeared suddenly, and under circumstances which might cause a rupture; if the pain have been first felt about the ring or crural arch, and if pressure in these situations increase it; and, lastly, if the patient, shortly before, had been in perfect health, there is strong reason to suspect the existence of a hernia. " When a person labouring under ileus has a hernia, which can be reduced easily, there is no ground for doubt; if, on the contrary, the parts cannot be replaced, strangulation may be reasonably suspected, although we cannot immediately conclude, with certainty, that the swelling is the cause of the inflammation. We should first ascertain whether the parts could be replaced pre- viously to the attack ; if they could not, and the swelling be hard and old, they are probably adherent, and the impossibility of reduction proves nothing. If they could be returned, and particularly a short time only before the access of the symptoms, strangulation may be suspected with justice; but it is still not quite certain." (Law- rence.) Strangulation consists in pressure upon the protruded parts. As this pressure is generally made by a tendon, it is perhaps improper to use the term stricture, and Mr. Lawrence objects to employing it, asserting that the aperture is generally dilated instead of being contracted. I would beg leave to remark here, however, that the re- lative size of the ring, or part which makes the compres- sion, and of the compressed parts, is so changed when strangulation takes place that the term stricture may be retained, provided the passive nature of the tendinous ELEMENTS OF SURGERY 15 aperture be kept in view. A portion of omentum or in- testine pushed forcibly through the abdominal ring may become strangulated, or the contents of an old hernial sac may be suddenly increased by the descent of more intestine, or by faeces or flatus, in such a manner as to become strangulated. The neck of the sac as well as the aperture in the parietes of the abdomen is capable of making constriction upon its contents, in consequence of the thickening and induration which the peritoneum undergoes in some cases of hernia. Mr. Astly Cooper believes that in some cases of in- guinal hernia the stricture is truly spasmodic; he says that "when the strangulation is above the ring, a por- tion of intestine protrudes under the edge of the internal, oblique, and transversalis muscles, compressing them, which in their turn being excited to contraction by the irritation of this pressure, react upon the intestine with a force sufficient to produce a strangulation accompanied by spasmodic symptoms." The strangulation in some instances comes on imme- diately. I have known a patient straining at stool sud- denly force down an additional portion of intestine into an old hernial sac; and immediate strangulation was the consequence. In such cases "the symptoms, Mr. Law- rence remarks, come on suddenly, and their progress is rapid; the swelling is tense and highly painful, particu- larly at the ring, where the slightest pressure is intole- rable; the abdomen quickly becomes painful, and is tense and elastic to the feel. The constitutional affec- tion partakes of the inflammatory character. So quickly does the complaint run through its stages in this case that grangrene has been known to occur in twenty-four hours from the expulsion of the intestine." In other cases the strangulation is slow and progres- sive. In some of these cases many days elapse before 16 ELEMENTS OF SURGERY. it is complete. In such cases successful operations have been performed a fortnight, and even three weeks after the commencement of incarceration. This slow stran- gulation generally happens in large old hernias which have been often protruded and replaced, or which have been long unreduced. There is generally an unusual heaviness and hardness of the tumour in such cases ow- ing to an increased quantity of the contents of the intes- tine. Inflammation sometimes attacks the parts protruded from the abdomen, especially in cases where the tumour is very large. This if possible should be distinguished from strangulation, and although it be difficult to discri- minate, yet it may sometimes be done by careful atten- tion. The ring will be found in the present case free from tension, and the parts within it, will not appear compressed. If the ring, however, should become tense, and the protruded bowels painful, the case ought to be treated as if strangulated. ELEMENTS OF SURGERY. 17 CHAPTER IV. Treatment of Reducible Hernia. "The treatment of a reducible rupture comprehends the return of the protruded parts, and their retention within the abdominal cavity by means of an appropriate truss. The necessary observations concerning the mode of replacing ruptures will be delivered, when the treat- ment of strangulated hernia is considered. " So long as the protruded viscera can be made to pass freely into the abdomen, this complaint carries with it no immediate danger to the patient. It may indeed be troublesome, both from the bulk of the swelling, and from the intestinal derangements, which the residence of the viscera in their unnatural situation is apt to create; but, independently of these circumstances, it may exist throughout life, without causing more than slight incon- venience. This innocent state of the disorder, cannot, however, be at all depended on; as numerous accidental ^causes may at any time bring it into a condition, where the life of the patient is exposed to the greatest risk. A trifling bodily exertion, by forcing down an additional quantity of the bowels, an excess in eating or drinking, an indigestion, or any intestinal disorder, may convert the rupture from a reducible to an incarcerated state. Should the patient escape this fate, the unrestrained in- crease of the swelling constitutes a sure source of future inconvenience and disease. The vast size to which ne- glected hernia sometimes increases, not only prohibits all active exertion; but, by involving in the male, the inte- guments of the penis, incapacitates the subject from the VOL. II. d 18 ELEMENTS OF SURGERY. act of copulation, and gives rise to excoriation from the discharge of the urine over the swelling. Probably too the testis may be affected by the pressure of a very large scrotal hernia. Disorders of the intestinal functions in- variably attend these large ruptures, and increase in fre- quency and violence, in proportion to the size of the swelling, and age of the patient. All the moveable vis- cera of the abdomen gradually find their way into the hernial sac, if a rupture be entirely neglected. Nume- rous instances are recorded, in which the jejunum, ileum, colon, and omentum, have been entirely included. The constant force acts even upon the more fixed parts, and entirely changes their relative positions: thus the stomach is brought into a perpendicular line parallel to the axis of the body; and its pyloric orifice has been ac- tually within the mouth of the sac. It was drawn down to the pubes in the case of Mr. Gibbon. " These considerations should render every person af- flicted with a rupture, anxious to get the parts replaced, and to have a proper truss applied; and they should lead surgeons to inculcate the necessity of these measures, as forcibly as they can on the minds of all such as seek re- lief from their advice." (Lawrence.) OF TRUSSES. The object in applying a truss, is to close the opening by which the viscera protrude, by permanent pressure, and thus when the parts are reduced to prevent their re- descending. The best instrument for this purpose is an elastic spring of steel, so constructed as to make pres- sure upon the precise spot where the protrusion takes place. When this spot is the abdominal ring, or the crural arch, the truss in common use, provided it fit the patient accurately, is the best instrument hitherto em- ployed. ELEMENTS OF SURGERY. 19 It consists of a flat narrow piece of steel passing round the body, and adapted to its form; it terminates in a plate of iron which is to be fixed over the place of protrusion. The posterior surface of the plate is furnished with a convex cushion termed the pad, adapted in form and size to the opening which it is de- signed to close. The spring is covered externally with leather that it may sit easily on the body. Its inner sur- face is lined with some soft substance. A strong strap extending from its posterior end passes round the sound side of the trunk, and is fastened to a hook on the front of the plate. This strap being perforated by several holes enables the patient to tighten or loosen the truss at pleasure. The curvature of the spring should be accommodated to the breadth of the haunch in each individual, for this varies very considerably. "A piece of cork is fastened to the posterior surface of the iron plate, and this is co- vered with leather stuffed with hair or wool, so as to give it the due firmness, and to bring it to a slight and uniform convexity." The size of the pad should be rather larger than the opening it is intended to cover. When the patient is ruptured in both groins he should j|have a double truss, one spring going quite round the body, and terminating in two pads, one over each aper- ture. Should the truss slip upwards, a strap may be passed between the thighs which will prevent it; if downward it can be remedied by a shoulder strap; but this is sel- dom necessary except in very corpulent persons, and in general if the instrumennt be properly constructed it maintains the proper position. " The pad of the truss should be placed over the opening at which the viscera have protruded : hence, in a small, or recently formed inguinal rupture, the proper SO ELEMENTS OF SURGERY. position for it is considerably exterior to the pubes, and rather above that bone. The surgeon must, in all cases, endeavour to ascertain the precise point at which the rupture has taken place, and that is the right position for the pad. When he is going to apply the truss, he will place it round the pelvis, and put the patient into the recumbent position. Having carefully replaced the whole protrusion, he presses on the opening with one hand, and with the other applies the pad of the truss in its proper situation, holding it there until he has adjust- ed the rest of the instrument, and fastened the strap to the plate. The patient will follow the same plan in ap- plying the instrument himself; and the most convenient time for this purpose is before he rises, as the viscera generally re-enter the abdomen during night, and have no disposition to descend again until he assumes the erect position. "When the bandage is applied, the patient rises, and the surgeon examines it carefully in every point, to see whether the skin is folded, pinched, or too much com- pressed in any situation. He may walk, cough, and make slight efforts for the purpose of ascertaining wheth- er the parts are well kept up; and if they are not, it must arise from some error in the construction or appli-f cation of the bandage which will require attention. "If the viscera are well supported by the instrument, the patient may follow his ordinary occupations: yet he should bear in mind the affected part. Violent exercise or bodily exertion, and excess of eating or drinking should be avoided. The surgeon should examine him in two or three days. If any part has escaped, or if there be swelling or pain in the spermatic cord, some imperfection must exist in the instrument, and must be remedied. The omentum very often escapes, and great difficulty is frequently experienced in keeping it reduced. It may be necessary, if the pad retains its situation on ELEMENTS OF SURGERY. 21 the ring, and the truss in general sits well, to tighten the strap a little. Some individuals find the pressure of the truss extremely disagreable at first, although it Is no more than tbe case requires. These may wear a very weak instrument for an hour or two daily, increasing the length of time of such application, until habit has ren- dered its constant use supportable. " The use of an elastic truss not only keeps the vis- cera within the abdominal cavity, and thereby protects the ruptured person from all the dangers to which the existence of his complaint would otherwise* expose him; but if continued for a sufficient length of time, even af- fords a prospect of a radical cure. The constant pres- sure of the pad keeps the neck of tjje sac empty, and this part together with the surrounding tendinous open- ing,,*^) ntraets, in obedience to the general law, by which all hollow parts of the body adapt themselves to their contents. Sometimes the truss excites a kind of slow inflammation, which produces an actual agglutination of the sides of the aperture." (Lawrence.) The patient often asks how long he must wear his truss: it is not easy to determine this. In young persons, it should be worn at least two years, and in elderly pa- tients duisiug life. Mr. Lawrence dissected a patient in whom a very old and extensive rupfure had in this manner been radically cured by an adhesion at the neck of the sac. In£hil- dren there is great reason to^expect radical cures in this manner,* as many such have been effected. The truss should be worn constantly and not taken oft" at night, as is the custom with many patients. When the cure is effected it may be laid aside, but this is a point not easily ascertained. When a person afflicted with hernia is obliged to make any unusual effort, he should forcibly press on the pad of the truss to prevent the ill effects of his exertion. »« ELEMENTS OF SURGERY. The degree of pressure necessary, varies in different cases, and is easily regulated by the thickness of the spring. In those cases which require so strong a spring as to produce pain by pressing on the spermatic cord, a hollow space should be left in the pad for that part; this caution is particularly necessary when the testis or cord is in a diseased state. Mr. Gooch recommends in cases where the spermatic cord is enlarged, to have the pad constructed with a pro- jection in the middle, just sufficient to fill up the abdo- minal ring. A truss for umbical hernia has been constructed by Mr. Marison of Leeds. It is composed of two pieces of thin elastic steel, .which nearly meet behind the back; in front Ihey form an oval ring where they are thicker than at any other part. A steel spring and a pad of stuffed leather, are fastened to this riug, in such man- ner as to press upon the hernia. It is covered with soft leather, and is tied with tapes behind. In the opposite plate are represented the trusses for inguinal, crural, and umbilical herniae. Plate jtvi. Paffen.Vol.2. HtT/tftr fltgntifi/ Truj's (rural 7rufs ELEMENTS OF SURGERY. 23 CHAPTER V. Treatment of Irreducible Hernice. Ruptures are very often irreducible when they are not in a state of strangulation. The chief circumstances which prevent their return are an increase of bulk, and preternatural adhesions to surrounding parts. Bands formed of coagulating lymph pass in some cases in va- rious directions through the hernial sac, and water in many cases collects in considerable quantity, rendering it necessary to tap the tumour for its evacuation. I have at this time a patient thus circumstanced; he has a large scrotal hernia, and every month I draw off from it seve- ral pints of water. Irreducible herniae must in great measure be left to themselves. The inconveniences arising from the bulk are considerable, and there is constant danger of stran- gulation. This risk is diminished in many cases by the great dilatation of the ring, but it nevertheless exists, and should render the patient extremely cautious of all violent exertions, and he should especially guard against costiveness. A suspensory bag such as is used in cases of swelled testicle or hydrocele, will be found to ob- viate some of the unpleasant effects of the tumour. Cases considered as irreducible hernia have in some instances been gradually returned into the abdomen in consequence of long confinement to bed, and frequent purges, together with an adherence to an • abstemious diet. In addition to these remedies, when the patient consents to employ them, moderate and increasing pres- 24 ELEMENTS OF SURGERY. sure should be made upon the tumour by means of a sac of firm linen made so as to lace up to it in front. Irreducible hernia should be carefully protected from accidental injuries, as the most serious consequences have sometimes resulted from blows upon such parts. And it is to be recollected that during the whole time of protrusion there is a risk of straugulation in consequence of any violent exertion. Patients afflicted with irreducible hernia are liable to indigestion and bowel complaints, from very slight causes, and therefore they ought to be extremely guarded against errors in diet; they should also pay particular attention to prevent costiveness, by the use of clysters or laxative medicines when these become necessary. If, however, strangulation shdlild take place in an irreducible rup- ture, it will generally be found to arise from an accumu- lation in the contents of the bowels, and therefore ca- thartic medicines and clysters very frequently relieve it without mjich difficulty. ELEMENTS OF SURGERY. 25 CHAPTER VI. Treatment of Strangulated Hernia. The great object is, to replace the protruded parts in their natural situation within the abdomen, except in cases where they are probably mortified. The measures employed for this purpose are very various; the principal of which are, the taxis—bleeding—the warm bath—clys- ters of tobacco—the application of ice or cold substances to the tumour—opium—and cathartics. I. OF THE TAXTS. By this term surgeons express the attempt to reduce a hernia by the hands. The operation consists in varied endeavours to push up the protruded intestines. The patient is generally placed in a recumbent posture. When the case is an inguinal or femoral hernia, the pelvis should be placed higher than the shoulders, and if pos- sible the patient should avoid straining, coughing, and every exertion of the abdominal muscles. " The position of the patient must also be regulated with a view to the opening, through which the parts have descended. Hence, in inguinal and crural hernia, the thigh should be bent, and rolled inwards, in odder to relax the tendon of the external oblique muscle. It is also recommended to elevate the shoulders slightly, as well as the pelvis. This brings the trunk into a curved state, and completely relaxes the abdominal muscles. Since the position now described is the most favourable to the return of the protruded parts, it should be continued, as VOL. II. E 26 ELEMENTS OF SURGERY. nearly as circumstances will admit, until the rupture is replaced. " When things are thus prepared, the surgeon begins his attempt by a gentle pressure on the tumour, which may be gradually increased, but should not be earned to such an extent as to cause pain: violence cannot indeed be beneficial, as it is more likely to press the parts in a mass against the ring, and thereby bruise and injure them, than to urge them through the opening. " Numerous instances are recorded, in which this un- scientific roughness has produced the most injurious con- sequences. Suppuration of the omentum, and gangrene or rupture of the intestine, have been its more immediate or remote consequences : and the danger of the subse- quent operation must be greatly increased, if the attempts at reduction are ineffectual. " We usually grasp the tumour with one hand, while the other is placed at the aperture, where it may be em- ployed in facilitating the entrance of the parts, and in keeping up those which have been already returned. Success will often be obtained by exerting a general pressure on the whole surface of the swelling; in which method both hands must be employed, in order to subject the entire tumour to the action of the force. This method is strongly recommended by Petit. " The pressure should be exerted according to the course in which the parts have been protruded: thus, the contents of a bubonocele pass obliquely downwards and inwards; those of a femoral rupture downwards and then forwards; yet we should not confine ourselves en- tirely to such a kind of pressure as the course of the her- nia would suggest; but in failure of those attempts, make other trials in different directions. " The following manoeuvre will sometimes succeed in a bubonocele or scrotal hernia, after the more ordinary methods have failed, particularly in cases where the ELEMENTS OF SURGERY. 27 strangulation seems to have been caused by an accumu- lation of fecal matter. Let the surgeon embrace the neck of the swelling, close to the tendon, with the finger and thumb of one hand, and carry them down with a mode- rate pressure, so as to remove the contents from the por- tion next the ring; this will reduce the size of that part, which he may then attempt to pass into the ring with the other hand. Indeed, since the obstacle exists at the mouth of the sac, reduction will in general be more easily effected by pressing the upper part of the tumour towards the ring, than by exerting a general pressure over the whole swelling. " The return of a piece of intestine is generally pre ceded by a peculiar noise, caused by the passage of air through the strictured part. It recedes at first gradually, and then slips up suddenly. The omentum goes up slowly to the very last portion, which must be actually pushed through the opening. " If the taxis should not succeed at first, it may often be successfully repeated after the use of the warm bath, bleeding, or cold applications. " The surgeon is not warranted in relying on the taxis as his chief method of accomplishing reduction; he should not waste in unavailing efforts of this kind, that time which ought to be devoted to the prosecution of more vigorous measures. When he cannot reduce a rupture at one fair trial, he has less and less chance of effecting this object in the subsequent progress of the case, unless he can produce an alteration in the state of the tumour by other means. "Mr.Wilmer, of Coventry, has suggested apian which should be noticed in this place. He proposes to make pressure by means of a weight left on the part for several hours. It succeeded with him in two cases. A two pound leaden weight was employed in one of these, and a com- mon smoothing iron in the other. If the swelling were 28 ELEMENTS OF SURGERY. free from pain, and the circumstances not urgent, there could be no objection to a trial of this method. "After the reduction is accomplished, great care should be taken to avoid all irritation of the bowels, a mild ca- thartic should be employed to cleanse them." (Law- rence.) ii. of blood-letting. If the taxis should prove unsuccessful, blood should be drawn from the arm. Surgeons of the greatest re- spectability differ as to the propriety of this measure. Having never witnessed any ill effects from it, but on the contrary, having frequently seen it successful, I have no hesitation in recommending it. The quantity of blood to be drawn, should be sufficient to produce considerable sensations of weakness, and if possible, a tendency to syncope ; to effect which, the stream of blood should be large, and the patient's head should be propt up during the operation. Mr. Cooper remarks, " that a person unaccustomed to the small thready pulse of a patient suffering under stran- gulated hernia, feels apprehensive of taking away blood, conceiving the patient's strength to be fast sinking, but this fear is groundless, as the pulse becomes larger after this evacuation." The cold extremities, pale counte- nance, and weak respiration, of the patient, are also re- lieved rather than augmented by the operation. If syn- cope occur, it affords a favourable opportunity for at- tempting the reduction by the taxis. III. THE WARM BATH. Should the hernia uot be reduced by this attempt, the patient is to be placed in a warm bath, the temperature of which should be about one hundred degrees, and ELEMENTS OF SURGERY. 29 should be gradually raised till the patient becomes fainty, at which time the taxis should be again tried. " The warm bath is used with views partly analagous to those which guide the practitioner in the employment of venesection, it induces a state of faintness and relaxa- tion under which the reduction may be attempted with advantage. The weakness produced by this remedy is temporary, and is not attended by any subsequent de- bility." IV. THE TOBACCO CLYSTER. The tobacco clyster is the next remedy to be employ- ed; the most convenient mode of preparing it is by infusing a dram of tobacco in a pint of boiling water for ten minutes—one half of which may be injected first, and the remainder in twenty or thirty minutes if neces- sary. The quantity can be still further increased if the remedy prove inefficient, but extreme caution is neces- sary in the employment of this powerful medicine. Mr. Astly Cooper witnessed the death of a patient to whom two drams had been administered as a clyster. In anoth- er case related by the same author, a girl had a single dram injected; " it produced violent pain of the abdo- men with vomiting, in which was thrown up a matter which smelt strongly of tobacco, and she died in thirty- five minutes after the clyster had been administered, most evidently from its effects." Mr. Cooper adds, that " when the tobacco acts in the manner to be desired,- it produces extreme languor, a weak and quick pulse, a cold sweat, and such universal relaxation that the pa- tient has not power to exert any of the voluntary muscles of the body. In this state, the hernia will often return into the abdomen with a slight pressure, though it has previously resisted a considerable degree of force." 30 ELEMENTS OF SURGERY. V. COLD APPLICATIONS. The next powerful remedy to be employed is cold. The mode of using it is by applying pounded ice or cold water in bladders to the tumour. Certain salts which in dissolving occasion great degrees of cold, may be substituted, when ice is not to be procured. A solu- tion of sal ammoniac and nitre in equal parts answers very well; ten ounces of this mixture may be dissolved in sixteen ounces of water. Mr. Wilmer has very strong- ly recommended the application of cold, and I am happy to state that I have in several cases found it complete- ly successful. In the employment of ice care should be taken not to freeze the skin, an accident which oc- curred to a patient under the care of Mr. Cline and Mr. Sharp. VI. OPIUM. Opium is often beneficial; it allays vomiting, and some- times appears to be instrumental in effecting the reduc- tion. After passing an hour in fruitless attempts to re- duce an inguinal hernia, I gave the patient at midnight a large dose of laudanum, and left him, expecting to per- form a surgical operation for his relief in the morning— I found next day to my surprize that the patient had slept soundly, and that during sleep the protruded in- testine had returned into the abdomen. A second case somewhat similar has since occurred. VII. CATHARTICS. Cathartics are by most surgeons laid aside in the treat- ment of strangulated ruptures. There are cases, how- ever, in which they appear proper, and these are cases ELEMENTS OF SURGERY. 31 iu which the strangulation takes place slowly, and the bowels appear loaded with fecal matter. Whenever vomiting occurs, medicines taken by the mouth generally increase it and do no harm. The best cathartic I have seen employed is a combination of jalap and cream of tartar. In omental hernia purges are generally useful when the stomach can retain them. The following remarks of Mr. Lawrence on the em- ployment of the preceding remedies are extremely judi- cious. "It may be expected, that these observations on the various modes of treating strangulated hernia should be applied to cases as they actually occur; but this must be done by the surgeon in his practice. He should endea- vour to ascertain the cause and species of the incarcera- tion ; and he must exert his own judgment in the selec- tion of his means, and their adaptation to the circum- stances of the case. If he is called in the early state of the complaint, and the taxis has been unsuccessful, warm bathing and blood-letting, where the circumstances admit of it, will be the first means for him to employ. I should not, however, be inclined to recommend the warm bath, unless it can be prepared expeditiously. " Cold applications to the tumour hold the next rank in the list of remedies. Should these be unsuccessful, he will give a fair trial, with as little delay as possible, to the tobacco; and, in the event of its failure, imme- diately operate. " When as it very frequently happens, the aid of the surgeon is not required until the complaint has lasted for some time, a trial of the tobacco, together with the topical use of cold, should be immediately resorted to; as circumstances will not admit of delay in the previous use of less powerful remedies. His own discernment must be trusted for adapting his means and conduct to 33 ELEMENTS OF SURGERV. the different circumstances of an inflammatory and a chronic case. The use of purgatives and clysters, which are beneficial in the latter, do not afford a chance of suc- cess in the former description. They should never be employed, unless the slow progress of the case clearly shows that the danger is not urgent. " I wish to impress the surgeon with the propriety of giving, without delay, an adequate trial to the most pow- erful means which the art affords, and of performing the operation as soon as it can be clearly perceived that these are unsuccessful. There is no reason to expect that a less active remedy will succeed, when a more potent one has failed. The chance of reducing a rupture is lessened in proportion to the duration of the complaint: the pro- lapsed parts becoming more inflamed, are more closely pressed by the stricture, and soon fall into a state where attempts at reduction by the hand are inadmissible." The dangers resulting from delaying the operation too long, have been clearly inculcated by all the late writers on hernia. Mr. Hey's very candid account of his own timidity and its consequences, is a striking comment upon the subject; he says that he lost three patients in five, when he first began business. Having more experience of the urgency of the disease, he made it his custom, when called to a patient, who had laboured two or three days un- der the disease, to wait only about two hours, that he might try the effect of bleeding, (if that evacuation was not for- bidden by some peculiar circumstances of the case) and the tobacco clyster. In this mode of practice he lost about two patients in nine, upon whom he operated. This com- parison is drawn from cases nearly similar, leaving out of the account those cases in which gangrene of the intes- tine had taken place. "I have now," he adds," at the time of writing this, performed the operation thirty-five times: and have often had occasion to lament that I performed it too ELEMENTS OF SURGERY. 33 late, but never that I had performed it too soon." It is unfortunate that no mode of ascertaining, from the symptoms which occur, the proper time for operating has yet been pointed out. It would be very import- ant for the surgeon to ascertain the latest period to which his operation could be postponed. It has been supposed that the occurrence of hiccough denotes the commence- ment of mortification; but for this opinion there is no ground, since it often takes place before gangrene comes on, and is often absent when the intestines are mortified. Mr. Cooper says, that he is always anxious to perform the operation before the abdomen becomes sore to the touch:—he does not allude to the tension of the abdomen which occurs soon after strangulation, but to a pain aris- ing from pressure on the belly, which denotes that its contents and lining membrane are inflamed, in which case death generally follows the operation. A fair trial therefore of the remedies already described, having been made, the operation of liberating the stran- gulated intestine by the knife should be promptly per- formed; the modes of doing it will be described hereafter. Most of the preceding observations refer to hernia generally.—We proceed next to speak of particular rupture*;. VOL. Tf. F o4 ELEMENTS OF SURGERY. CHAPTER VII. Of Inguinal Hernia. Inguinal hernia, and scrotal hernia, are that spe- cies of rupture in which the protruded viscera pass out at the abdominal ring. It is inguinal hernia whilst the tumour is confined to the groin, in which situation it is also called bubonocele ; it becomes scrotal hernia when it descends so low as to be covered by the integuments of the scrotum. In women it forms a tumour in one of the labia pudendi. It is impossible to communicate correct ideas of this disorder to a person unacquainted with the anatomy of the parts affected. Mr. Astly Cooper has bestowed a great deal of labour in investigating and describing the important structure of the abdominal ring, and the parts in its vicinity; he has illustrated his descriptions by very accurate and very splendid engravings, taken from ac- tual dissections, and in this manner has laid before the public one of the most useful and instructive volumes of which modern surgery can boast.* To Mr. Cooper's book, and to the dissecting room I refer for the anatomy of these parts, contenting myself with one or two remarks. The aperture through which the parts descend in this species of hernia, is not to be considered as a ring, or hole, but as a passage or canal, the internal extremity of which, is the part where the spermatic vessels leave the abdomen, which is generally • Engravings have also been published by Soemmering from drawings by Camper, and more recently by Scarpa, illustrative of the anatomy of hernia which have great merit. ELEMENTS OF SURGERY. 35 one inch and a quarter distant from the abdominal ring, the inner margin of the opening being almost invariably half way between the spinous process of the ilium and the symphysis pubis ; through this opening and through the abdominal ring, the spermatic cord passes down in the male subject to the testis. The following description of the complaint is extract- ed from Mr. Cooper's treatise. Inguinal hernia makes its first appearance in the form of a small tumour, situated about an inch and a half to the outer side of the abdominal ring, in a line extend- ing from the pubis to the anterior superior spinous pro- cess of the ilium. If its progress is interrupted, it proceeds gradually obliquely downwards, and inwards, in the direction of the spermatic cord as far as the abdominal ring. As long as it remains above the ring its existence is of- ten unsuspected by the patient, because it requires a care- ful examination to detect it; but to a surgeon acquainted with the natural feel and appearance of the parts it is sufficiently obvious. The length of the swelling above the ring will be found the same as the part of the sper- matic cord included between the upper opening and the abdominal ring; that is, about an inch and a half in the adult subject. The tumour next descends through the abdominal ring into the scrotum (here taking the name of scrotal hernia,) and being now less confined than before, it forms a distinct swelling, sufficient to awake the pa- tient's attention, who now, generally for the first time, is led to require surgical assistance. As the growth of the tumour, when in the scrotum, is little restrained by external pressure, it increases to an almost unlimited, and sometimes enormous size. One of the largest of these swellings which is recorded, occurred in a man who was sent to Guy's Hospital by Mr. White, surgeon at Lambeth. It reached to the patient's knees, its length 36 ELEMENTS OF SURGERY. was twenty-two inches, and its circumference thirty-two. Another measurement taken by Mr. White when it had been for some hours strangulated, gave thirty-four inches for the circumference, and twenty-two for the length. When an inguinal hernia is dissected, immediately under the skin of the scrotum is found a fascia of great- er or less thickness according to the duration and size of the tumour. This fascia is given off by the tendon of the external oblique muscle above the abdominal ring. In general, it appears little more than a condensed cel- lular membrane, but in old herniae it becomes as dense as the fascia that covers the muscles on the outer part of the thigh. Under this fascia is the cremaster muscle, which forms another covering to the hernial sac; for this mus- cle, in passing down through the abdominal ring, is united both to the fascia and to the sac, separable from both, however, by an easy dissection. This muscle be- comes much more extended and thicker in hernia, than in the natural state. When the fascia and cremaster muscle are removed, the proper hernial sac becomes exposed to view. This is thinner than the two former coverings, but somewhat thicker than the peritoneum from which it is immediate- ly derived. Many writers have represented the sac as much denser than it really is, mistaking the two above coverings for the sac itself. Behind the hernial sac lie the spermatic cord on the upper part, and the testicle on the lower; so that.the sac is situated between the cord and the cremaster mus- cle, anterior to the former and posterior to the latter. The direction of the hernia above the abdominal ring is obliquely upwards and outwards towards the spiue of the ilium, the same as that of the spermatic cord. Above the ring, the hernial sac is covered by the tendon of the external oblique muscle; the spermatic cord is still be- ELEMENTS OF SURGERY. 37 hind it, and further backwards are the tendons of the in- ternal oblique and transversalis muscles and the fascia before mentioned. At the upper aperture in the fascia, the sac penetrates the abdomen along with the spermatic cord. This part is called its mouth, and is generally, though not always, its narrowest dimension. Between the mouth of the sac and the symphysis pubis passes the epigastric artery. This vessel runs in some degree un- der the sac, and along its inner side. There is no ves- sel of importance above the mouth of the sac, nor exter- nally, that is, between it and the spinous process of the ilium. The relative situation of the hernia with the abdomi- nal openings above described, applies only whilst it re- mains of small size; for when hernia has existed a con- siderable length of time, and has carried with it a large portion of abdominal viscera, the constant pressure di- lates the parts in each direction, extending the opening through which it passes from the abdomen, both towards the spine of the ilium, and especially towards the sym- physis pubis. Hence it is, that in old and large hernia, the orifice of the sac into the abdomen is brought to be almost in contact with, and opposite to, the abdominal ring. It has been stated that the hernial sac in its descent is anterior to the spermatic cord. This is its most fre- quent situation, but varieties occur in this respect which the surgeon should keep in mind during the operation, and the cord is sometimes found separated, and the her- nial sac protruded between its vessels. The inguinal hernia is very generally pyriform, small towards the ring, and enlarging as it descends. It occurs much more frequently on the right than the left side. The circumstances whereby this disease may be dis- 88 ELEMENTS OF SURGERY. tinguished from other tumours with which it is liable to be confounded, are the following: First, When the patient is desired to cough, the tu- mour becomes immediately distended, owing to the pres- sure of the abdominal muscles forcing down into the sac more of the viscera or their contents. Secondly, When the patient can state from his remem- brance, that on the first appearance of the tumour in the groin, it had used to return into the abdomen when he was in a horizontal posture, and to re-appear on stand- ing erect; though circumstances may have long prevent- ed this symptom from continuing. Thirdly, When the progress and the tumour has been from the groin gradually downwards to the scrotum. Fourthly, When the tumour contains intestine, it is elastic and uniform to the touch ; and on being pushed up into the abdomen, it returns with a guggling noise. But when omentum is contained, the tumour is less equal on its surface, receives an impression from the fingers, is heavier than in the former case, and does not make the same noise when returned into the abdomen. Most com- monly, however, both intestine and omentum are the con- tents of the hernia; a circumstance which impairs the accuracy of any very nice distinctions by the touch; though still on pushing back the contents of the tumour, the presence of intestine, which returns the first, will often be indicated by the guggling noise, whilst the more solid omentum may be felt going up after it. Lastly, The functions of the viscera are somewhat in- terrupted. Eructations, sickness, constipation, colicky pains, and distention of the abdomen occur; and pain is produced by violent exertions, coughing, or sneezing. These are the symptoms that generally give the patient some suspicion of the nature of the complaint. However there are several diseases of the groin and scrotum with which hernia is liable to be confounded; ELEMENTS OF SURGERY. 39 so that there are few surgeons who have seen much of her- nia, who have not frequently witnessed mistakes, made even by medical practitioners, which have led to the ap- plication of trusses in diseases where they not only are useless, but even productive of much injury. The repu- tation of the surgeon, and the safety of his patients, re- quire of him a very accurate attention to this point. A hydrocele of the tunica vaginalis testis resembles hernia in its form, but may be distinguished from it by the following marks: The hydrocele begins to form at the lower, part of the scrotum, and gradually extends towards the ring. It also involves the spermatic cord and testis, so as to ren- der them with difficulty distinguished by the touch ; whilst in hernia they may in general be felt with ease behind the tumour. Hydrocele gives a fluctuating feel when struck with the fingers, does not become dilated when the patient coughs, and appears considerably trans- parent when a lighted candle is held by its side. There are cases of hydrocele, however, in which there is unusual difficulty in deciding upon the nature of the complaint. When it becomes so large as to ex- tend upwards through the abdominal ring to the abdo- men, the form of the tumour is precisely the same as that of hernia, and it even dilates when the patient coughs, owing to the sudden pressure upon that part of it which lies above the ring. The transparency, the fluctuating feel, and the observed progress of the swelling from be- low upwards, are then the only distinguishing marks. A tumour sometimes appears in the scrotum, which descends in the erect posture, returns when the body is recumbent, distends upon coughing, fluctuates, and is transparent. This disease is a collection of water which runs backwards and forwards from the cavity of the ab- domen within the tunica vaginalis, owing to the opening of this membranous sheath never having been closed 40 ELEMENTS OF SURGERY When this disease is complicated with ascites it becomes distended to an enormous size. It is readily distinguish- ed from hernia from its transparency, which may always be observed. Water sometimes collects in a cyst upon the spermatic cord, forming a hydrocele of the cord. When it is placed entirely below the ring, its want of connexion with the ab- domen readily distinguishes it from hernia; but when it passes within the ring to the abdomen, some difficulty occurs in understanding its nature. If from its situation the transparency cannot be examined, and if the fluctu- ation is not very distinct, a surgeon should be very cau- tious in operating on such a tumour. Nothing but great want of attention can cause a her- nia to be confounded writh an enlargement of the testis. This latter is sufficiently distinguishable by the form of the organ, which is retained under morbid enlargement. by its weight, by the pain with which it is generally ac- companied, and by that peculiar and intolerable sensa- tion always produced by pressure upon this part. Hematocele, or a collection of blood in the tunica vaginalis testis, as it generally arises from a blow, is of the same form as hernia, and liable to be confounded with it. But the firmness of hematocele, the redness of the skin with which it is accompanied, its refusing to dilate under coughing, and freedom from swelling of the spermatic cord at the abdominal ring, which is generally the case, will usually afford the means of distinction from hernia. But of all the diseases of the scrotum, which are mistaken for hernia, none is so much so as the varicocele* or enlargement of the spermatic veins. Mr. Cooper has kuown persons (even the children of medical men) to wear trusses for a supposed hernia, which they complain- ed did not fit, gave them pain, and could not prevent the • By varicocele Mr. Cooper means the disease more properly denominated circocele. ELEMENTS OF SURGERY. 41 descent of the tumour, when it was found that the disease was this enlargement of the spermatic veins. Varicocele has indeed many of the marks of hernia. When large it dilates upon coughing, but not otherwise; it appears in the erect position, and retires when the body is recumbent; aud it is first observed near the ring. The only sure method of distinction according to Mr. Coop- er is to place the patient in the horizontal posture, and empty the swclliug by pressure upon the scrotum, then putting the fingers firmly upon the upper part of the abdominal ring, desire the patient to rise : if it is a her- nia, the tumour cannot re-appear as long as the pressure is continued at the ring; but if a varicocele, the swelling returns with increased size, owing to the return of blood into the abdomen being prevented by the pressure. Some judgment may also be formed by the feel of the tumour, for that of varicocele is always ropy, as if a bundle of cords were contained within the scrotum. There are, however, some cases of a complicated nature which demand much judgment and accurate dis- crimination. For instance, hernia is sometimes compli- cated with hydrocele of the tunica vaginalis ; and some- times the sac contains omentum, adhering to its upper part, and a collection of water below. If the adhesion of the omentum is complete, there is no danger of at- tempting the cure of the hydrocele by injection; however, if the case clearly appears to be of this kind before ope- ration, it is best to use the method of incision. OPERATION FOR INGUINAL HERNIA. Having already described the means to be employed for the reduction of inguiual hernia, it remains to describe the operations which become necessary, when the stran gulated parts cannot by these measures be, returned. vol. II. c, 42 ELEMENTS OF SURGERY. The object of a surgical operation in the present case is to replace the protruded bowels, if they be not gangre- nous, and to remove such portions as may be mortified. The patient should be placed upon a common dining table, with his legs hanging over its end, his shoulders and knees being a little raised by pillows in order to relax the abdominal muscles. The bladder should be emptied. The hair being removed from the pubes, an incision should be made with a common scalpel through the skin and cellular membrane, beginning an inch from the ab- dominal ring, in the direction of the fibres of the exter- nal oblique muscle, and extending nearly, or in small hernias, quite to the bottom of the tumour. The external pudental artery is generally divided by this incision, but seldom requires a ligature; if it bleed so as to incom- mode the surgeon, an assistant may compress it with his finger, or if necessary, the surgeon can take it up with a tenaculum and ligature. If the operation be performed in a case in which it would be desirable to return the parts, if practicable, by the taxis; that is to say, if no symptoms of gangrene be present, then the operation should be conducted in the following manner: the abdominal ring, and the portion of the tendon forming it, should be exposed; a small hole should be scratched through the tendon half an inch from the ring, in a direction upwards and outwards, towards the spine of the ilium; a director should be passed through this hole under the tendon and out at the ring; when this is done, a bistoury or scalpel should be passed along the groove of the director so as to divide the ten- don. If the stricture have been caused by the abdomi- nal ring, it will in this manner be removed, and the pro- truded parts can be easily returned into the abdomen. If the stricture be seated higher up than the ring, and the parts can be pushed up without violence by the finger, ELEMENTS OF SURGERY. 43 it ought now to be done, without opening the sac. This very simple and easy operation has in a variety of cases, in Dr. Physick's practice, succeeded completely in ef- fecting a cure; the after treatment is very simple, and the patient experiences very little inconvenience, as the wround speedily heals, and no danger of peritoneal in- flammation follows. This practice of not opening the sac is ascribed by Mr. Lawrence to Petit. Mr. Lawrence thinks it ought to be employed more frequently than it is, and Dr. Mon- ro's testimony is also in its favour; having seen it al- most uniformly successful I have no hesitation in recom- mending it; lam aware of the objections which have been urged against it, but I rest its defence upon the question, whether it would have been proper, before commencing the operation to have returned by the taxis the prolapsed parts ? If so, it cannot be more necessary to expose the contents of the sac, after the stricture has been divided. If after reducing the hernia, the sac can also be returned into the abdomen (which is but seldom practicable) this ought to be done. It is extremely important, however, to bear in mind the necessity of opening the sac, in all cases where there is any reason to apprehend gangrene in its contents, or adhesions which will prevent their reduction, Mr. Astly Cooper directs the external fascia which proceeds from the tendon of the external oblique musele to be exposed by a free incision through the skin and cellular membrane; this fascia forms the thickest cover- ing of the sac; the middle of it is to be next cut through and a director introduced beneath it, upon which it is to be divided, upwards towards the abdominal ring, and downwards to the bottom of the tumour. This opening through the fascia exposes the second covering of the hernial sac, viz. the cremaster muscle which must be divided precisely in the same manner, when the sac 44 ELEMENTS OF SURGERY. will be exposed. "It should be remarked that to those not accurately acquainted with the anatomy of the parts, the division of these layers causes great embarrassment and delay, for the operator expecting to see the sac it- self as soon as he has divided the common integuments, cuts the fascia with extreme caution, fibre after fibre, from fear of injuring the intestine beneath, mistaking this thickened covering and the cremaster muscle for the hernial sac. "When the sac is completely exposed, if the hernia is intestinal, and the intestine does not adhere to the sac, a sense of fluctuation may generally be perceived at its anterior and inferior part, when the tumour is grasped, and the fluid which it contains is pressed forward. "The surgeon is next to pinch up some of the cellular membrane which closely adheres to the anterior and in- ferior part of the sac, by means of a pair of dissecting forceps, and when the sac is thus raised, and separated from the intestine, he is to place the edge of the knife horizontally, and to cut a small hole just sufficiently large to admit the blunt end of a probe or that of a di- rector, upon which the sac is to be further divided, be- ing cut upwards to within an inch of the abdominal ring, and downwards to the bottom of the sac. The reason that the anterior and inferior part of the sac is selected for the first incision into it is, that the intestine seldom descends so low, and if it does, the fluid which it con- tains is generally found interposed between the intestine and that part of the sac. The sac should not be divided higher than to an inch below the abdominal ring, as its division near the abdomen makes it more difficult to close the wound, and exposes the patient to the danger of peritoneal inflammation. " As soon as the sac is opened, a quantity of fluid es- capes ; its colour, if the strangulation has not been long continued, is that of serum, but if the intestine has been ELEMENTS OF SURGERY. 43 for a long time compressed, it becomes of a coffee co- lour, and sometimes offensive to the smell. Its quantity, if there is no adhesion of the intestine to the sac, is pro- portioned to the quantity of intestine strangulated, for if adhesion exists, little, if any is found, so that the sur- geon who depends on meeting with it, would wound the intestine in the operation. In the omental hernia also there is seldom any fluid in the sac, and if any, a com- paratively small quantity; for this fluid seems to be prin- cipally a secretion from the surface of the intestine. "When the sac is opened, the contents of the hernia appear; and if both the intestine and omentum have de- scended, the latter is the first that presents, and general- ly covers, and sometimes entirely envelopes the intes- tine. The omentum retains much of its usual appear- ance, its colour being only a shade darker than natural; but the intestine is covered with a coat of coagulablc lymph, and appears red if it has not been long strangu- lated; but of a chocolate brown colour if the stricture has been very tight, or the strangulation long continued. The veins upon it are turgid with blood, and I have seen the lacteals upon the jejunum and ileum distended with air. " The next part of the operation is the division of the stricture, and the surgeon carries his finger into the her- nial sac to examine accurately into its situation, which he will find in one or other of the three following parts. "First, at the abdominal ring. " Secondly, above the ring from one inch and an half to two inches, and inclining outwards toward the spi# nous process of the ilium. "Thirdly, in the mouth of the hernial sac. "If the stricture is owing to the pressure of the co- lumns of the tendon which form the abdominal ring, it is then to be divided in the following manner. The sur- geon passes his finger into the sac as far as the stricture, 46 ELEMENTS OF SURGERY. and then conveys a probe-pointed bistoury on the fore part of the sac, and to an extent proportioned to the size of the tumour. The dilatation of the ring should not be larger than is sufficient to return the protruded parts; but it should allow them to pass without committing any violence by the pressure exerted in effecting a return. In general, if the finger can be readily admitted into the abdomen, by the side of the protruded parts, the dilata- tion is sufficiently free. " It is best to divide the stricture by passing the knife between the ring and the sac, as a larger portion of pe- ritoneum is thus left uncut, and the cavity of the abdo- men is afterwards more easily closed. The direction given to the knife in dilating the stricture has been usu- ally upwards and outwards towards the spine of the ilium, but I prefer doing it directly upwards, for the two following reasons. "First, as the higher aperture must only be dilated directly upwards, it is better that the surgeon should have one general rule for the use of the probe-pointed bistoury, applicable to every case of inguinal hernia, than to be perplexed in the operation by a variety of di- rections, which only partially apply to one or other seat of the stricture; and secondly, the division of the tendon in this direction weakens the abdomen less than up- wards and outwards, because as the cord passes towards the abdomen In that direction, and the hernial sac is pa- rallel with the cord, a dilatation in that course takes off the resistance which the tendon would otherwise make to any future descent. When the ring is divided direct- ly upwards, the upper column of the tendon which forms it is cut, when it is dilated upwards and outwards, the transverse fibres uniting the columns, are divided. The dilatation upwards is equally safe with the other, for if this were not the case, no subordinate advantage ought to interfere with the most important one of security. ELEMENTS OF SURGERY. 47 " A frequent situation of the stricture, however, is not at the abdominal ring, but at the place at which the sac opens into the abdomen, that is an inch and an half or two inches above, and to the outer side of the ring; and it is there occasioned by the pressure of the tendon of the transversalis which passes over it, and by the resis- tance of the border of fascia which passes under it. "If the stricture is at this orifice it is to be divided as follows : The surgeon passes his finger up the sac, and through the abdominal ring, until he meets with the stricture; he then introduces the probe-pointed bistoury with its flat side towards the finger, but anterior to the sac, and between it and the abdominal ring, his finger being still a director to the knife. Thus he carries the knife along the fore part of the sac until he insinuates it under the stricture formed by the lower edge of the trans- versalis, and internal oblique muscles, and then turning the edge of the knife forwards, by a gentle motion of its handle he divides the stricture, sufficiently to allow the finger to slip into the abdomen : the knife is then to be withdrawn with its flat side towards the finger as it was introduced, to prevent any unnecessary injury of the parts. The direction in which this orifice is divided is straight upwards, opposite the middle of the mouth of the sac, as in this way the epigastric artery can scarcely be cut, whatever be its relative situation with respect to tiie sac. " An advantage is derived from dilating the stricture, without cutting the sac itself, for there is danger of injuring the intestine with the naked edge of the knife, which I have twice known to happen when the stricture was divided from within the sac; in one case the patient died from the contents of the intestine escaping into the cavity of the abdomen. In the other the intestine was > obliged to be retained in the sac, to allow of the escape of the feces by the external wound. An additional ad- 48 ELEMENTS OF SURGERY. vantage is derived from this mode of dilatation, viz. that if by any mistake of the operator the epigastric artery is cut, as the peritoneum is undivided, the flow of blood would be immediately perceived, and then the vessel might be secured; whereas if the sac is included in the incision, the artery would bleed into the abdomen and the consequences would be fatal, without the cause being known but by dissection. " The third seat of stricture is the hernial sac itself, from its becoming thickened or contracted; but I have already said that it is not so frequent an occurrence as has been imagined, for the pressure of the surrounding parts above the ring has been often mistaken for it. It is however undoubtedly true, that it does sometimes occur." (Cooper.) Mr. Cooper adds, " that he had lately dissected a sub- ject, in which the peritoneum at the mouth of the sac was considerably thickened, and had pressed upon a portion of intestine which it included, so as to occasion its stran- gulation." I have myself seen a very singular case in which the stricture existed at the neck of the hernial sac:—A wag- goner who had a long time been afflicted with a scrotal hernia for which he had worn a truss, was attacked sud- denly with symptoms of strangulated rupture. 1 visited him and found a small hernial tumour, but so free was it from all appearance of strangulation, that I doubted very much whether his symptoms were at all connected with it—the abdominal ring was an inch in diameter, and admitted freely the fingers to pass up, and the tu- mour could be pressed up, but was immediately after re- turned. Suspecting a stricture at the upper aperture of the canal, I requested a consultation, and Dr. Physick was sent for; all the usual remedies for the reduction of the hernia had been tried before I saw the patient, by a me- dical gentleman who had previously been called in. V Plate xvii Case described ?<*#* 49. Neck of the Sac Str<^ rjM9 Alt* rrt^ (ncisicm into the Sac i*v the Scrotum, JS.Dorsty Ml #. Setup. ELEMENTS OF SURGERY. 49 Dr. Physick recommended that the hernial tumour should be opened, in order to ascei laiR whether it contained a strangulated intestine or not. This operation was per- formed, and upon cutting into the sac some dark colour- ed fluid escaped, but nothing else could be discovered in it. The finger apparently entered the cavity of the abdomen, but touched nothing but peritoneum; at length the extremity of my middle finger came in contact with a piece of intestine, near the fundus of the bladder, and this appeared fixed in its situation : I succeeded however in pushing against it somewhat firmly, and it slipped up evidently out of a narrow aperture. The patient died a few hours after the operation, and upon dissection the nature of this obscure case became evident. An old hernial sac existed, which had been reduced and was now almost entirely within the abdo- men, a small process of it only extending through the abdominal ring. Into this hernial sac, a piece of the ileum had been forced, became strangulated, and was found mortified.* When the stricture is formed in this way by the neck of the sac, in whatever situation that may be, it should be divided by a careful use of a bistoury having only a small cutting surface near its extremity.f Such an instrument has been recommended by Mr. Cooper, but a good substitute may be made by covering a com- mon probe-pointed bistoury with waxed linen, except at its extremity, where a quarter of an inch of the edge may be left bare. "When the stricture has been completely removed, the protruded intestine is to be attentively examined to ob- serve whether the brown colour which it assumes under * Several cases are recorded somewhat analagous to this; Mr. Cooper's sixth case of crural hernia in some respects resembled it, but in no case I have seen described, was there a stricture in the neck of an old hernial sac which had been a long time returned into the abdomen. f Mr. Cooper's bistoury is represented in the first plate of this volume. VOL. 11. ]\ 30 ELEMENTS OF SURGERY. strangulation lessens or disappears, as this is a proot of the return of circulation in the part. The veins on its surface may also be emptied by pressure, and their sudden filling noted, and the intestine should be pulled down a little to make these observations on the part which has imme- diately been compressed by the stricture. If the intes- tine appears to have a free circulation the surgeou should directly but gradually return it, thrusting up about an inch at a time, and securing each part with his fingers until the whole is returned into the abdomen. All vio- lence and improper haste should be carefully guarded against; for the intestine is tender, and will easily tear at the"strictured part." (Cooper.) If any difficulty is experienced in replacing the intes- tine, the position of the patient should be the same as when the taxis is employed so as to relax the aperture into the abdomen. "If the intestine is connected with the sac by adhe- sion, an extraordinary degree of caution is required on opening the sac, as it contains no interposed fluids. If the bands which form the adhesion are long enough to allow of the intestine being drawn a little from the sac, they may be completely separated by dissection; but if they are so short that the intestine and sac are aggluti- nated together, it becomes necessary to cut off portions of the sac, and to return them still adhering to the bowel, into the cavity of the abdomen. Sometimes the adhe- sion exists only at the orifice of the sac, all the lower part being perfectly free; a circumstance which requires great caution in the operation to ensure the entire return of the protruded intestine, as otherwise the operation will fail of its object. "It sometimes happens that the convolution of intes- tine in the hernial sac has its sides glued together by recent adhesions. When this happens, it is right to se- parate them before the intestine is returned, because the ELEMENTS OF SURGERY. 51 stools do not readily find their way through an intestine which is thus doubled. "It is an operation of extreme difficulty and delicacy to divide adhesions at the mouth of the hernial sac. It requires that the sac should be dilated to its mouth, and that the tendon of the external oblique should be slit up to the part at which the hernia descends from the abdo- men. Great danger of wounding the intestine, even when the parts are thus completely exposed, attends the divi- sion of the adhesions. "'When the intestine has been returned, the omentum is to be examined with attention, and if it is in a healthy • state, and not of very considerable bulk, it should be re- turned into the cavity of the abdomen by as slight a pres- sure as possible. But if it is very bulky, a part of it should be removed; which may be done by the knife with great freedom, and if properly managed, without any danger. I have myself removed it in several instances without the patient seeming to suffer any subsequent in- convenience. The surgeon raising the omentum, whilst an assistant grasps it higher up to prevent its return into the abdomen, cuts it off near the mouth of the sac. Some small arteries always bleed, which are to be secured by a fine ligature; and when the hemorrhage is stopped, the omentum is to be returned into the abdomen, with its divided surface applied to the mouth of the sac, from which the ligatures are suspended, and it thus forms a plug that shuts up its cavity. "The practice of applying a ligature round the whole of the protruded omentum, to make it slough away, though it has had its advocates, is now very generally laid aside. Indeed it appears extraordinary that it should ever have prevailed. The very object for hernia, is to take off from the omentum the stricture derived from the pressure of a surrounding tendon, which acts as a cord upon the part; and no sooner is this removed, than the surgeon 52 ELEMENTS OF SURGKUY. applies a ligature, which produces a more perfect con- striction than that which had previously existed. I have several times known the omentum tied, and the patient still recover; but it appeared to me that its living powers had been already destroyed by the pressure of the stric- ture ; and if the part is mortified, a ligature cannot ex- cite constitutional irritation, or produce any dangerous consequences, but, on the other hand, its application is attended with no utility, as the omentum would have sloughed if the thread had not been used. "If mortification has taken place in the omentum, it is to be removed by excision at the sound part, in the manner I have already described. Even if there is only suspicion, and not positive certainty of the omentum being mortified, it should be cut away; as the removal is so far as T have seen, unattended with danger; and its return into the abdomen, if mortified, or even approach- ing to, that state, is attended with the utmost hazard, and generally proves fatal. One exception, however, to this opinion, I have seen. A man underwent the operation for hernia in Guy's Hospital, and the sac was found to contain both omentum and intestine, which as they ap- peared not mortified, although considerably changed, were returned into the abdomen. On the sixth day after the operation the man appeared to be dying, his pulse was extremely feeble, and he complained of severe pain in the abdomen. The ligatures upon the scrotum were cut away, fomentations and poultices were applied to the wound, and on the following day a small portion of omentum protruded in a gangrenous state. More of it continued to come down, in this state, from time to time, during seven days, after which the whole portion which had been originally contained in the hernial sac, ap- peared in the wound, and gradually sloughed oil". The wound then healed, and the patieut recovered. This fa- vourable termination could only have happened in a case ELEMENTS OF SURGERY. 53 in which the mouth of the •hernial sac was wide, and where the omentum was lying in the abdomen just op- posite to its orifice. " If the omentum adheres to the sac, the adhesions may be cut through with considerable freedom, and the bleed- ing vessels being secured, the omentum should then be returned into the cavity of the abdomen. "It is sometimes necessary to cut away the omentum on account of its being in a scirrhous state. A case of this kind occurred in a man who was operated upon for a hernia congenita; and the omentum being thus dis- eased, formed a large and hard tumour; which is pre- served in the Anatomical Museum at St. Thomas's Hos- pital." (Cooper.) In some cases in which the colon is prolapsed, the ap- pendices epiploicae protrude in a diseased state, in these cases they should be cut off; no danger attends the ope- ration.' 54 ELEMENTS OF SURGERY. CHAPTER VIII. Of Mortified Intestine. Many of the following observations on mortified in- testine are extracted from Mr. Cooper. The symptoms by which this state of the intestine is known are, that the tumour which was tense and elas tic becomes soft and doughy, and air can be felt crack- ling in the cellular membrane; that its colour which was at first of a florid red, becomes purple. The hiccough and tension of the abdomen still continue, but the vomit- ing is less frequent. The pulse is intermittent, but ful- ler and softer than during the inflammatory state; the eyes are glassy. The hernia now sometimes returns into the cavity of the abdomen without assistance, and the patient survives but a few hours : but sometimes the skin over the tumour sloughs, the intestine gives way, and the feces being discharged at the opening, the symptoms of strangulation soon after cease. When this happens, the intestine contracts adhesions to the hernial sac. The portion which has been mortified sloughs away, and an artificial anus becomes established, through which gene- rally during the remaining part of the patient's misera- ble existence, the feces are constantly discharged. How- ever, it sometimes happens, when the intestine has slough- ed, that a re-union takes place of its extremities, the ex- ternal wound gradually heals, the artificial anus is closed, and the feces resume their natural course. The degree of danger which attends the artificial anus, depends upon the vicinity of the sphacelated in- testine to the stomach, for if the opening is in the jeju- num, so little spacers left for the absorption of the chyle, that tbe patient dies from inanition. ELEMENTS OF SURGERY. 55 When the artificial anus is in the ileum, it is attend- ed with less danger than in the jejunum. If it is situ- ated in the large intestines, patients scarcely appear to suffer in their general health, for Mr. Cooper has seen several instances of this disease in the colon, all of them in women, and from umbilical or ventral hernia; and they s'eemcd to possess the same bodily health with others, some of them being afterwards extremely corpu- lent. With respect to the treatment which is required in these cases of sloughing hernia, very little more can be done than to quicken the process of separa- tion by fomentation and poultice, and to support the strength by cordial medicines and bark; and any at- tempt made to lead the feces into their natural course, prior to the sloughing being completed, will only irritate the parts, prevent the regular progress of separation, and endanger the destruction of the patient. When the ar- tificial anus is completely established, all that can be done is to lessen as much as possible the offensive state of the patient, by confining the feces until it is conve- nient to discharge them. For this purpose a square cushion, covered with oiled silk, is to be placed over the artificial anus, and a steel truss, which exerts but a slight degree of pressure, being placed upon it, confines the feces so as to lessen the offensive smell, and allows the patient to seek a convenient situation for an evacu- ation. This plan answers extremely well if the faeculent matter has some consistence, but if the aperture is in the ileum, the contents of this intestine are with difficulty confined. In performing the operation for strangulated hernia, if the intestine is mortified, the appearance which it as- sumes is that of a dark purple, or leaden coloured spot, or spots, which readily break down under the impres- 56 ELEMENTS OF SURGERY. sion of the finger. The other part of the intestine is of a chocolate brown colour, which has been often mistaken for mortification, but its colour and firmness prove that it has not advanced to that state. Every part of the sur- face of the intestine is covered by a layer of coagulated lymph, of a brown colour.* As the intestine cannot, when mortified, be returned into the cavity of the abdomen, the surgeon is to consi- der in what manner he is to proceed to save the patient from that most miserable state of existence, which is pro- duced by an artificial anus. In forming his judgment upon this subject, he will be directed by the state in which the part is found. If a small hole only has been produced, the intes- tine should be returned into the abdomen, excepting that portion of its cylinder in which the hole exists. A needle and ligature should be passed through the mysentery at right angles with the intestine, to prevent its including the branches of the mysenteric artery which supply that part of the intestine, and then through the mouth of the hernial sac; and tying the thread, the intestine becomes confined to the mouth of the sac, and the feces pass rea- dily from the opening by the wound, but will in part take their course by the rectum. As granulations arise, and the wound becomes closed, the opening in the intestine is gradually shut, and an artificial anus is effectually prevented. When the whole cylinder of the intestine is morti- fied, it is necessary to proceed very differently. Then the mortified part of the intestine should be cut away, and the ends are to be brought in contact and confined by means of four ligatures." * The only test of the mortification of a portion of intestine is the coagu- lation of blood in its vessels; this is ascertained by pressure with the fin- ger : if the colour disappears, and returns when the pressure is removed -it is not mortified, otherwise it most probably is. ELEMENTS OF SURGERY. 57 From a number of experiments performed by Mr. A. Cooper and Mr. Thomson of Edinburgh, and by Dr. Smith in this city, it appears, that when the intestines of animals are stitched in this manner, the ligature passes through the alimentary canal with the feces,* and the intestine heals very completely. Mr. Cooper infers, that the proper practice when an intestine is divided by "mortification, is to cut off its mortified extremities, and " then to pass four stitches through them, one at the me- sentery and the three others at equal distances 'ound the intestine; then returning it to the mouth of the hernial sac, which should be opened higher up than usual, it must be there firmly confined by a ligature, being passed through the mysentery in the manner already directed. If stools pass the ligature and the patient goes on well, the ligatures may remain until they are thrown off by ulceration; but if there are no stools, and the patient suffers from a distended abdomen, three of the stitches should be cut away, leaving that which attaches the in- testine to the hernial sac, as well as that which joins its edges at the mysentery. The feces can then readily escape at the external wound; and as granulations arise and the wound heals, the mouths of the divided intes- tine will become united, so that the feces will take their natural course." (Cooper.) The proposal of Mr. Ramdohr to put the upper ex- tremity of the intestine into the lower, and to confine it there by a ligature, is objected to by Mr. Cooper, who found it impossible to effect it in brutes, and infers its impracticability in the human subject. When a slough forms on one side of the intestine, so as to destroy half the cylinder, the wound generally * The manner in which the Ugature is prevented from escaping into the cavity of the abdomen, has been briefly noticed in the chapter on wounds of the abdo- men, in vol. i. VOL. II. I 58 ELEMENTS OF SURGERY. heals, so as to form an artificial anus. When the intes- tine heals in such a case, its cavity is not sufficient to transmit the feces, and abscesses form, by which they are discharged. If the wound in the integuments is small, and the intestine has more than half its cylinder, it would be naturally supposed easy to unite it; and cases of success are related, but in the instances in which Mr. Cooper knew it attempted, it has not been attended with success. " As it appears, therefore, that there is little proba- bility of relief to the patient when this state is once es- tablished, the surgeon should attempt, by all the means in his power, to prevent its occurrence. "The means which will occur to the mind as being most likely to effect this object, will probably be to make an uninterrupted suture upon the opening in the intes- tine; but this treatment would leave the intestine with only half its cylinder, the feces will not pass, they will either soon burst the stitches from the wound, or it will become necessary for the surgeon to cut them to unload the intestine, and prevent the death of his patient. " There is a curious difference in the facility with which a longitudinal and transverse wound of the intes- tine unite. It has been already shown, that the trans- verse heal readily; but with respect to the longitudinal, they have a contrary tendency." From some experiments performed in this city by Dr. T. Smith of St. Croix, it appears that the intestines of dogs readily recover from extensive longitudinal wounds, though more attention to prevent the escape of their con- tents is necessary. In every case where the intestinal canal is partially destroyed by mortification it is best to cut out the whole cylinder at the mortified part, and not to attempt to treat it as a longitudinal wound by cutting out only the portion actually gangrenous. ELEMENTS OF SURGERY. 59 After the operation for hernia, it is necessary to close the edges of the wound by adhesive plaster, or if neces- sary from its extent or from a difficulty of retaining them without it, by an interrupted suture. The patient should remain at rest on his back during the cure, avoiding all efforts of the abdominal muscles, and every thing likely tp occasion peritoneal inflammation. In general, the bowels evacuate themselves within a few hours after the operation; if not, a mild injection may be given. In very large hernias, especially in those where there is reason to expect adhesions of the sac and its contents, Mr. Cooper advises simply to dilate the stricture without exposing the cavity of the sac. Herniae are sometimes strangulated when they are so small as not to protrude externally at the abdominal ring, the stricture being situated at the inner opening of the inguinal canal i. e. "the aperture at which the sper- matic cord first quits the abdomen." This is not easily de- tected, and has been found on dissection, in cases where no such thing has been suspected. A fulness is generally to be felt just above the abdominal ring, and when stran- gulation takes place great pain and soreness are per- ceived at the part. Mr. Cooper directs in these cases the operation to be performed in the following manner. "The incision is to be begun over the tumour half way between the symphy- sis pubis and the spinous process of the ilium, and extend- ed downwards parallel to Poupart's ligament, as low as the abdominal ring. This incision, which only divides the integuments, exposes the tendon of the external oblique muscle, which being next cut through in the same direc- tion, without cutting the abdominal ring, the hernial sae comes in view, extending from the abdominal ring to the opening at which the spermatic cord quits the abdomen. The sac is theu to be opened in the manner described in a former chapter, and the intestine examined. A probe- 60 ELEMENTS OF SURGERY. pointed bistoury being then introduced behind the stric- ture which is formed by the tendon of the transversalis, this is to be divided in an upward direction. In this case, however, it is of little consequence whether the stricture be divided straight upwards, or outwards, or outwards and upwards towards the ilium; as the epi- gastric artery is in this variety of hernia on the inner side of the hernial sac. But for the same reason a di- rection of the incision inwards or towards the pubis, must always be carefully avoided; and to prevent any doubt at the time of the operation, the incision upward at the middle of the mouth of the sac will be the most proper. "After this operation, as this part of the abdominal parietes is weakened by the division of the tendon, a truss must be put on as soon as possible. "It has been proposed to return into the abdomeu the hernial sac, without opening it. For this purpose the stricture is first to be divided, the intestine and omentum returned from it if possible, and the sac is then to be pushed into the cavity of the abdomen. " In a very small hernia this operation is practicable, because the sac has then contracted no strong adhesion to the surrounding parts, and it can be also readily done in the female; but if the hernia is comparatively large, it cannot be effected without much dissection, which in in- guinal hernia in the male could not always be safely per- formed, on account of the frequent varieties in the course of the spermatic cord, the vessels of which in large her- niae are always more or less turned from their usual course. "As there would be often much difficulty in executing this part of the operation, it will be best to push back the contents only, without attempting to return the sac, as the patient is equally liable to a future protrusion, al- though the sac is returned." Mr. Cooper has related several cases of inguinal her- ELEMENTS OF SURGERY. 61 nia in which the hernia was situated at the inner side of the epigastric artery. " The abdominal ring is closed towards the abdomen by the tendons of the internal ob- lique and transversalis muscles, the lower part of these tendons are inserted into the pubis, and connected with the fascia, which passes upwards from the external ob- lique muscle at Poupart's ligament; if this tendon is un- naturally weak, or if from mal-formation it does not exist at all, or from violence has been broken, a protrusion of the viscera may then take place immediately behind the ring. "Below the abdominal ring the appearance of this tu- mour differs from that of common bubonocele in being near the penis; and the spermatic cord passes on its out- er side instead of its posterior part, particularly at and above the abdominal ring. " Above the abdominal ring the sac passes directly upwards, so that no part of it takes the usual oblique di- rection towards the anterior superior process of the ilium. but rather the contrary direction inwards towards the navel. Examined by accurate dissection its course is as follows:—The sac first protrudes betweeu the fibres of the tendons of the transversalis, nearly an inch directly above the ring. It then passes under the fibres of the tendon of the internal oblique muscle. The epigastric artery ^uns upon the outer side of the hernial sac. The spermatic cord has no connexion with it above the ring. The hernia then emerges from the abdominal ring, the spermatic cord being on its outer side, and it is covered with the fascia given off by the tendon of the external oblique, but not by the cremaster muscle." This species of hernia when reducible should be treat- ed in the usual way, " the truss should be longer than that required for common hernia, because the hole through which the sac emerges from the abdomen is an inch and 62 ELEMENTS OF SURGERY. a half further inwards towards the pubis; so that the pad of the truss must reach round as far as the abdomi- nal ring itself, but still is not to rest upon the pubis. In other respects the form of the truss does not require to be changed. "If irreducibje, the same means must be employed as in the common species of inguinal hernia. "When strangulated, the attempt at reduction should be directed differently from the usual mode. Thctumour is as before, to be grasped with one hand, but the fin- gers of the other are to be placed at the abdominal i ing to knead the hernia at that part, directing the pressure upwards and outwards, to return the tumour into the ab- domen. " If the operation for this variety of hernia be perform- ed in the maimer usually advised in bubonocele, that is by dilating the hernial sac and stricture upwards and outwards, the epigastric artery will certainly be divided. It has therefore been recommended to alter the direc- tion of the dilating incision to upwards and inwards, to avoid the epigastric artery; and, if the surgeon is certain as to the species of hernia, that is the safest plan. But if in some instances, the operator is directed to make the incision in one way, and in others precisely the re- verse there will always be reason to fear some mistake in practice, which would be attended with the m<$st seri- ous consequences; such mistakes, it is true, would hard- ly occur to a surgeon constantly in the habit of dissection, but to the greater number, the distinguishing marks of the two species will not be sufficiently discriminative. It is therefore desirable to point out such a mode of operat- ing as would ensure the safety of the patient, whatever kind of hernia was found. Such are the advantages possessed by the method of making the division directly upwards, opposite to the middle of the hernial sac, for in this direction the epigastric artery is certainly avoided. ELEMENTS OF SLRGERY. 63 " The operation, therefore, is to be performed in the following manner:—The surgeon first makes an incision through the iuteguments, along the middle of the tumour, from its upper to its lower part, following the longitudi- nal direction of the tumour; so that if it has any inclina- tion inwards towards the navel, the incision is to incline the same way. The fascia being thus exposed, is divi- ded over the surface of the tumour from the abdominal ring, down to its lower extremity. The hernial sac, which now comes in view, is then opened, from an inch below the ring down to the lower part of the sac, in the same cautious manner as has been formerly described. The surgeon then passes his finger into the sac and feels for the stricture ; if at the abdominal ring, he introduces the blunt-pointed bistoury between the sac and the ring, slitting the latter directly upwards, till the aperture is large enough to allow of the return of the parts; if the stricture is above the ring, he follows it with the knife still in the same direction, and anterior to it, opposite the middle of the mouth of the sac, till the dilatation is suffi- cient to allow his finger to slip into the cavity of the abdo- men ; after which the hernia is to be pushed up, or, if not in a fit state for that purpose, to be treated as men- tioned in a former chapter. The parts anterior to the sac above the ring, and divided by the knife, are the tendons of the transversalis and internal oblique muscles. If the stricture is within tffe sae, still the same direction is to be preserved, but the knife must -then be passed into the sac itself. " In this way the epigastric artery will, with certainty, be avoided; which it cannot be if the division of the stricture is made outwards, and in the common hernia it will be divided by dilating inwards." (Cooper.) Inguinal hernia is much less frequent in women than in men. It is not so liable to be mistaken for other dis- eases in the female as in the male. The treatment is 61 ELEMENTS OF SURGERY. nearly the same; when reducible a truss is to be worn: if irreducible it should be supported by a T bandage passing over it. It never acquires a large size. When strangulated the usual remedies are to be employed, and if these be unsuccessful the operation is to be performed. The first incision should extend from the abdominal ring to the lower extremity of the tumour which is not far be- low it: the stricture is to be dilated if the contents of the sac are judged to be in a state proper for reduction ; and if this be doubtful, the sac is to be opened, and the viscera contained in it examined and treated as under similar circumstances in the male. Inguinal hernia in women, as in men, is sometimes so small as not to appear externally, the parts not having forced their way through the abdominal ring. When the disease is discovered, it is to be treated in the usual man- ner; and if an operation become necessary an incision must be made, and the tendon of the external oblique muscle exposed; this is next to be cut through, and the hernial sac will be brought into view. If the protruded viscera cannot now be returned, the sac must be opened, and if necessary the stricture which will be found at the internal orifice of the inguinal canal must be divided. ■41 ELEMENTS OF SURGERY. 65 CHAPTER IX. Artificial Anus. When in consequence of mortification the intestinal tube is partially or completely destroyed, and unites to the wound in the parietes of the abdomen, an unnatural or artificial anus is produced through which the feces • are evacuated. If this aperture be high up in the in- testine death is said to result from inanition, in conse- quence of the deficiency of absorbents to take up nou- rishment for the body. The intestine contracts conside- rably below the aperture, and no feces are voided by the anus, although some mucous evacuations are occasional- ly discharged. Such a condition is truly deplorable, and every effort should be made to avoid the evil by effecting the restora- tion of the parts, previously to mortification, but where the intestine is found mortified, surgical aid is very often unavailing, and the artificial anus is the only event by which life can be preserved. The involuntary discharge of wind and feces from the artificial anus, is a great inconvenience, and compresses have been applied with a view to prevent it, but the most common apparatus is a receptacle of leather or horn fas- tened over the part by means of a band passed round the body. Various machines have been constructed for the purpose, but the more simple are to be preferred for a very obvious reason—they are the most cleanly. What- ever apparatus may be used however, should be so con- structed as to make pressure upon the part, in order to VOL. II. K 66 ELEMENTS OF SURGERY prevent a prolapsus or eversion of the intestine, which i* otherwise apt to occur. When this prolapsus takes place, a tumour of consi- derable size forms, and sometimes the prolapsed intes- tine inflames and swells, obstructing the evacuation of the feces. In general it can be readily replaced and occasions no permanent inconvenience, but it is best to guard against a return of it, by means of a compress of lint bound firmly upon the part, a plan which Uesault recommends in preference to all others ; when, however, the reduction cannot be effected by the hand, it must be attempted by gradual and long continued pressure upon the prolapsed parts. In order to prevent the inconveniences attending such cases, Mr. Cooper recommends a square cushion covered with oil silk which is to be placed over the artificial anus, and a steel truss which exerts but a slight degree of pressure being placed upon it confines the feces so as to lessen the offensive smell, and allows the patient to seek a convenient situation for an evacuation. This plan answers extremely well if the feculent matter has some consistence, but if the aperture is in the ileum, the contents of this intestine are with difficulty confined. These remedies only palliate the disease, in order to ef- fect a radical cure, other measures become necessary. Desault accomplished the radical cure of artificial anus in several instances. The means which succeeded in his hands were the application of compresses or plugs of lint, introduced into both portions of the intestine, which by pressing down the angle formed by their junc- tion, make a direct passage for the feces and dilate the canal at the injured part. When this is done air and feces are found to pass sometimes through the natural pas- sage, after which the external aperture gradually closes. Laxative medicines are to be occasionally administered during the treatment. Unhappily, however, the plan ELEMENTS OF SURGERY. 67 found successful in a few cases by Desault, has not suc- ceeded equally with other surgeons, and it evidently cannot be employed where the angle of junction between the two ends of intestine is very acute. In a patient with artificial anus at the Pennsylvania Hospital Dr. Physick performed an operation, which will probably be found to afford complete relief in many si- milar cases. The sides of the intestine in this instance, were consolidated laterally, or in Mr. Cooper's lan- guage, like a double-barrelled gun. In order to ensure this union a ligature was passed through the intestine and suffered to remain a week, keeping its sides in close contact, after which Dr. Physick cut a hole in the side of the intestine where the two portions had thus united, and by stopping the external orifice, the feces regained their natural route, the external aperture was afterwards healed, and the patient relieved from his most loathsome complaint; he has for several years enjoyed perfect health. 68 ELEMENTS OF SURGERY. CHAPTER X. Of Femoral Hernia. Hernia is denominated femoral or crural, when the protrusion takes place under the crural arch.* It is entirely impossible to understand this subject without a knowedge of the anatomy of the parts concern- ed, to the investigation of which much attention has of late I teen paid by several eminent anatomists and sur- geons. The present Dr. Monro, availing himself of the labours of Albinus, Gimbernat, and Hey, has published iu his essay on crural hernia, and still more recently in his morbid anatomy, some very important observations on this subject. In addition to his works, the reader is particularly referred to Mr. Astly Cooper's matchless treatise on this subject, and to the valuable essay of Mr. Lawrence iu which a few corrections of Mr. Cooper's plates are contained. The necessary dissections being per- formed in addition to the study of these authors, the stu- dent will be prepared to understand the nature and treat- ment of crural or femoral hernia; but I cannot forbear to repeat the necessity of dissections, for it is certain that no correct ideas can be otherwise obtained. Indeed the best anatomical descriptions, appear sometimes confused and unintelligible, to those who have never made use of the knife in their investigations. Femoral hernia occurs more frequently in women than in men, and in general commences with a pain on straigh- * Crural arch is a synonyme for Poupart's ligament, which is formed by the lower edge of the tendon of the external oblique muscle, extending from the an- terior superior spinous process of the os ilium to the os pubis. ELEMENTS OF SURGERY. 69 tening the thigh, which extends to the stomach and pro- duces nausea, which subsides when the thigh is flexed upon the pelvis. " The first distinct external mark of crural hernia is a general swelling of the part easily returnable by pres- sure, descending in the erect, and ascending in the re- cumbent posture, and which at first seems to be only the dilatation of the sheath that contains the crural artery and veiu. The next appearance is that of a small cir- cumscribed tumour, about the size of the finger's end, si- tuated under the crural arch, about an inch on the out- side of the tuberosity of the pubis, and lying in the hol- low between this process and the crural artery and vein. As the tumour enlarges, instead of falling downwards like the inguinal hernia, it passes forwards and often turns over the anterior edge of the crural arch, this being the direction in which there is the least resistance. As it proceeds, the swelling increases more laterally than upwards or downwards, so as to assume an oblong shape, the longest diameter being in a transverse or horizontal direction. In the female it is generally very moveable, and being soft, and the skin not being discoloured, it has the appearance merely of an inguinal tumour of the absorbent glands, but in the male the skin is generally not so loose, the swelling not so distinctly circumscribed, and the tumour appears buried more in the substance of the thigh." (Cooper.) This species of hernia seldom acquires a large size; Mr. Cooper, however, has seen it in two cases very large, occupying the whole of the hollow from the an- terior superior spinous process of the ilium to the pu- bis ; and he quotes a case from Mr. Thompson of Edin- burgh, iu which the tumour extended half way down the thigh. In this case, the parietes of the abdomen were so thin that the peristaltic motion of the intestines could be distinctly perceived. The crural hernia is. how- 70 ELEMENTS OF SURGERY. ever, smaller than the inguinal, and therefore more dan- gerous. " The direction in which the crural hernia passes, is obliquely inwards and forwards, and, excepting at first, very little downwards, so that in cutting into this tumour the incision is made in its fundus. This is the general situation of the tumour; but it sometimes happens, that instead of crossing the thigh in the direction of the crural arch, it extends downwards along the edge of the crural vein and the vena saphsena major. "The crural hernia, when dissected, presents the fol- lowing appearances: when the skin is removed, the su- perficial fascia of the external oblique muscle is laid bare, which, though it is of a delicate texture in its com- mon state, when pressed upon by a hernia becomes ex- tremely thickened and very distinct, more especially in a subject loaded with fat. Under this covering there is generally another fascia, precisely of the form of the hernia itself, and which it very closely embraces. A thin fascia naturally covers the opening through which the hernia passes and descends on the posterior part of the pubis. When the hernia therefore enters the sheath it pushes this fascia before it, so that the sac may be per- fectly drawn from its inner side, and the fascia which covers it left distinct. The fascia which forms the cru- ral sheath, and in which are placed the hole or holes for the absorbent vessels, is also protruded forwards, and is united with the other, so that the two become thus con- solidated into one. If a large hernia is examined, this fascia is only found to proceed upwards as far as the edge of the orifice on the inner side of the crural sheath by which the hernia descends, but in a small hernia it passes into the abdomen as far as the peritoneum and forms a pouch, from which the hernial sac may be with- drawn, leaving this forming a complete bag over the her- nia. In a small hernia the fascia is thicker than the sac ELEMENTS OF SURGERY. 71 itself, but by being gradually extended it becomes thin- ner and less distinct. " It may be termed the fascia propria of the crural hernia, when this fascia is divided, a quantity of adipose membrane is found between it and the sac, and when this is cut through, the peritoneal sac itself is exposed. Behind the hernial sac is the fascia lata, and the sac rests in the hollow between that part of it which covers the crural vessels, and that which passes over the pec- tineus and triceps muscles so that the fascia lata is si- tuated posteriorly to the hernia." The sac in crural hernia is pyriform, resembling in shape the small bottles of elastic gum. " The orifice of the sac is surrounded by a fascia or cellular membrane, much condensed by an adhesive pro- cess which forms with the fascia below a complete bag, out of which the hernia may be drawn and the bag left behind perfect. Between the orifice of the hernial sac and the tuberosity of the pubis is situated the insertion of the external oblique muscle into the liuea ilco-pecti- nea, and ligament of the pubis. Behind it, is the pubis covered by its ligament and fascia iliaca; anterior to it, is the beginning of the posterior edge of the crural arch, and below this the lunated edge of the fascia lata and part of the crural sheath; and on its outer side is a thin process of fascia, which passes between it and the iliac vein. Indeed, it is according to the size of the hernia that there is more or less remaining of the original fascia, which extends from the insertion of the external oblique, to the iliac vein. If the hernia is small, a process of this fascia remains round the orifice of the sac; but if it is large, the orifice of the sac occupies the whole space be- tween the insertion of the external oblique and crural vein; excepting that a thin portion of fascia still remains between the vein and the sac. This vein runs on the outer side of the hernial sac, .about half an inch from the 7- ELEMENTS OF SURGERY. centre of its orifice, and half an inch beyond the vein; and exterior to it is the centre of the external iliac arte- ry; the epigastric artery arises from the external iliac, about three quarters of an inch from the centre of the sac, and as it passes forwards and upwards it approaches this point about a quarter of an inch nearer. The gene- ral distances of the different parts are as follows. MALE. INCHES. "From the symphysis pubis to the center of the orifice of the sac. . . . • 2 the center of the orifice of the sac to the external iliac artery. ... 1 the center of the orifice of the sac to the center of the external iliac vein. . 0£ the center of the orifice of the sac to the origin of the epigastric artery. . 01 the center of the orifice of the sac to the inner edge of the internal abdominal ring. 1 the tuberosity of the pubis to the center of the orifice of the crural hernia. . 1 FEMALE. "Each measure is from one-eighth to one-fourth of an inch more where the pelvis is large and well formed. "The spermatic cord of the male, and the round liga- ment of the uterus of the female, pass about half an inch anterior to the mouth of the hernial sac, being first si- tuated to the outer side, and afterwards crossing its fore part. "When the opening through which the hernial sac has passed is examined anteriorly, it will be found that the sac, after descending a little way into the crural sheath, turns inward and protrudes the inner part of this ELEMENTS OF SURGERY. 73 sheath where the absorbent vessels pass. The hernial sac is here plaeed between two columns of fascia of the crural sheath; the one proceeds from the anterior part of the insertion of the external oblique muscle into the pu- bis, is reflected upon the crural vein, and passes over the neck of the sac: the other attached to the point of insertion of the external oblique into the linea ileo-pec- tinea and ligament of the pubis, is continued behind the neck of the sac, and is at last undistinguishably blended both with the fascia that covers the crural vein, and with that part of the fascia lata which passes over the pecti- neus muscle. "The same general symptoms characterize crural as inguinal hernia; it appears in the erect, and disappears in the recumbent posture; it dilates when the patient coughs, is elastic and uniform to the touch when it con- tains intestine, and then gives a guggling noise when it returns into the abdomen. When it contains omentum the surface is less equal, it feels doughy, and gives no particular sound when it returns into the abdomen. "The crural hernia is less liable to be confounded with other diseases than the inguinal, because tumours of the groin from other causes, are much less frequent than those of the scrotum, but still great care is required to prevent the practitioner from mistaking the disease, and persons have to my knowledge, lost their lives from such errors, or from the swelling being altogether over- looked." (Cooper.) Crural hernia bears some resemblance, however, to some complaints from which it is important to distin- guish it. The glands of the groin are sometimes enlarged in the situation where femoral hernia is generally situa- ted, and such glands have been mistaken for this spe- cies of rupture; there can seldom, however, be any diffi- culty in discriminating them unless both complaints exist VOL. II. i. 74 ELEMENTS OF SURGERY. in the same groin, and then if strangulation take place the difficulty ceases, and if not, it is of no importance. Psoas abscess has some of the appearances of femoral hernia, the matter passing down the thigh in an erect posture and returning into the abdomen when the pa- tient lies down; coughing and other efforts of the abdo- minal muscles produce an enlargement of the tumour in both cases. In general, however, the symptoms which precede psoas abscess sufficiently indicate its existence, and the fluctuation of the pus is easily felt; pressure on the abdomen occasions a tension in the tumour which cannot be produced in hernia. The tumour is also in psoas abscess, generally nearer the spine of the ilium than in hernia, and is larger; it is unattended with any interruption to the alvine evacuations. Inguinal and femoral hernia are often mistaken the one for the other, they may be distinguished by the fol- lowing marks. In inguinal hernia the neck of the her- nia may generally be distinguished at the abdominal ring, considerably above the os pubis, whereas in femo- ral hernia, it is lower, and more towards the outer side. The crural arch iu femoral hernia may be traced in its course from the pubis to the ilium, passing above the hernial tumour; in inguinal hernia it cannot be felt, as the tumour is situated above it. Crural hernia is said to occur most frequently on the right side; it certainly occurs oftenest in the female sex, and iu those women who have borne children, oftener than in others. A portion of intestine most frequently forms the con- tents of the sac iu femoral hernia, but occasionally the omentum is also found, and sometimes the case is an entero-epiplocele. The ovaria have been found contain- ed in the sac of femoral hernia, and Mr. Cooper has given a plate of a case in which the uterus was drawn to the orifice of the hernial sac. This hernia seldom occurs in early life. ELEMENTS OF SURGERY. ?J Crural hernia is a more dangerous complaint than In- guinal; it is smaller and therefore oftener attended with obstruction of the bowels; it returns with less facility into the abdomen, because the opening by which it pass- es is narrower; and for the same reason it is more apt to be strangulated. The reduction of a strangulated crural hernia is less easy than that of an inguinal, and some difference is to be observed in the manner of applying the taxis to effect itp Mr. Cooper directs it to be done in the following manner. "The position of the patient is to be such as to relax the abdomen as much as possible, for which purpose the shoulders should be elevated, and the thighs bent at right angles with the body ; but even this posture pro- duces but little effect, unless the knees at the same time are brought together. If the parts are dissected directly with the view of observing what difference is made in the relative tension of parts in the dead body, it will be found that when the thighs are extended, the crural arch and all its fascise are upon the stretch; when the thighs are bent, but the knees turned outwards, the fascise are somewhat relaxed; but when the thighs are bent and the knees brought together, the crural arch and its fascia are all extremely loosened, and still more are the parts loosened by throwing one thigh, when bent, across the middle of the other. Wheu the body is in the recum- bent posture, the thighs bent, and the knees thrown inwards, the surgeon is to place himself over the body of the patient, and putting both his thumbs on the surface of the tumour, he is to press gently di- rectly downwards, as if he were endeavouring to press the tumour into the thigh rather than towards the abdo- men. If this pressure is steadily kept up for some mi- nutes till the surface of the tumour is brought even with the line of the crural arch, the hernia may then be press- ed towards the abdomen and will return into that cavity. 76 ELEMENTS OF SURGERY. I am convinced that much of the difficulty found in re turning this species of hernia often depends on the im- proper direction given to the pressure; for if the tumour is pressed at first towards the abdomen, it turns over the crural arch instead of turning under it, and then the ut- most degree of force which may be applied will endan- ger the bursting of the intestine, but cannot contribute to its reduction." In order to keep the parts from descending a spring truss must be used, similar to that recommended for in- guinal hernia, except that the pad must be constructed so as to act lower down. (See Plate 1.) It seldom pro- duces a permanent cure and therefore should be worn constantly. Crural hernia is sometimes irreducible from adhesions of its contents, or from the contained parts becoming too large to pass back into the abdomen. When strangulated the symptoms are the same as in cases of inguinal hernia; the seat of the strangulation ac- cording to Mr. Cooper, may be in three different places; first, in the crural sheath, and semilunar, orlunatededge of the fascia lata; secondly, at the posterior edge of the crural arch; or thirdly, in the mouth of the hernial sac and fascia which covers it. "With respect to the first of these, it will be found that a portion of the crural sheath remains below the cru- ral arch, which forms a strong circular band by which the hernial sac is surrounded. When the sac is drawn from the sheath in the male, the orifice by which it has passed will be found to be formed by two strong co- lumns of fascia, one passing above, and the other below the sac, and meeting on the inner side at the posterior insertion of the external oblique muscle into the ligament of the pubis, and on the outer side at that part of the sheath which covers the crural vein. In the female these columns are not equally strong, still a portion of the ELEMENTS OF SURGERY. 77 sheath surrounds the hernial sac. If the hernia is large, it reaches to the semilunar edge of the fascia lata, and is compressed by it. "The second place at which the stricture is found, and which requires division in large crural herniae, is the posterior edge of the external oblique muscle and the fascia transversalis, which pass before the mouth of the hernial sac, and which extending inwards to be in- serted into the pubis, forms also the inner boundary of the sac at this part, whilst a small process of fascia on the inner side of the vein forms its outer boundary. Thus then there are two seats of stricture, one the edge of the aperture in the crural sheath, and the other about half an inch above it, formed by the posterior edge of the ex- ternal oblique muscle. t "The mouth of the hernial sac is the other seat of the stricture. " This aperture is very generally small when compared with the size of the hernial sac, and being much press- ed upon by the posterior edge of the crural arch it un- dergoes a slow process of inflammation, which thickens very much the fascia in which it is enclosed. If the sac is removed with the fascia which incloses it, its mouth will be found to form a dense and compact substance, which firmly resists any attempts to dilate it by pres- sure. "The anterior edge of the crural arch, or Poupart's ligament, does not form the stricture, or require any di- vision, excepting in very large herniae. " The possibility of crural hernia being the cause of strangulation, renders it even more than in inguinal her- nia necessary for a physician, called in on account of symptoms of ileus, to inquire whether there is any tu- mour in the groin, or the upper part of the thigh, for in crural hernia the tumour is smaller and less prominent 7S ELEMENTS OF SURGERY. than in the inguinal, and more liable to be overlooked. These tumours are sometimes so small that it is not without hesitation that the surgeon determines with re- spect to the operation; for they are, when small gene- rally covered with an absorbent gland, and with so much difficulty distinguished, that I confess, I have more than once began the operation with much doubt about the na- ture of the tumour, making it rather the means of deter- mining with certainty, than being assured that it was the disease which I suspected. "The treatment which this hernia requires when stran- gulated, differs but little from that of inguinal: the mode of using the taxis has been already explained. OF THE OPERATION FOR THE CRURAL HERNIA. "The patient is to be placed upon a table three feet six inches in height, the body lying in a horizontal pos- ture, but with the shoulders a little elevated; the legs as high as the knees, hanging over the edge of the table; and the thighs a little bent, in order to relax the abdomi- nal muscles. The bladder must be emptied and the dis- eased side shaved. "The incision is to be begun an inch and a half above the crural arch, in a line with the middle of the tumour, and extended downward to the centre of the tumour be- low the arch. A second incision nearly at right angles with the other is next made, beginning from the middle of the inner side of the tumour and extending it across to the outer side; so that the form of this double incision will be that of the letter T reversed. The advantage of this form of the incision is, that it gives an opportu- nity both of examining the parts distinctly, and of turn- ing them aside to give a view of the orifice by which the hernia has descended, and of the parts which form the external portion of the stricture. ELEMENTS OF SURGERY. 70 " For want of this precaution I have known great diffi- culties occur in the operation, the incision, when single, being too small to give a sufficient view of the parts, and the depth at which the hernia is situated not allowing the surgeon to have a distinct view of the progress of the operation. "The longitudinal incision sometimes occasions a slight bleeding from the division of the external puden- dal artery, and it is better to secure the vessel before any thing further is done. "The first incision exposes the superficial fascia, which is given off by the external oblique muscle, and which covers the anterior part of the hernial sac; but if the pa- tient is thin, and the hernia has not been long formed, this fascia escapes observation, as it is then slight and delicate, and adheres closely to the inner side of the skin. " When this fascia is divided, the tumour is so far ex- posed that the circumscribed forms of the hernia may be distinctly seen, and a person not well acquainted with the anatomy of the parts would readily suppose that the sac itself was now laid bare. This, however, is not the case, for it is still enveloped by a membrane, which is the fascia that the hernial sac pushes before it as it pass- es through the inner side of the crural sheath. This membrane, the fascia propria, is to be next divided lon- gitudinally from the neck to the fundus of the sac; and if the subject is fat, and adipose membrane lies between it and the sac, from which it may be distinguished by seeing the cellular membrane passing from its inner side to the surface of the sac. This is in my opinion, the most difficult part of the operation, for the fascia propria is very liable to be mistaken for the sac itself; so that when it is divided, it is supposed that the sac is exposed and the intestine laid bate; following up this idea, the 80 ELEMENTS OF SURGERY. stricture is divided in the outer part of the sac, and the intestine, still strangulated, is pushed with the unopened sac into the cavity of the abdomen. " It must be remembered, however, that in large her- niae the fascia propria of the sac is sometimes insepara- bly united to the superficial fascia, so that the same inci- sion divides both. "The hernial sac being exposed is to be next opened; and to divide it with safety, it is best to pinch up a small part of it between the finger and thumb, to move the thumb upon the finger by which the intestine is distinct- ly felt, and may be separated from the inner side of the sac; and then to cut into the sac, by placing the blade of the knife horizontally. Into this opening a director should be passed, and the sac opened from its fundus to the crural sheath. A small quantity of serum usually escapes when the sac is opened, which is either trans- parent or sanious according to the length of time that the strangulation has continued. The intestine, or omentum, or both, then become exposed. "It often happens, however, that there is no fluid con- tained in the sac of femoral hernia, even although no ad- hesion exists between the sac and its contents; a circum- stance which probably may be attributed to the small size of the sac and its contents, and the very limited se- creting surface which it affords, for when there is much unadhering intestine, there is always a notable quantity of serum. If the strangulation has continued for many hours, the intestine is also covered with a coating of coa- gulable lymph, but not otherwise. "The next part of the operation consists in the divi- sion of the stricture; for this purpose the finger is to be pushed gently into the sac, and the omentum and intes tine separated from its anterior part, the probe-pointed bistoury which I have recommended, which does not cut ELEMENTS OF SURGERY. 81 near its point, is to be pushed into the crural sheath at the anterior part of the sac, and the sheath is to be cut as far as the anterior edge of the crural arch, or Pou- part's ligament. In a small hernia this division, which does not exceed half an inch, will be sufficient for the reduction of the parts. " But when the sheath has been thus divided, if the intestine, wheu slightly compressed, cannot readily be emptied, the finger must be passed at least half an inch higher, and then the posterior edge of the crural arch and the fascia that covers it will be felt, forming a sharp edge, strongly compressing the mouth of the hernial sac. To divide this edge the knife must be carried within the stricture, and being inclined obliquely inwards and up- wards at right angles with the crural arch, a cut may be very safely made in that direction sufficient for the pur- pose of liberating the intestine from pressure. "The two incisions which I have directed being made from the interior of the sac, any stricture arising from the contraction of the sac itself will be at the same time removed, and the protruded parts be thus completely li- berated. " If the hernia is large and any pressure has been made on its contents by the semilunar edge of the fascia lata, the first incision will divide that edge. "Much danger will arise from any forcible attempt to press the intestine into the abdomen after the dilata- tion of the opening of the crural sheath; for if the stric- ture is at the second part, viz. at the posterior edge of the crural arch, this makes so firm a pressure on the parts, that the intestine will rather give way than the stricture will yield, and I am induced to believe, that this seat of the stricture has not been generally under- stood ; yet in several of the cases in which I have ope- rated, it has been situated there. Mr. John Pearson also informed me that he lately operated upon a crural her VOL. II. M 83 ELEMENTS OF SURGERY. nia, and divided all the parts which he could at first feel forming the stricture, but still an impediment existed to the return of the protruded parts, and he was obliged to divide the stricture much higher up before he could re- turn them. "Surgeons talk very carelessly upon the subject of dividing the stricture; they say that the finger must be put into the sac, and wherever the stricture is felt it should be divided. Again, it is said, the stricture is si- tuated on the inner side of the sac, and derived from the pressure of the insertion of the tendon of the external oblique, or what they call Gimbernat's ligament. They do not consider that a stricture is a circle produced in the same way as if a cord were tied round the protruded parts, and that the division might be made at any part excepting the posterior, where the bone is placed, if other circumstances did not prevent it. The stricture may be divided on the inner side of the sac, that is, towards the pubis; but to this there are strong objections to be men- tioned hereafter. It cannot be divided directly outwards, for there the crural vein must necessarily be injured, and if the division is made upwards and outwards, towards the spinous process of the ilium, the epigastric artery is much endangered. However, this artery is not so liable to be cut in the crural hernia as has been imagined; for it does not approach nearer than half an inch from the up- per and outer part of the sac, and an incision of half an inch is more than is usually required to liberate the pro- truded parts in crural hernia. The stricture may be safely divided upwards and with slight obliquity •in- wards. "Mr. Hey, whose name should be never mentioned but with respect, who is not contented with the mere practice of his profession, but who studies to improve it, advises that the knife should be introduced on the in- ELEMENTS OF SURGERY. 83 ner side of the sac, and the division be made directly upwards. " In tbe female, if the hernia is large, it will be some- times, though very rarely, necessary to cut through the anterior edge of the crural arch, or Poupart's ligament, and this may be done from the inner side of the hernial sac by cutting obliquely inwards and upwards. But in a large hernia in the male subject, when the division of the crural arch is required, a different operation becomes necessary to prevent the spermatic cord from being in- jured. When the parts have been laid bare, and arc found to be too large to be liberated by the division of the sheath and posterior edge of the crural arch, an in- cision should be made through the tendon of the external oblique muscle over the mouth of the hernial sac, about a quarter of an inch above the crural arch, which will expose the spermatic cord. This being drawn by the finger, or by a curved line, and removed from the direc- tion of the incision, the surgeon carries his finger into the sac with the bistoury upon it, and the anterior edge of the crural arch is cut without the smallest risk to the spermatic cord. "'When the stricture has been divided, and the pro- truded parts liberated from pressure, the state of the in- testine must be examined, and if the circulation returns iu it, if the dark colour produced by the constriction dis- appears or is much diminished, and if on drawing down the intestine, the part at which it had been girt by the stricture appears uninjured, it may then be returned into the cavity of the abdomen. If the intestine is mortified, that portion of it is to be cut away, and the ends of the intestine joined; and I would advise, that instead of leaving an opening in the intestine for the escape of the feces, after the contents of the intestine have been eva- cuated at the wound, four ligatures should be applied, so as to shut the bowel iu the whole of its circumference. 84 ELEMENTS OF SURGERY. and my reasons for differing in this respect from the opi- nion I gave in my former work are, that I have found in one case, that, by leaving a small opening, an artificial anus followed, and in another that where the upper part of the ilium had been mortified, by the small aper- ture that was left, every thing the woman swallowed was so speedily discharged at the wound that it afforded no sustenance, and she died in four days after the opera- tion. The stricture must be very freely dilated when the restoration of the canal is attempted, or the feces will not pass through the intestine ; and if after twelve hours no feces have passed by the anus, and the vomiting con- tinues one of the stitches must be cut, and the chance of sustaining life by an artificial anus must be given. " I should still have great fears of returning the intes- tine into the abdomen after sewing it, notwithstanding the experiments which were made by Mr. Thompson and myself, and since confirmed by Mr. Smith, in his Inaugural Dissertation, which proved that an intestine may be returned into the abdomen after being secured by ligatures. But it is to be recollected that in the dis- ease before us the intestine is highly inflamed, and that ligatures ulcerate so quickly in inflamed parts that there would be great danger of the escape of the feces into the cavity of the abdomen; for in a case in which I left the intestine within the sac, after securing it by liga- tures, the intestine burst open on the third day and an artificial anus was produced. I therefore think it safer to carry the intestine to the mouth of the hernial sac and there fix it by its mysentery. "If the intestine is mortified, it requires great care in the operation to prevent the portion within the abdomen from being torn from the mortified part, which if the fin- ger is forcibly introduced into the sac will undoubtedly happen, and the feces escaping into the abdomen will destroy the patient in a few hours. To prevent this; ELEMENTS OF SURGERY. 85 after exposing the intestine, and finding it mortified, the finger should not be put into the mouth of the sac, but the bistoury only be passed into the stricture; and when this is divided, the intestine is to be gently drawn down into the sac to expose the part at which it has been girt. " If the intestine adheres to the sac, extraordinary caution is required, both in the division of the stricture and in separating the adhesions. Tt is best to begin with gently separating the adhesions with the finger rather than with the knife, which can generally be effected without doing violence to the parts; but if the adhesions are short and very firm, portions of the sac must be cut away and returned into the abdomen with the intestine to which they adhere; the stricture too must be divided fibre by fibre with extraordinary care. "Putting a ligature around the whole of the protruded omentum is either useless or dangerous : if it is placed on the mortified part, it is obvious it must be useless, as the sloughing process will go on above it: if it is placed upon the healthy part of the omentum, why divide the stricture, as another is made immediately by the thread which is applied around it. "Leaving the omentum in the hernial sac to slough appears to me uuadvisable because it is unnecessarily preserving a discharge for a length of time and protract- ing the cure. I have never seen this intentionally done, but in a patient in Guy's Hospital; the omentum which had been returned into the abdomen redescended into the sac on the sixth day from the operation and gradually sloughed, keeping up during the time a very offeusive discharge, and a great degree of constitutional irrita- tion. " When the protruded parts have been returned into the cavity of the abdomen, sutures are to be made upon 86 ELEMENTS OF SURGERY. the integuments, and the wound closed as carefully as possible by lint, adhesive plaster, and bandage." (COOPER.) Varieties in crural hernia are more rare than in most other species. Some of the most frequent have been noticed by Mr. Cooper; the only one which I think it important to mention is that in which the obturator ar- tery passes round the neck of the hernial sac. Of this variety which Mr. Cooper never saw he quotes two cases; I have myself seen one. In this case no part of the neck of the sac could be felt free from the pulsation of a very considerable artery. Dr. Physick very promptly divided the stricture by cutting in the usual direction, but taking great care to make a very small incision or rather scratch with the point of a bistoury, through the stricturing tendon. A very small dilatation of the stric- ture in these cases is sufficient, and therefore, I think the direction in which the incision is made is of less im- portance than many surgeons have imagined, as we may safely cut directly towards a bloodvessel, without risk of wounding it provided the surgeon be cautious and dex- terous.* As Dr. Physick's patient happily recovered and is now living I am unable to describe particularly • For a more minute account of this subject, I refer to Cooper, Law- rence, and Monro ; the last writer supposes that in one of twenty cases, this variety occurs ; he adds " there is still another variety as to the distribution of the epigastric and obturator arteries; these arteries in some cases come off from the anterior iliac artery by separate trunks; and the obturator artery pass- es around that part of the crural arch called Gimbernat's ligament, and is at. tached to it by cellular substance. When this happens, the obturator artery, by the descent of a portion of the intestine through the crural ring, is pressed upon the very part of the crural arch divided by Gimbernat, in his operation for crural hernia. " I have seen the obturator artery sent off from the external iliac artery, about an inch and an half above, and in others, about an inch below the epigastric artery ; and in other cases, even on the outer side of the pelvis, from the super- ficial femoral artery; in which case, the artery ascends along the pectineus mus- cle, and enters the pelvis at the crural aperture. The artery in this case, is placed behind the crural hernia." (Monro.) ELEMENTS OF SURGERY. 87 the anatomy of the parts, but in one of the cases related by Mr. Cooper, from Dr. Barclay it was found that the "epigastric and obturator arteries had arisen by a com- mon trunk and that they had passed, anterior to the sac before they divided; after which the epigastric artery proceeded upwards to the rectus muscle, and the obtura- tor artery passed backwards on the inner side and close to the neck of the sac to the obturator foramen through which it usually passes. The obturator artery indeed very frequently deviates from its natural course, and in- stead of arising separately from the internal iliac artery, it derives its origin from the external iliac in common with the. epigastric. But in all the cases which I have myself dissected where this variety existed with crural hernia, the obturator has passed into the pelvis on the outer side of the neck of the sac entirely out of the reach of any injury by the knife. In twenty one preparations of crural hernia I found six had this variety in the ori- gin of the obturator artery. When therefore this artery passes before to the sac (as in the case observed by Dr. Barclay) the arterial trunk common to it and to the epi- gastric is of unusual length; for when the trunk is short, the obturator passes behind the sac. A hernia thus si- tuated is surrounded by blood-vessels, except at its pos- terior part, which might seem to render it advisable to deviate from the usual mode of operation to prevent this blood-vessel from being wounded. This, however, is not so liable to happen where the division of the stric- ture is made upwards, or a little upwards and inwards; for I suspect it will be found that the greatest distance between the artery and the hernial sac is at its anterior part. It is impossible to feel this artery before the in- troduction of the knife, for the finger cannot be passed behind the posterior edge of the crural arch, beyond which this artery is placed, until the stricture has been divided. The sac therefore is to be carefully divided 88 ELEMENTS OF SURGERY. anteriorly; but even supposing the artery to be wounded in the operation, it may be asked, what other direction of the wound would afford greater facility of tying the bleeding vessel? For by slitting up the crural arch, and drawing down the mouth of the hernial sac, the vessel would be brought into view, and might be secured." (Cooper.) The operation proposed by Gimbernat of cutting in- wards, is more difficult than that which has been des- cribed, and is attended with more danger of wounding the intestine, besides which in some cases the opening thus made is not sufficiently large to permit the return of the prolapsed parts, and the obturator artery is in great danger of being wounded, in which case it could not be tied up, whereas if this vessel should be wounded in the operation which has been recommended it could be very readily secured; these reasons have induced Mr. Cooper and other surgeons to decline the operation. ELEMENTS OF SURGERY. 80 CHAPTER XL Of Exomphalos or Umbilical Hernia, The sac in umbilical hernia passes through a hole at the navel by which in the foetus the umbilical vessels had been transmitted. This aperture is situated in the linca alba, and is never completely filled up with ten- don, but with condensed cellular substance and the re- mains of the umbilical vein and arteries. The peritoneum is perfect behind the umbilicus and consequently the umbilical hernia has a sac similar to that of the herniae already described. " Umbilical hernia begins in the form of a small tu- mour, about the size of the tip of the finger, at the navel which can be returned by very slight pressure into the cavity of the abdomen, but by directing the patient to cough, it immediately reappears. As it increases in bulk it begins to gravitate, so that the anterior extremity of the bend is generally below the level of the umbilical opening. If the person is thin, it becomes very pendu- lous and distinctly circumscribed, and is then usually of a pyriform shape. If nothing is done to check its growth, it grows to an enormous size, extending downwards to- wards the pubis. The disease in this state produces a great deal of suffering, and often endangers life if the hernia is intestinal. Almost every thing that is eaten too produces flatulency, pain in the protruded part, and sickness; and even slight pressure to return it, gives the same uneasy sensations when the intestine is passing back through the abdominal opening. If no bandage is VOL. II. N 90 ELEMENTS OF SURGERY. habitually worn to confine the hernia, the patient feels so much weakness and sinking at the pit of the stomach as to be often incapable of any exertion. The bowels also are generally irregular, and if the tumour becomes inflamed, it swells to a great size, and vomiting and con- stipation ensue. These symptoms are much more fre- quently happening in this than in the other species of hernia, but at the same time they are generally more ea- sily removed." Umbilical hernia almost uniformly contains both omen- tum and intestine. "The umbilical hernia is very frequent in the young subject, and forms a tumour like the inflated finger of a glove, with a slight obliquity downwards. It very gene- rally contains intestine, which may be easily returned, unless the orifice is very small, in which case the cries of the child shew that some pain is given. Irregular bowels and Costiveness, succeeded by griping and long continued purging, are attendant on this disease. "A fascia may be distinctly traced over the tumour when the hernia is small, but when it becomes of large size, the skin, sac, and fascia become so united at the anterior part of the swelling, that it is difficult to sepa- rate them there, although the fascia may still be dis- tinctly observed on the sides of the tumour. "There are some varieties in the umbilical hernia which require to be mentioned. First, with respect to figure, in a thin subject it is generally pyriform, as I have already stated, but in fat persons it forms a broad and flat swelling, which extends as much upwards as downwards. Sometimes in consequence of there being a large quantity of fat which separates the skin at a great distance from the abdominal muscles, the hernia projects as far as the skin of the navel, and then extends up- wards and downwards so as to form a tumour which is ELEMENTS OF SURGERY. 91 scarcely apparent upon a superficial examination. But when the hernia assumes this extended and flattened form in thin persons (which is sometimes the case,).it can be embraced by the hand, and its dimensions readily ascertained. I have also seen this umbilical hernia di- vided into a number of different cells. "Besides this variety in the figure of the hernia, there is a great difference in the state of the sac. When this is small, it is as complete as in other herniae; but I have an example in my possession of the sac having been either absorbed or burst, by which openings have been formed and portions of omentum protruded through them, producing small herniae through the sac of the large one.* In this instance two small omental herniae are seen pro- truded through the hernial sac, and on the opposite side an opening may be observed through which either omen- tum or intestine might have passed." (Cooper.) A curious case of this disease is described by Mr. Cooper in which two sacs were found. The causes which most frequently occasion umbilical hernia are pregnancy, obesity, and ascites in adults, and in children, it is occasionedjby an unusually large umbi- lical cord, and a congenital deficiency of tendon at the navel. I have known umbilical hernia suddenly formed during parturition, the patient was sensible of something giving way at the umbilicus, she was flooding at the time, and was delivered of twins ; a tumour formed soon after and gradually augmented to a very large size. When the reduction of umbilical hernia is to be effect- ed by the taxis, the patient should be placed on the back, the pelvis and shoulders being slightly raised, and the thighs bent forwards. The tumour should be pressed backwards, and some- what upwards, as the neck of the sac is not in the centre of the tumour but above it. • An engraving of this may be seen in Mr. Cooper's work. 9^i ELEMENTS OF SURGERY When the reduction is effected a truss should be worn; Mr. Hey recommends a new instrument of this kind constructed by Mr. Marrison of Leeds, and in large umbilical hernia it deserves the preference, but in cases where the tumour is small, a circular spring and pad constructed like the truss for inguinal hernia, answers just as well, and is much more simple. Gra- duated compresses, of a conical form, bound round the body answer in many cases, where the irritation of the steel spring is found inconvenient, which in very corpu- lent persons is frequently the case, a great variety of bandages and belts are in use for this purpose ; the most convenient I have seen used, resembles a pair of drawers the compress being fixed to the middle of the waistband prevented from descending by a suspensory shoulder strap. When umbilical hernia becomes strangulated, the usual remedies for effecting the reduction are to be em- ployed, and if they fail, the stricture must be dilated with the kuife. I once witnessed a most remarkable re- duction of umbilical hernia in a lady, upon whom all the usual means of accomplishing this purpose had been perseveringly tried for several days without effect. The operation was accordingly commenced by Dr. Physick, and as soon as the skin over the tumour was divided, the lady being greatly terrified, a guggling noise was heard in the hernia, and a very slight pressure being made, it suddenly returned into the abdomen, and no un- pleasant symptom followed. OF THE OPERATION FOR UMBILICAL HERNIA. This is generally very simple : the integuments are to be divided over the tumour, with great caution not to wound the intestine, as there is frequently no sac, or a ELEMENTS OF SURGERY. 93 very thin one, intervening between the skin and the pro- truded viscera. The external incision should in small herniae extend from the top to the bottom of the tumour, but in large herniae this extent of incision is unneces- sary ; after which its contents are to be exposed by a small incision through the sac, or parietes of the hernia. When this opening is made, a small quantity of fluid escapes; a director is now to be introduced and the parts divided sufficiently to permit a finger of the sur- geon to enter; with this finger he very readily finds the aperture at the umbilicus; a probe pointed bistoury* is now to be passed along the finger, and the tendon di- vided upwards sufficiently to permit the protruded parts to be returned without much force ; the intestine is to be first returned, and afterwards the omentum, unless it be neeessary to remove it by the knife. The integuments are next to be approximated and retained in contact by one or two stiches, or if the aperture into the sac be very small, by adhesive plaster. Mr. Astly Cooper, with a view to diminish the dan- ger of peritoneal inflammation, after the operation for umbilical hernia, has in two instances performed the operation in a different manner. " As the opening into the abdomen is placed towards the upper part of the tu • mour, he began the incision a little below it, that is, at the middle of the swelling, and extended it to its lowest part. He then made a second incision at the upper part of the first, and at right angles with it, so that the dou- ble incision was in the form of the letter T, the top of which crossed the middle of the tumour. The integu- ments being thus divided, the angles of the incision were turned down, which exposed a considerable portion of the hernial sac. This being then carefully opened, the finger was passed below the intestine to the orifice of the * That of Mr. Cooper is to be preferred. 94 ELEMENTS OF SURGERY. sac at the umbilicus, and the probe-pointed bistoury be- ing introduced upon it, he directed it into the opening at the navel, and divided the linea alba downwards to the requisite degree, instead of upwards, as in the former operation." When the omentum and intestine are re- turned, the portion of integument and sac which is left at the upper part undivided, falls over the opening at the umbilicus, covers it and unites to its edge, and thus lessens the risk of peritoneal inflammation by more readi- ly closing the wound. The same writer recommends, when the hernia is very large, to dilate the stricture without opening the sac at all. In such cases he has succeeded by making a small incision opposite the neck of the tumour, exposing the fascia which covered it, passing a probe-pointed bistoury between the fascia and the sac, and dividing the former to the edge of the umbilical ring, then putting his finger to the edge of the linea alba, he passed his knife through the umbilical hole behind the linea alba, and made a small division of it upwards, then withdrawing the knife, he pressed upon the tumour and it immediately re- turned . Mr. Cooper states that " this operation did not take more than four minutes in its performance ; it is attended with no more danger than the taxis, and if insufficient the operation may be afterwards performed in the com- mon way by extending the same incision." When strangulation takes place in an old irreducible hernia, the stricture should be divided in the manner last described, and then the contents of the intestine can be readily pressed out of the hernial tumour into the ab- domen, and the usual course of the feces is restored; an operation which has been successfully performed by Mr. Cooper. The colon is more frequently found in umbilical her- ELEMENTS OF SURGERY. 95 nia than any other intestine, and its appendices epiploic* are often enlarged and indurated,—when found in this condition it is proper to remove them. When the sac contains a very large quantity of omen turn, or when the omentum adheres extensively and has become indurated, it is to be removed with the knife, care being taken to secure the bleeding vessels by liga- tures ; the portion of divided omentum should be left as a plug to fill up the orifice of the hernial sac. In one case of umbilical hernia, I was greatly em- barrassed, by finding the intestine strangulated in several different places by bands passing from the omentum to the intestine. These bands, which were elongated ad- hesions of a very firm texture, converted the hernial sac into a cavity resembling the ventricles of .the heart; the morbid productions extending like the chordae tendineae, from one part of the cavity to another ; under several of these cords, portions of the ileum had become strangu- lated, and by cautious dissection I succeeded in liberat- ing and returning into the abdomen the recently pro- truded parts. Umbilical hernia, in very young infants is by no means unusual; Dr. Hamilton declares that for the last seventeen years, he has usually seen two cases annually of umbilical hernia in new born children. When the hernia is small it may be cured by com- press bandages; Mr. Hey succeeded in effecting the ra- dical cure of a case of congenital exomphalos in which the tumour was as large as a hen's egg, by means of a conical compress. Dr. Hamilton has used a mode of treatment by no means so safe or simple: after reducing the contents of the sac " a ligature was tied firmly round its base after which the sac was cautiously opened. It proved to be the sheath of the umbilical cord. With two 96 ELEMENTS OF SURGERY. silver pins and some adhesive straps the separated pa- rietes abdominis were brought closely together. The sac was allowed to drop off, and in a few days the cure was complete." Umbilical hernia in young subjects according to De- sault, occurs more frequently at the age of two or three months than at birth. In some rare instances the com- plaint which is produced and increased by the cries of the infant gradually subsides, but this event is unusual. To obtain a radical cure in infancy is of the utmost importance, because in the adult it is impossible. By keeping the viscera constantly in the abdomen the um- bilical ring will gradually contract, and a cure will be effected by its obliteration. Desault has of late years revived the ancient mode of treating this complaint by the application of a ligature, and in upwards of fifty cases he found it completely suc- cessful. The mode of operating is very simple. The child should be laid on its back, the thighs being some- what bent, and the head inclined forwards. The sur- geon having returned the protruded viscera presses on the opening with one hand whilst with the other he raises the sides of the sac, and ascertains that no part remains unreduced. When this is done a waxed liga- ture is to be passed several times round the basis of the hernia and secured at each turn by a double knot drawn tight enough to occasion " an inconsiderable degree of pain." The tumour is to be covered with lint, over which compresses are to be applied secured by a ban- dage and shoulder straps. In a day or two after the first ligature is applied, the parts enclosed within it shrink, and it becomes necessary to .tie a second ligature considerably tighter. A third ligature some days after often becomes necessary. In eight or ten days the tu- mour falls off, and leaves a small ulcer which speedily ELEMENTS OF SURGERY. 97 dials. Although the umbilicus is by this time sufficient- ly firm to resist the protrusion of the viscera yet pru- dence dictates the propriety of a bandage and compress, for several months. The probability of the cure dimi- nishes with the age of the patient, and in Desau^'s hands it failed in a girl aged nine years. The opera- tion should therefore be recommended and performed early. This short account of umbilical hernia I shall conclude by describing a mode of operating which has been pro- posed by Dr. Physick. It consists in making a crucial incision through the integuments of the tumour, and dis secting the four angles thus formed down to the neck of the sac; an opening is next to be made into the sac at its upper part of a sufficient size to afford a view of its contents; should these be sound they are to be reduced if practicable, without dilating the umbilical aperture ; but if this cannot be done, that aperture is to be enlarged outside of the sac, taking care not to wound the neck of the sac. When the contents of the sac are reduced, a li- gature is to be tied round its neck. The chief advantages proposed by this mode of ope- rating are, that a full examination may be made of the protruded viscera by a free opening of the sac, and all danger of peritoneal inflammation from this opening is precluded by the ligature which produces a closure of the neck of the sac and prevents the exposure of the ab- dominal cavity. Dr. Physick has never had an oppor- tunity of trying the plan, but I am happy to state that Dr. Wistar has performed it with complete success. vol. ri. o 9& ELEMENTS OF SURGERY. CHAPTER XII. Of Ventral Hernia. This resembles the umbilical, except that the protru- sion instead of being at the navel is situated in somo other part of the parietes of the abdomen; most fre- quently in the linea alba, but sometimes in the linea se- milunaris. It is a very rare complaint. The symptoms of ventral hernia resemble those of the umbilical, except that the stomach is sometimes contain- ed in the hernial sac when it is situated high up near the sternum in consequence of which the tumour is augment- ed after eating and the digestive process is greatly inter- rupted. The disease is produced by natural or praeternatural apertures in the parietes of the abdomen; the holes by which blood-vessels pass through the tendons are some- times unusually large, and a protrusion of the viscera takes place. Sometimes there are deficiences of tendon at particular places, and sometimes wounds of the abdo- men give rise to ventral hernia, the part injured not being properly filled up. With respect to the treatment, the remarks made on umbilical hernia will suffice, as there is no important difference between the two cases. ELEMENTS OF SURGERY. 99 CHAPTER XIII. Of Hernia Congenita. In the male subject, congenital hernia is formed by a protrusion through the abdominal ring into the tunica Vaginalis testis; it can only happen in those cases where this cavity remains continuous with the general cavity of the abdomen. The protruded viscera are in contact with the testicle, the hernial sac being the tunica vagi- nalis. This peculiar species of hernia excited the attention of many anatomists and surgeons about the middle of the last century, among whom Dr. Hunter, Baron Hal- ler, and Mr. Pott, have been very conspicuous, and have described it very accurately. The differences between hernia congenita, and com mon inguinaf hernia, are of no great practical impor- tance, their symptoms and treatment being nearly si- milar. Hernia congenita may be distinguished from common inguinal hernia, by its existence from the period of in- fancy, and by the impossibility of feeling the testicle, which in common scrotal hernia is very easily distin- guished. In applying trusses in very young subjects, the sur- geon should attend particularly to two circumstances, the replacement of all the protruded parts, and the de- scent of the testicle which might be prevented by the truss. If an operation become necessary for the relief of a strangulated congenital hernia, the sac should be divided. 100 ELEMENTS OF SURGERY. no lower than the upper end of the testis, a sufficient por- tion being left to cover that organ. Mr. Hey, and Mr. Cooper, have each published a cu- rious case of congenital hernia, in which the protruded viscera contained in a hernial sac passed down into the tunica vaginalis testis. In such cases it would be un- necessary and improper to open the hernial sac, the tunica vaginalis being opened the sac and its contents should be reduced together. A species of congenital hernia may occur in the fe- male, the intestine passing in these cases with the round ligaments of the uterus through the abdominal ring. Its existence could not however be ascertained in the living subject, and no peculiar treatment would be required if it were known. An opening called by Nuck a " diverticulum," exists in about one of eight or ten female infants, at the abdo- minal ring, and this diverticulum forms the sac of female hernia congenita; the diverticulum is a small process of peritoneum, passing over the round ligament of the uterus, and terminating in a blind pouch at the groin. Having described the circumstances and treatment of the most common species of hernia, I refer for those which more rarely occur (and their varieties are very great) to Mr. Astly Cooper, and to Mr. Lawrence. The principal of them are described by the former of these writers in his chapters on pudendal, vaginal, peri- neal, thyroideal, CYSTIC, ISCHIATIC, PHRENIC. MESEN- TERIC and mesocolic hernije. ELEMENTS OF SURGERY. 101 CHAPTER XIV. Of Hydrocele. A collection of water within the scrotum, is called Hydrocele. The situation of the fluid varies, and ac- cordingly systematic writers notice several species of hydrocele. The first of these is the anasarcous tumour of the scrotum, which most frequently occurs as a symptom of general dropsy, but in some rare cases is produced in the following manner. A hydrocele of the tunica vaginalis tes- tis bursts, and the water escaping into the surrounding cel- lular texture, forms the anasarcous tumour, which is gra- dually absorbed, and the aperture healing, the disease resumes its original form, the water being confined with- in the tunica vaginalis. The anasarcous hydrocele forms a soft tumour of the scrotum, affecting equally the cellular texture surround- ing each testicle. The skin is not reddened or inflamed, but when distended considerably, becomes tense and smooth, its rugae entirely disappearing. The testicles cannot be felt, they are situated in the middle of the tu-* mour. When pressed with the finger, it has a doughy feel, the indentation remaining some time after the pres- sure is removed. The skin of the penis is also similarly distended. The treatment of this complaiut differs in nothing from the treatment of general anasarca. The only surgical operation required, is when punctures become necessary for the evacuation of the water. Large incisions are im- proper, and endanger gangrene. Five or six small 102 ELEMENTS OF SURGERY. apertures should be made, by inserting the point of a laiL cet just deep enough to pierce the cutis vera, through these the water flows freely, aud the distention of the skin is removed, after which soft dry linen cloths should be applied, and renewed occasionally as they become wet. In addition to the anasarcous hydrocele, Mr. Pott describes three other species. First, That which consists of a collection of Water, in the cells of the tunica communis, or cellular mem- brane, enveloping and connecting the spermatic vessels. Second, That which is formed by the extravasation of a fluid, in the same coat as the former, but which, in*. stead of being diffused through the general cellular struc- ture of it, is confined to one cavity or cyst, in which all the water constituting this species of disease is contain- ed; the rest of the membrane being in its natural state. Third, That which is produced by the accumulation of a quantity of water, in the cavity of the tunica vagina- lis testis. "These three are distinct, local, and truly within the province of surgery. They may accidentally be com- bined or connected with other disorders, but not neces- sarily ; and are frequently found in persons whose gene- ral habit is good, and who are perfectly free from all other complaints." The first species I believe is very rare, and for an ac- count of it I,refer to Mr. Pott, it is much more common to find the water collected in one or more cysts upon the spermatic cord. In the ENCYSTED HYDROCELE OF THE SPERMATIC CORD, the testicles can be felt distinctly at the bottom of the tumour, there is an evident fluctuation of a fluid within the scrotum, and the parts are generally diaphanous. The swelling extends gradually upward, and in some cases probably extends through the abdominal rijig, in ELEMENTS OF SURGERY. 103 which case it resembles hernia, and in one case I have known a truss worn for such a tumour, the surgeon hav- ing mistaken the disease for bubonocele. In the case alluded to Dr. Physick was consulted, and found that, although, as in hernia, the tumour could be nearly pres- sed up into the abdomen, yet it returned the moment the pressure was removed ; the testicle was felt distinctly at the bottom of the tumour, which was diaphanous, and evident fluctuation could be perceived by pressure upon its opposite sides. A puncture was made, and the water was evacuated, after which no tumour remained, and of course no protrusion of the bowels was connected with the hydrocele. The treatment of hydrocele in those cases where the water is contained in one or more cysts upon the sper- matic cord, is to be effected by drawing off the fluid with a lancet or trochar; in young subjects a perma- nent cure is often effected in this manner. Should the water collect again, it is to be treated by injectiug wine into the cyst, in the manner practiced for the cure of hydrocele of the tunica vaginalis. Mr. Pott recommended a free incision through the coats of the cyst, a severe and dangerous operation which he confesses to have known sometimes followed by the death of the patient; the milder method of in- jection is certainly to be preferred. The HYDROCELE OF THE TUNICA VAGINALIS TESTIS, is that in which the water is collected in the process of the peritoneum which invests the testicle. The tunica vaginalis, in a natural state, secretes a fluid which lubricates its internal surface and that of the testicle. An increased secretion, or a diminished absorption of this fluid, causes a gradual distention of the cavity in which it is contained, and in some cases the quantity of fluid augments to a very great size. 104 ELEMENTS OF SURGERY. In some instances the disease forms too suddenly to be thus accounted for. Mr. Else declares, that he has known a hydrocele to form immediately after a sensation in the parts, which the patient ascribed to a rupture of something within the scrotum. In such cases the burst- ing of a lymphatic vessel probably occasions the disease. Mr. Ramsden has rendered it extremely probable, that in many instances, hydrocele of the tunica vagina- lis is occasioned by the existence of stricture, or local irritation in the urethra.* That this is sometimes the case, has been taught for several years by Dr. Physick, in consequence of his having cured a hydrocele, in a citizen of Philadelphia, by bougies. The bougies being omitted, the stricture returned, and with it a hy- drocele, which was a second time cured iu the same manner. It is certain however that in very many cases of it, no disease of the urethra exists. This species of hydrocele occurs at all ages, and is sometimes congenital. The tumour generally forms at /the bottom of the scrotum, near one of the testicles, and is commonly confined to one side only; it is pyriform, being larger below than above; it is soft at first but be- comes hard and incompressible; it is not inflamed or changed in colour, and is attended with no pain, the principal inconvenience sustained by the patient being from the weight and bulk of the parts. The testicle can be felt at the posterior and inferior parts of the scro- tum, until it becomes large and tense. In general, a fluctuation can be perceived, and the tumour is diapha- nous. A careful attention to these symptoms, and to those which characterize other tumours in the scrotum, will effectually discriminate between them. * Practical Observations on the Scleroccle, &c. London, 1811. ELEMENTS OF SURGERY. 105 TREATMENT. The administration of internal remedies has no effect, qion this disease, unless employed in a very early stage. The affusion of cold water has been found useful in a few cases, especially in young children, in some in- stances however the hydrocele of children spontaneously subsides, but the cure is evidently expedited by the cold water. When this remedy is used it should be pour- ed out of a tea-pot, four or five times a day over the scrotum. Severe purging has, in some instances, occasioned a speedy cure of hydrocele; it very rarely however is found useful, and a surgical operation becomes necessa- ry for the evacuation of the water. The radical cure of hydrocele cannot be effected by merely drawing off the fluid, as it very speedily collects again. In order to prevent this, and finally to cure the patient, it is neces# sary to excite an inflammation of the tunica vaginalis, and a consequent obliteration of its cavity, by an adhe- sion of its coats.—This is the general opinion of the manner in which hydrocele is cured, but Mr. Ramsdeu asserts, that a radical cure may be effected without obli- terating the sac. I shall presently quote his words. OF THE PALLIATIVE CURE. As hydrocele is by no means a painful disease, many patients prefer submitting to the inconvenience it occa- sions, to encountering the pain of a surgical operation; by means of a suspensory bag the weight of the tumour is supported, and the excoriation of the neighbouring parts in some degree prevented. When the tumour however acquires a very large size, the inconvenience VOL. II. p 106 ELEMENTS OF SURGERY. resulting from its bulk and weight cannot be obviated by any mechanical contrivance, and the water must be evacuated. The most convenient mode of performing this operation is to insert a common lancet into the tu- mour in such a situation as to avoid the testicle.* A small trochar may l)e substituted for the lancet, but it gives more pain. If the lancet be used, a probe, a grooved director, or what is still better, a small canula, should be introduced through the puncture as soon as the lancet is withdrawn; if this be not done, the skin of the scrotum is apt to slip over the puncture in the tunica va- ginalis, in such a manner as to prevent the ready escape of the fluid; the aperture through the skin no longer corresponding with that in the sac, the water escapes into the cellular texture, and cannot be evacuated. After drawing off the water a small piece of adhesive plaster, or a dossil of lint, is to be placed upon the wound, and a suspensory bag applied over the scrotum. In ge- neral the wound heals very readily, but in some instances it inflames and suppurates, and effects a radical cure of the disease; this is however not very frequent. Mr. Pott has known the simple operation of tapping a hydrocele, attended with fatal consequences, owing to the peculiari- ty of the patients constitution. Iu some cases the water when once evacuated does not collect again, even though no obliteration of the ca- vity takes place. This is, however, a very unusual oc- • In general the testicle is situated at the posterior and inferior part of the tumour; die usual place of drawing off the water is at the middle of die ante- rior part of the scrotum, but a difference is observed in this respect, and Mr. Hunter recommends to ascertain before inserting the lancet, the precise skoa- tion of the testis, which may be done by pressing upon the different parts of the tumour, as a very peculiar sensation is produced by squeezing the testicle. In Uiis way Mr. Hunter once succeeded in drawing off the water of a hydrocele, by inserting die lancet where the testicle is generally found. Several previous attempts, having been made by other surgeons, who inserted the trochar at Its usual place, where it entered the testicle. ELEMENTS OF SURGERY. 107 currence, although in recent cases of hydrocele I have known several successive tappings to effect a radical cure, and this in two or three instances. OF THE RADICAL CURE. To produce inflammation and adhesion of the sides of the tunica vaginalis, a variety of operations have been employed. The principal of which are, an extensive incision into the cavity containing the fluid—The exci- sion of the tunica vaginalis—Caustic applied so as to occasion a slough extending through the scrotum into the cavity—The introduction of a tent or seton—Cer- tain external discutient applications—The injection of wine or other stimulating liquors, and the introduction of flour through a small incision into the cavity, after evacuating its contents. The two latter are most commonly employed at the present time, and I shall not describe any of the others, because they are unnecessarily severe, and have justly gone into disuse. The method of treating hydrocele by injection has been lately recommended in very strong terms by Sir James Earl. It was first performed I believe by Mr. Lambert, a French surgeon, who injected a solution of corrosive sublimate in lime water. A variety of other fluids have been tried, but the best is believed bv Sir James Earl, and by the generality of surgeons to be wine. It is sufficiently irritating to effect the purpose, and not so irritating as to occasion unpleasant effects. Sir James Earl recommends about two thirds of wine (common port wine) to one third of water. If the parts appear insensible and no pain is produced, he recom- mends, to add to the proportion of wine. If on the con- trary the pain be very great, especially in recent cases, the proportion of water should be increased. 108 ELEMENTS OF SURGERY. Mr. Ramsden although he advocates the operation of Sir James Earl, insists that the obliteration of the sac does not in all cases succeed it. He remarks, "I am ready to allow that when inflammation is induced to a certain extent, the annihilation of the cavity of the tunica vaginalis will be a necessary consequence; but I know also that the radical cure of the hydrocele may be ef- fected (and is so in a large majority of cases) by excite- ment of that sacculus without any such extinction of its cavity." His theory is, that inflammation induces a sup- pression of the action of the secretory vessels which pour out the fluid, even when the degree of inflammation is insufficient to produce adhesions, and consequent ob- literation of the cavity. It has been recommended by Mr. Pott, in every case previously to performing any operation for the radical cure of hydrocele to draw off the water, in order to exa- mine the testicle and ascertain whether it be diseased or sound. Sir James Earl urges another reason for this, which is that the size of the tumour may in this way be considerably diminished, and therefore the operation for the radical cure will be less severe. He considers the remark as chiefly applicable to large hydroceles; when the tumour is of a smaller size, the previous tapping is unnecessary. The usual method of performing the operation is to seat the patient upon a chair, and to tap the tumour with a trochar at the anterior part a little below the middle, care being taken to avoid the testicle and any large vein, of which a great many are commonly visible in the scro- tum—when the whole of the water has flowed through the canula of the trochar, a syringe or bladder and pipe, w hich fit the canula are to be employed, and the cavity distended with the wine and water to its former dimen- sions. This fluid is to remain till considerable pain in the back and loins is perceived. In general, this pain ELEMENTS OF SURGERY. 109 is very severe in five or six minutes, but it is sometimes necessary to keep it in longer, and sometimes it cannot be borne so long. I have known fainting ensue, and immediately on injecting the wine the patient has drop- ped from his chair. When the wine has been suffered to remain a sufficient length of time in the sac, it is al- lowed to pass off again through the canula, and the pa- tient is placed in bed. The subsequent treatment consists in regulating the degree of inflammation; if it be very severe bleeding and purges, with a low diet are to be prescribed, and if on the contrary too moderate, an opposite plan is to be pursued, and a generous diet and wine are to be di- rected. The only cautions necessary in performing the opera- tion are to be certain that the canula is within the tuni- ca vaginalis when the wine is injected, and to avoid ir- ritating the testicle by the trochar or lancet, and also by moving the end of the canula so as to rub its surface. In order to prevent the canula from slipping out of the cavity, it should be inserted upwards to a consider- able distance, and held in the same situation during the operation by pressing it between the fingers which are to enclose also the skin of the scrotum at the part where it entered so that the scrotum may be pinched between the finger and the canula. From a neglect of this precau- tion the cellular texture of the scrotum has been injected instead of the tunica vaginalis, and extensive mortifica- tion has been the consequence. This operation by far the mildest which has been found successful, does not invariably succeed, and this is a good reason for rejecting a modification of it lately proposed, by substituting warm water for wine.* I have * I have seen this plan proposed in a late European publication, but I am un- able to recollect with certainty by whom it was suggested, I think by Mr Wheatlv. 110 ELEMENTS OF SURGERY. known one case in which this practice succeeded, but certainly the wine is preferable because more stimula- ting, and because its degree of stimulation can be varied according to circumstances. In a large majority of in- stances the injection of wine will be found to effect the cure. If it should however fail, it can be repeated, or Mr. Hunter's operation may be substituted. This consists in making an incision an inch in length, into the tunica vaginalis at the anterior part of the scro- tum, ev acuating the water, and filling the cavity with balls of dough, the aperture being held open by two hooks in the hands of an assistant. The patient being placed in bed generally a good deal of pain and fever supervene; suppuration takes place, and the flour is washed out with the pus. The cavity gradually con- tracts, and ganulations form, which uniting, completely fill it up. This is a most certain and effectual cure for hydro- cele, and although more severe than the injection, is by no means comparable in severity to the incision, seton, or caustic, formerly employed. I have seen it performed in several instances, always with success and without any very distressing consequences. Congenital hydrocele is that species of the disease in which the tunica vaginalis retains a communication with the general cavity of the abdomen. Desault in these cases injected red wine, making pressure at the abdomi- nal ring to prevent its entering the abdomen. He was successful, and never occasioned peritoneal inflamma- tion. In one instance in which it was connected with congenital hernia, he performed the operation, the tuni- ca vaginalis was obliterated, and both hernia and hydro- cele were radically cured. The principal chronic enlargements of the testicle which are called by the general name of sarcocele ELEMENTS OF SURGERY. Ill have been briefly noticed in the chapter on cancer. It is proper to state in this place, however, that these en- largements often accompany hydrocele, and in many cases forbid the use of any of the remedies proper for the radical cure of the latter disease. Tn these cases (which are denominated hydro-sarcocele) frequent evacuation of the fluid is the safest and best mode of treatment. As I shall not treat of any of the forms of venereal disease in the present work, I cannot enter on the con- sideration of hernia humoralis, or swelled testicle, re- sulting from gonorrhoea. It may not, however, be im- proper to state that the repeated introduction of bougies is frequently found successful in reducing enlargements of the testicle which have originated from this source, even in cases where they appear to exist independently of strictures in the urethra. In all obstinate cases of sarcocele which resist the usual discutient remedies and become painful it is the safest plan to remove the affected part. IIS ELEMENTS OF SURGERY. CHAPTER XV. Of Hematocele. This term has been used by surgeons to express those swellings of the scrotum which are occasioned by effused blood. The blood may be situated in the common cel- lular texture of the scrotum differing in no respect from common ecchymosis; or it may be situated in the tuni- ca vaginalis. Ecchymosis in the substance of the tes- tis, constitutes another species of hsematocele. The cause of this affection is a rupture or puncture of a bloodvessel, and the remedies are such as promote the absorption of the effused blood—the treatment is similar to that employed in cases of ecchymosis; cold applica- tions, moderate pressure, and occasional purging. It sometimes happens that a large quantity of blood is collected in the tunica vaginalis, after the tapping of a hydrocele; this blood should be evacuated by a punc- ture, and the scrotum supported in a suspensory bag. 1 have known the whole scrotum suddenly become dis- tended with effused blood from the rupture of the tunica vaginalis, in a case of hydrocele. The patient and his surgeon in this case were greatly alarmed by the new ap- pearance of the parts, which became tense, and assumed a dark purple colour, indicative, as they supposed, of gangrene. No such consequence however followed. The encysted became an anasarcous hydrocele, the wa- ter mixed with extravasated blood was diffused through the cellular texture of the scrotum; in a few days the aperture through which it had escaped, healed up, and the parts resumed their usual appearance ; the encysted hydrocele returning, the extravasated blood and water were absorbed. ELEMENTS OF SURGERY. 113 CHAPTER XVI. Of Varicocele and Circocele.* Varicocele consists in a varicose or morbidly dilated state of the veins in the scrotum. In general this is the consequence of other diseases of the neighbouring parts, and these are the chief objects of attention, as the en- largement of the veins occasions no particular inconve- nience; Circocele is a varicose state of the spermatic veins. It occurs in a great majority of cases in the spermatic cord and testicle of the left side, in consequence, as Mr. Home supposes, of the circuitous route which the blood of the left testicle pursues, in its return to the vena cava; the spermatic vein commonly terminating at a right angle in the left emulgent. It sometimes occasions a dimuni- tion of the testicle. The tumour occasioned by this dis- tention, is sometimes very considerable; it is generally greatest at the lower part near the testicles. The dis- ease has sometimes been mistaken for omental hernia, but it may always be distinguished in the manner pro- posed by Mr. Astly Cooper; he directs the patient to be placed in a horizontal posture, and the veins to be emptied by pressure, after which the surgeon is to place his fingers on the upper part of the abdominal ring, and desire the patient to rise. If the disease be hernia, no • These terms are often promiscuously used, but they may very properly be applied with more precision to express two very distinct morbid affections. Cel- sus and after him the classical Mr. Percival Pott applied the term circocele in the sense which I have adopted. VOL. II. Q 114 ELEMENTS of surgery. return of the tumour can take place whilst the pressure. is continued, whereas this pressure encreases the swel- ling in cases of circocele, by interrupting the passage of the blood through the veins. In addition to this we are generally able to feel distinctly, in cases of circocele, the round figure of the convoluted vessels at the top of the testicle. In general the disease occasions but little inconveni- ence, and the patient is not anxious for a cure ; but when distention is very great and the weight of the tumour considerable, severe pain in the back and loins are the consequence. In the treatment of this complaint, a radical cure is seldom attempted. A suspensory bag is generally re- commended, and the old remedy of castration which has been too often performed for the cure of circocele, is now justly disused. Mr. Home has tied up the spermatic vein for the cure of this disease, but the symptoms consequent were ex- ceedingly severe, and unless in cases of enormous dis- tention of .the veins, the operation ought not to be per formed. ELEMENTS OF SURGERY. 115 CHAPTER XVII. Of Strictures in the Urethra. A stricture of the urethra consists in a contraction, or diminution of diameter in a part of this canal. It is either spasmodic and temporary, or permanent. The spasmodic stricture consists in a contraction of the urethra at a particular part, depending upon spasm, and subsiding when that spasm ceases. The permanent stricture is attended with a change in the structure of some part of the urethra, generally in the first instance a very small part, not more than would be forced together by a pack thread tied on the outside of the canal. The two cases are occasionally blended, and spasm supervenes upon a permanent stricture. Strictures in their commencement are in general spas- modic, and Mr. Hunter and Mr. Home consider them in the first stage, as a wrong action of the muscular fibres of the urethra, which at times completely subsides, and leaves the parts unchanged. As the disease progresses the canal at the affected part loses the power of expand- ing again to its original diameter, and thus becomes per- manently contracted. Permanent strictures are generally liable to spasm, as we find patients affected witli them, frequently suffering a complete suppression of urine, in consequence of ex- posure to cold, or the intemperate use of wine, of violent exercise, or similar causes of an irritating nature. Mr. Charles Bell in a recent work on the diseases of the urethra, denies that the urethra " is muscular or ca- 116 ELEMENTS OF SURGERY. pable of contraetiug, and consequently declares Mr. Hunter's opinion of the origin and nature of strictures in the urethra to be unfounded. He has endeavoured to prove that the membrane of the urethra is destitute of muscular fibres by experiment:—having introduced an ivory ball into the urethra, he directed the man who was the subject of the experiment to expel it, which he was unable to do. He imbued the ball with stimulating ar- ticles as soap and spirits, but still there was no power in the urethra to retain the ball or to push it forth. The ball could only be expelled by the urine behind it, or by the ejaculator seminis. An experiment was made to as- certain the action of the urethra upon fluids. Mr. Bell found that when the urethra was distended with water to a distance of five inches from its external orifice, the patient was utterly unable to empty it by any effort of the parts. Mr. Bell's experiments do not appear to me by any means to establish the point; because the urethra is evi- dently capable of emptying itself, a fact which is readily proved by distending it with urine, keeping the external orifice closed; if at this time a finger be placed in such a manner as to compress the urethra three or four inches from the end of the penis, and the orifice of the urethra be now opened, a jet of urine takes place, and that part of the urethra is emptied. It is evident in this case that the urine from the bladder being intercepted, nothing but the contraction of the urethra could evacuate its con- tents. Mr. Bell is right, however, in ascribing much to in- flammation, in the formation of stricture, but when he asserts that the sole origin of all strictures in the urethra is inflammation, he goes too far. Wishing to avoid all controversy on this, as on all other occasions, I pass over many arguments which might be advanced to prove the contractile power of elements of surgery. 117 a stricture in the urethra, but of the fact I think few surgeons who are conversant with the subject will enter- tain a doubt. It often happens in practice that a stric- ture which commonly admits a large bougie shall sud- denly deny to the efforts of the surgeon a passage to every instrument. After a time this temporary barrier ceases as suddenly as it came on, and again the large bougie gains a ready entrance. The change is too sud- den to be ascribed to inflammation; it must be owing to spasm. Every surgeon of experience must have seen bougies expelled the urethra by the action of this canal. This progress of a stricture of the urethra is in gene- ral very slow at first; I have known a person insensible of its existence even when the stream of urine was re- duced to one fourth its natural size, so gradual and slow had been its increase. After a time, however, it ad- vances more rapidly. The urine is voided very fre- quently, and great efforts of the bladder are required to pass it; it comes out in a spiral or forked stream, and a tenesmus urinae or straining continues after this viscus is emptied. When the stricture is in this state, a debauch with wine; exposure to cold; and a variety of other occasional irri- tations aggravate the disease, and sometimes occasion a suppression of urine. Mr. Home ascribes this to a clo- sure of the urethra at the strictured part by spasm, and I think it gives great plausibility to his opinion, that the remedies most successful in removing the complaint are such as are generally employed in the treatment of spas- modic diseases, as opium, the warm bath, &c. Strictures are very often attended with a discharge from the urethra; a dull heavy pain in the back and loins attends the complaint, and many of the symptoms of stone are occasionally experienced. The bladder is sometimes greatly thickened in conse- quence of strictures. Sometimes it inflames and dis- 118 elements of surgery. charges mucus and pus; in some instances a discharge takes place of a whitish adhesive viscid substance, which Mr. Home pronounces to be a vitiated secretion of the prostrate gland, an opinion founded upon dissections. In some patients a nocturnal emission of semen at- tends, and in others the discharge of semen is prevented by the obstruction. The urine is often turbid, deposit- ing a sandy sediment. All the symptoms of stricture, are greatly aggravated by accidental circumstances of an irritating nature, es- pecially by exposure to cold. In some rare instances peritoneal inflammation and death have resulted from strictures of the urethra. If the stricture be suffered to go on without any in- terruption from the surgeon, it sometimes produces a complete obliteration of the urethra, and suppuration takes place behind it, forming an abscess which opens through the external teguments, and a passage is thus formed for the escape of the urine forming a fistula in PERINEO. Fevers and shiverings frequently attend the progress of strictures, accompanied with nausea, vomiting and indigestion. In some cases these symptoms come on in consequence of the introduction of bougies, or of other irritation. The appearance of strictures on dissection vary very much. They sometimes occupy only a small portion of the urethra, and at other times an inch or more of its length is found irregularly contracted, forming a wind- • ing canal. Sometimes the appearance is that of a mere narrowing of the canal, and in other cases a complete ridge projects into the urethra. The bladder after death is found greatly thickened, and sometimes the ureters and kidneys are diseased. In some cases one, and in some several strictures ex- ist. Mr. Hunter has known six in one urethra. ELEMENTS OF SURGERY. 119 The most frequent situation of stricture is at the bulb ; Mr. Hunter says he has never seen a stricture at the prostrate gland, but they occasionally form in every other part of the canal. Mr. Home thinks the order of frequency greatest at six and a half or seven inches from the external orifice, that is at the bulb of the urethra; and next about four and a half inches. I have seen the very extremity of the canal affected with stricture. The causes of stricture in the urethra, are not very well understood. Sometimes they result from irrita- tion, and probably from gonorrhaea and the use of ir- ritating injections, although Mr. Hunter doubted wheth- er these were frequent sources of the disease. Mr. Andrews relates a case where it appeared to result from the gravel, in a child between five and six years of age.* Mr. Hunter has seen a stricture in a boy only four years old, and I have recently dissected a young man aged about nineteen, who from infancy had been afflicted with a stricture of the urethra, his bladder for some time before his death, was not capable of holding more than two ounces of urine, and its coats were found more than half an inch in thickness. In general they occur without any evident cause, although as most men have had at some period of their lives, the venereal disease, they ge- nerally ascribe their strictures to this source. TREATMENT. The methods of treating strictures of the urethra in general use, are two; the dilatation by means of bougies, and the destruction of the stricture with caustic. Dr, Physick has contrived another plan, and in some in- stances, has cut through the stricture. The introduction of bougies to dilate the stricture, al- though considered by Mr. Hunter, as affording only a * Andrews on Strictures, p. 8. 120 ELEMENTS OF SURGERY. temporary relief, succeeds no doubt in curing completely a great many cases of this complaint. The manner iu which bougies act upon the stricture, is not simply by dilating mechanically the contracted passage, but by pressure they produce ulceration, and the stricture is destroyed by the absorbents. In this country it is essential for the surgeon to be ac- quainted with the manner of preparing bougies, because those which are imported and manufactured for sale are very unsafe, and are totally unfit for the purpose for which they are designed. They are unsafe because being formed generally of old linen they are apt to break, and in this manner may lodge in the bladder or urethra, and occasion great inconvenience, and they are unfit for use, from their bad form, and from the improper sub- stances of which they are composed. The best materials for the construction of bougies are fine new linen and pure yellow bees wax. The linen should be cut into pieces about twelve or fourteen inch- es square, and dipped into melted wax; it should be taken out in such a manner that the wax may drip off at one end, and not more by one corner than another; in this manner the linen will receive a coat of wax of a uniform degree of thickness, excepting that the depend- ing portion will be more thickly coated than the superior part; the linen is to be cut into strips of a proper width, care being taken always to cut in the transverse direc- tion, because as there is more wax upon the lower than the upper part, there would be an irregularity in the form of the instrument if this caution were neglected. The strip of waxed linen or bougie plaster is next to be cut of a proper shape, so that when rolled up it may ta- per to a point. The form which I prefer, is to have the bougie slightly conical, through its whole length, but to taper at the end, very quickly to a point. The small- ness of the point enables the surgeon to insinuate it into ELEMENTS OF SURGERY. 121 the stricture, and the conical form gives it a degree of firmness gradually increasing from the point to the oppo- site extremity. The art of rolling up the bougie and of giving it.a proper point is to be acquired by habit, and need not be particularly described. I will only re- mark, that a marble slab, or a polished mahogany table, and a broad spatula, or knife, are all the tools necessary for this purpose, and I conclude this part of the subject by recommending to the practitioners of this country the preparation of their own bougies. Previously to their introduction they should always be covered with sweet oil. In order to ascertain the existence of a stricture in the urethra, it is necessary to pass a large bougie with a round extremity along the urethra; the place at which it stops marks the situation of the stricture. A large bougie passes more readily than a small one as far as the stricture, because the point of a small bougie is apt to get entangled in the lacunae of the urethra. Mr. Charles Bell recommends for this purpose a ball or globe of sil- ver soldered upon a long probe. It has no advantage, however, over the common bougie. In passing a bougie, care should be taken to avoid pressing any part of the urethra, and the penis should be drawn forwards upon the bougie at the same time that the bougie is pushed gently on. It often happens that when the surgeon is first con- sulted, he finds the passage so small that no bougie can be passed through the stricture. In these cases it should be daily introduced down to the stricture and pressed against it with moderate force; after repeated trials of this kind, the bougie will generally gain an entrance, and if even the smallest bougie be once passed through the stricture it can always be dilated so as to admit a larger one. The pressure should never be great, l>e- Vol. ii. R 1,23 ELEMENTS OF SURGERY. cause a false passage might be formed by too much vio- lence. The attempt to introduce a bougie often excites spasm in the stricture, and this retards and sometimes pre- vents the introduction of the instrument. Mr. Hunter advises in such cases to press the bougie gently against the stricture for a few minutes, when in general the spasm will subside. The bougie when first introduced should not be suf- fered to remain long; after three or four minutes it should be removed. Its introduction should be repeated daily, and the time of its continuance gradually increas- ed ; it may at length be suffered to remain an hour or longer. The diameter of the bougie should also be augmented from time to time, until the strictured pas- sage is dilated to its natural size. The use of the bougie should not however be entirely discontinued even when this is done, because the parts retain for a long time a disposition to contract, and this must be obviated by an occasional introduction of the instrument; once in three or four weeks will be often. enough for this purpose. Patients sometimes faint and become sick, and cover- ed with a cold sweat, when a bougie is first used, this however seldom occurs at the subsequent introductions. It often happens that bougies are completely inefficient in the treatment of strictures, and a long and steady per- severance in their use, produces very little if any dilata- tion of the diseased part. In such cases, and in all those cases in which the bougie cannot be introduced, and the passage is almost or entirely closed, the destruction of the stricture must be effected either by caustic or the lancet. The application of caustic was introduced by Mr. Hunter. Mr. Home has written extensively upon the ELEMENTS OF SURGERY, 123 subject, and extols very highly this method of treating strictures. The best mode of applying the caustic I believe to be that recommended by Mr. Home : a bougie is to be pre- pared of a size which will pass readily down to the stricture ; into the end of this bougie a piece of lunar caustic (argentum nitratum) is to be fastened; it is co- vered laterally by the bougie plaster, and is uncovered only at the extremity of the instrument. For the purpose of security I have always tied a fine cambric thread neatly round the linen which invests the caustic* The bougie thus armed is ready for use ;—the distance to which it is to be passed in the urethra is ascertained by passing another bougie down to the stricture, and marking upon the armed bougie the depth to which it had entered when in contact with the stricture. The armed bougie is now to be dipped into oil, and passed down to the stricture, it produces no irritation and in- deed scarcely touches the urethra until it arrives at the stricture. The caustic should be suffered to remain in contact with the stricture about a minute, and should be then withdrawn. The pain experienced is generally very slight, and the consequences by no means severe. The patient should be directed to make water after the removal of the armed bougie. A little blood will some- times be found to tinge the urine voided. The applica- tion is to be repeated once in forty-eight hours, as often as may be necessary for the cure of the disease. It is seldom safe to use the caustic oftener, but in some cases where the sensibility of the parts is very much diminish- ed, Mr. Home has applied it every day. Mr. Whately has introduced a mode of destroying * The caustic should be nearly half an inch in length, and of about one-third of the thickness of the usual rolls of caustic. It is not easy to procure it of thfci shape, and the surgeon must either scrape it thin enorigb, or fuse the common ',-; nar caustic and cast it in an iron mould. 121 -ELEMENTS OF SURGERY. strictures by the application of the vegetable caustic al- kali. A piece of kali purum as large as a pin's head, he directs to be placed in an indentation made by the nail in *the end of a bougie, and this bougie is to be pass- ed down to the stricture. The caustic dissolves very speedily in the fluids of the urethra, and thus destroys any part of the canal with which it comes in contact. For a particular account of this plan, I refer to Mr. Whately's publication, just observing, that it is, in my opinion, a most uncertain mode of operating, as it is im- possible to know on what part the caustic will dissolve, and as Mr. Charles Bell remarks, it will be much more likely to act on the hollows and depressions in the ure- thra, than on any natural or accidental eminences. Mr. C. Bell has constructed an instrument for the appli- cation of caustic to strictures, wliich consists of an hollow globe writh an aperture at the end, or side, fastened on a long probe. A portion of alkaline or lunar caustic placed in this aperture may be passed down to the stric- ture, but the mode of applying caustic recommended by Mr. Home I believe to be preferable to any other me- thod. The division of a stricture by means of a cutting in- strument, was first performed by Dr. Physick in 1795, and in several instances since that time, he has repeat- ed the operation with success. The instrument em- ployed for the purpose is a lancet, concealed in a ca- nula; when the stricture is situated anteriorly to the bulb of the urethra, no danger or difficulty attends the division of it by means of this instrument, but if the stricture be situated at the bulb, a very accurate know- ledge of the anatomy of the parts will be necessary, and great caution in the operation. A small wound how- ever of the urethra, made with a sharp lancet, would oc- casion no great trouble, and would probably heal very ELEMENTS OF SURGERY. 125 readily. The urethra is generally distended behind the stricture, and of course it is not easy to pass the knife in a wrong direction. After the stricture is cut through, a flexible catheter should be introduced and kept in the bladder three or four weeks; after it is removed a bou- gie should be frequently introduced. The best method of treating spasmodic stricture with a view to a radical cure consists in applying caustic to the part. During the continuance of the spasm, bleeding, mercurial purges,opium, and the warm bath will be found useful. Emetics are also occasionally successful. Dr. Shaw of this city, succeeded in pro- curing relaxation of a spasmodic stricture by passing on a bougie a leaf of tobacco down to the stricture. Nau- seating medicines are very advantageous. Within a few years many volumes have been written on strictures of the urethra. Several of these are highly valuable, among the rest I beg leave to refer the reader to the writings of Mr. Hunter, and to the excellent his- tory which Mr. Home has given of this subject. Mr. Whately, Mr. Charles Bell, and Mr. Andrews have also written papers which contain very useful informa- tion. With respect to the mischievous effects said to have resulted from the use of caustic, I have no doubt that in many instances they have occurred, and the indiscri- minate use of caustic is therefore wrong. Where the stricture yields readily to bougies, they ought to be pre- ferred. Where it does not, the caustic should be sub- stituted, and if managed with proper caution, is I be- lieve very generally safe, though I have often known sup- pression of urine occasioned by it, and in one case a he- morrhage which reduced the patient to extreme debility, from which he never recovered. 126 ELEMENTS OF SURGERY. CHAPTER XVIII. Of Fistula in Perinea. In consequence of an entire stoppage or great obstruc- tion to the discharge of urine from a stricture in the ure- thra, inflammation and ulceration take place behind the strictured part; when the ulceration proceeds through the skin forming an outlet for the urine, the disease call- ed fistula in perineo is formed. The same circumstance also results in some cases from accidental injuries to the perineum which terminate in ulceration communicating with the urethra. The urine in some cases becomes extravasated into the cellular texture in the vicinity of the urethra, and occasions violent inflammation and mortification. When the sloughs separate if the patient survive, a fistulous ul- cer remains. The first thing generally necessary in the treatment of fistula in perineo, is to dilate and remove the stricture which caused it. A bougie should be passed, and in many cases it will find a ready access to the bladder, the stricture having been destroyed by the ulceration. If, however, the stricture remain, an opening should be made through it by the use of caustic, and an elastic ca- theter introduced and kept in the bladder until the exter- nal sore heals, which will generally happen speedily in recent cases. In many instances, however, the fistula is by no means so readily cured—the urine escaping into various parts of the cellular texture of the scrotum produces abscesses and sinuses running in various directions. The integu- ELEMENTS OF SURGERY. 1,27 ments of the perineum and scrotum, are knotty, hard, and irregular, with one or more outlets for the urine. The cure in these cases is often difficult; sometimes im- practicable. It should be attempted, however, by destroy- ing the stricture in the way already mentioned, and if this fails, by making a free opening externally into the urethra, in order to prevent the urine from entering the sinuses. The best method of doing this is to pass a silver female catheter, sound, or director, down to the stricture, and to make this project as much as possible in the perineum. A probe should now be passed into the fistula and the catheter sought for. If it can be felt (which is not al- ways the case) an incision should be made down upon it, and this incision should be carried farther towards the bladder so as to open the urethra freely between the stricture and the bladder; but if the catheter cannot be felt by the probe passed into the fistula, then an incision is to be made directly upon the extremity of the staff or catheter, and the stricture will in this manner be cut through. A catheter should now if possible be passed into the bladder; if this be, not practicable, and the surgeon be unable to find the urethra behind the stric- ture which is often extremely difficult, in such a case it has been recommended to perform a more decisive ope- ration. Mr. Charles Bell on this subject remarks: "It of- ten happens that in these diseases of the perineum, the urine obtaining a free discharge by the fistu- lous opening, the original stricture is more and more contracted, and a considerable part of the canal is to- tally obliterated. This contraction and increase of the length of the stricture is no doubt accelerated by the suc- cessive extension of the inflammation in the perineum; and very often in this complicated state of the disease, there is a large quaggy swelling of the integuments of the perineum,' great part of which it Mere better to take 128 ELEMENTS OF SURGERY. away by a double incision in the first part of the opera- tion. "In this operation, one longitudinal incision in the length of the diseased integuments of the perineum, or two, including a portion of the diseased skin, may be ne- cessary. In this the state of the parts must be our rule and guide. "Now the parts are to be pretty freely dissected, while we endeavour to make distinct the bulb of the ure- thra. The fistulous opening into the urethra is next to be sought for; and a staff, or sound, or catheter, having been introduced into the urethra, down to the upper part of the stricture, the track of the diseased urethra, and the point of the staff is to be explored; and if the urethra proves entirely diseased for some length, it is to be cut out. Now a bougie of the largest size is to be intro- duced from the wound, into the bladder, and another from the extremity of the urethra down to the wound. The parts are to be slightly dressed, and the patient put to bed. "After a few days, when suppuration has taken place, and the granulations are sprouting up about the bougie, it is to be withdrawn, and the catheter introduced along the whole length of the urethra; over which, if it be kept steady, and in a good situation, the parts will soon heal. "After the first dressing, when we find that the in- flammation is not likely to run to any dangerous degree, we must dress it with a stimulating ointment, on slips of lint, and over this put a warm poultice, which will pro- mote healthy granulations." The fistulous ulcer is in some cases so indolent as t© , require the most stimulating applications to induce gra- nulatious. In such cases caustics and escharotics are to be used. I have tried the hare-lip suture in a case of large opening into the urethra at the perineum, but no ELEMENTS OF SURGERY. 129 advantage resulted, although the urine flowed entirely through an elastic catheter, and not a drop escaped at the wound, the edges of which had been pared off and kept in contact. This backwardness to granulate and heal, depends therefore not only on the escape of urine at the ulcer, but also on the change of structure in the part, which is very great; all appearance of corpus spon- giosum being iu most cases lost, and succeeded by an indurated indolent substance. Fistulae in perineo sometimes contract to a very small size and appear to heal, and yet remain open, occa- sionally discharging urine during a number of years. I have had several patients with fistulae too small to ad- mit the finest probe, and these fistulae have remained open during life. Fistulae sometimes result from false passages formed by the improper use of the bougies used in treating stric- tures. For an account of this subject I refer to Mr. Hunter. vol. n. 130 ELEMENTS OF SURGERV. CHAPTER XIX. Of Retention of Urine. . A total obstruction to the discharge of urine situated at the neck of the bladder, or in the course of the ure- thra, is the most usual cause of a retention of urine, but it sometimes results from a paralytic state of the bladder, and a consequent inability to expel its contents. As the latter is not strictly a surgical complaint, and as the in- troduction of the catheter is easily effected, it will only be necessary to treat of the former. Wheu the sensation of a full bladder is perceived, if the patient be unable to evacuate his urine, great pain and violent straining efforts come on, the bladder gra- dually distends, and may be felt above the pubis, and swells in some cases so much that its fundus rises to the umbilicus. The abdomen swells and becomes tense and painful, hiccough, difficulty of breathing and cold sweats attend, the bladder inflames, and unless relief be obtained mortification follows. The causes by which the discharge of urine is pre- vented are various: inflammatory, and other swellings in the vicinity of the urethra, as hemorrhoidal tumours, abscesses, &c—a stone in the bladder or urethra ;-spasm at the neck of the bladder or in the urethra;—a perma- nent stricture, with or without spasm ;-inflammation of the neck of the bladder;—an enlargement of the prostate glands, &c. Retention of urine unless relieved, terminates in ge- neral by death; but in some cases this event is protract- ed very much. Where the obstruction does not entirely ELEMENTS OF SURGERY. 131 close the urethra, urine after a time begins to flow off, and although the bladder remains very greatly distended, yet the partial evacuation prevents the fatal consequences of the distention, and the patient continues in this situa- tion sometimes for several weeks making water as the French express it "par regorgement." If the discharge, however, be totally precluded, still death is not absolutely inevitable, because mortification may take place iu a particular spot without proceeding to any considerable extent. At this mortified part the urine escapes, and most generally the part which morti- fies first is situated in the vicinity of the neck of the bladder, so that the urine becomes extravasated into the neighbouring cellular texture, and fistula in perineo is the consequence. Sometimes the mortification is seated at the posterior part of the bladder and extends through the coats of the rectum, and the urine is suddenly in con- sequence of this, evacuated per anum. Instances have occurred in which the bladder has burst (mortification having probably preceded) at its anterior part, and the urine has been discharged by an abscess at the umbili- cus. In other instances the urine escapes into the ca- vity of the abdomen and produces death. The ureters and kidneys become affected in conse- quence of the interruption to the discharge of urine, and they swell very much and become distended with this fluid. TREATMENT OF RETENTION OF URINE. This depends greatly upon the cause of the evil. If a stone in the bladder have interrupted the discharge of urine by falling over the neck of the bladder, a change of posture will generally relieve the symptom. If a small calculus be lodged in any part of the urethra, this should lie extracted by means of an eyed probe bent at its per- 132 ELEMENTS OF SURGERY. forated extremity into a hook, or by means of long for- ceps concealed in a canula (an instrument employed for that^ purpose by Mr. Hunter,) or lastly, by cutting down upon the stone and removing it through the wound. The most frequent obstruction, however, in the ure- thra is a stricture, either in a state of inflammation, or affected with spasm. To ascertain the state of the canal it is best to intro- duce a bougie. In some instances this succeeds, and the urine flows as soon as the instrument is retracted, though it had not entered the bladder, but simply dilated the stricture. Should this fail, an elastic catheter should be introduced and passed as far as it will go without force; should it enter the bladder, the urine is evacuated through it. At the time that these efforts are made, the patient should be freely bled, a mercurial cathartic should be taken, and he should be placed in a warm bath. Eme- tics and nauseating medicines have in some cases suc- ceeded in relieving a suppresion of urine. Opium in considerable doses is to be next given if these remedies fail. It may be administered by clyster, or by the mouth. It has been recommended by Mr. Weldon to administer tobacco in infusion, perhaps its local application to the urethra and neighbouring parts would in some cases suc- ceed. The great reliance of the surgeon, however, in all cases of retention of urine is upon the catheter, and the introduction of this instrument is an object of immense importance to the safety of the patient, and of propor- tionate interest to the surgeon. I know no disease in the treatment of which dexterity and science are more essential than in the present, and there are very few in which more mistakes have been committed, or where the consequences of deficiency in the skill or knowledge of a practitioner are mora serious, and fatal. In the inte- ELEMENTS OF SURGERY. 133 rior of our country there is reason to believe that many valuable lives are annually lost from no other cause than a want of proper medical assistance in cases of retention of the urine. Catheters are tubes adapted to the purpose of drawing off urine. Until within a few years they were generally made of silver, and of course were incapable of altering their shape when passed into the urethra; the importance of flexibility in this instrument induced the older sur- geons to construct catheters of silver wire rolled in a spiral form, and polished smoothly on its external sur- face. Of late years a flexible metallic compound con- sisting chiefly of tin has been formed into catheters, some of which possess great flexibility. A French family of the name of Bernard, are in possession, however, of a composition for the construction of catheters far prefer- able to every other hitherto in use. The instruments prepared by Bernard have been supposed to consist of elastic gum. I do not myself believe that much if any elastic gum exists in the catheters manufactured by Ber- nard, because I have seen catheters made of elastic gum and they had no resemblance to those of Bernard; they were useless from their too great flexibility. A web of silk forms the basis of the instrument, and this silk is varnished with a peculiar secret composition, which when dry is hard and susceptible of a fine polish, and the in- strument remains in the urethra a week or ten days without producing much irritation, and without becoming rough or being in any degree dissolved—properties as I believe, peculiar to the French catheters, the best of which are those prepared by Bernard.* A great many catheters have been made in imitation of the French. Those made in England are much more • It is singular that Mr. Charles Bell should declare at the present day, that '* in the hands of a dexterous surgeon die silver catheter is in general preferable to every other •»'—The surgeon who uses it should be also a " dexterous" silver- smith. 134! ELEMENTS OF SURGERY. highly finished, and for the mere purpose of drawing oft the urine they answer extremely well, but when left in the urethra they become rough, and finally dissolve in the urine and mucus. Dr. Physick has made a great number of experiments With a view of discovering some composition possessing the requisite flexibility, and remaining insoluble in urine. A cylindrical silk web, wove by the whip makers upon wire of different sizes may be readily coated with var- nish, and when dried is easily formed into a catheter. Copal varnish may be used for this purpose, and a ca- theter well adapted for drawing off urine can be made without difficulty; the surface being polished by rubbing it with pummice stone. This instrument, however, Dr. Physick found becomes speedily rough when allowed to remain in the urethra, and no other composition which he used possessed the properties combined in the French catheters, nor have the labours of others been more suc- cessful, for though very numerous attempts have been made to contrive a substitute for this instrument they have all failed. I shall dilate upon this subject no farther than to men- tion a mode of preparing an extemporaneous catheter which under certain circumstances, may prove a very useful instrument to the country practitioner. It consists in regularly extending the spiral wire of the suspenders which form at this time an article of every gentleman's dress till it becomes of sufficient length. This wire is afterwards to be covered with bougie plaster, and a hole cut near the end; being properly rolled and prepared like a bougie it forms a very tolerable catheter. Dr. Physick in a case of emergency where no other catheter was to be procured, contrived this instrument, and on a similar occasion I Jiave once found it extremely useful. I find, however, that Mr. Daran was in the habit many years ago of preparing a catheter somewhat in the same . ELEMENTS OF SURGERY. 133 manner, by enveloping one of the old catheters formed of spiral silver wire in bougie plaster. It is difficult to give any general rules for the introduction of the catheter. When the flexible catheter is used, it is only necessary to pass it gently onward drawing the penis at the same time forward. When this fails, and thestiletof wire is introduced in order to give to the instrument a great- er degree of firmness, which is often necessary, then great caution must be used to avoid forming a wrong passage, by lacerating the urethra. Much is to be done by vary- ing the form of the instrument. I have myself been ac- customed when attempting to pass the catheter, to pro*. vide a great number of wires curved in different forms, and when one has failed I have without delay substi- tuted another; it is astonishing how greatly the suc- cess of the operation will in some cases be influenced by a slight alteration in the shape of the stilet. In addition to the usual curve of the stilets I have found great ad- vantages from different lateral curvatures near the point of the instrument. In general no great difficulty is ex- perienced in passing the catheter through the anterior part of the urethra, the greatest difficulty is at the bulb of the urethra, or at the prostate gland, or neck of the bladder. It is probably of no great consequence whether the instrument be passed with the convexity towards the abdomen, or towards the perineum, it is at all events very easy when one fails to try the other. If the opera- tion fail in an erect posture, it should be tried in a re- cumbent one, and vice versa; Mr. Hey prefers the re- cumbent position and in most instances it is as conve- nient as any and in old or debilitated patients should be preferred. The common obstacle to the passage of the catheter in tliat part of the urethra which is anterior to the prostate gland is a stricture, and the mode of treating this has been already detailed. A difficulty often arises from the 136 ELEMENTS OF SURGERY* • enlargement cither chronic or inflammatory of the pros- tate gland; to surmount this obstacle the catheter should be curved very much at the point, even more than has been recommended by Mr. Hey; much more than is re- commended by Mr. Charles Bell. In the succeeding plate I have drawn the shape of a catheter which I succeeded in introducing into the blad- der of an old gentleman with an enlarged prostate, after being baffled in every other attempt; it is perhaps as much bent as will in any case be found requisite, and yet not more so than in certain instances will be re- quired. Mr. Hey accidentally discovered a mode of increasing the curvature of the flexible catheter by retracting the stilet whilst in the urethra, a practice long used and for many years taught by Dr. Physick, and which in some cases is very successful, by elevating the point of the in- strument above the prostate gland. As the chronic enlargement of the prostate in old per- sons is one of the most important and frequent cases which calls for the introduction of the catheter, I shall mention under the present division of the subject a mode of relieving retention of urine which sometimes succeeds when most others have been tried in vain. It often happens not only in cases of stricture, but also of enlarged prostate, that a bougie will gain admittance to the bladder when neither a stiff nor a flexible cathe- ter can be introduced. The plasticity of the" bougie when formed of pure bees-wax and linen, is much great- er than that of the most flexible catheter, and it assumes the form of the part where the obstruction is seated, adapt- ing itself to every curve and contraction in the urethra, in such a manner that in many cases it may be gradually insinuated into the bladder when other instruments can- not be passed. ^ ELEMENTS OF SURGERY. 137 In a. case of retention of urine which occurred in the Pennsylvania Hospital in the year 1796, Dr. Physick was able to introduce a bougie, but no urine followed^ It, and his attempts to pass the catheter were completely. abortive; he immediately fastened the point of a bougie, upon the extremity of an elastic catheter, and very rea- dily passed the instrument into the bladder and eva- cuated the uriue. In a very great number of instances which have subsequently occurred the same method has proved successful. I consider this one of the greatest improvements which the catheter has ever received and shall briefly describe the mode of attaching a bougie point to a flexible catheter. A French catheter of the middle size is to be provided, and its point cut off, leaving a continued cylindrical ca- nal through it. A piece of bougie plaster between two and three inches long, is to be cut into a proper shape for forming a conical point to the instrument. When this plaster is rolled sufficiently to fill the cavity of the bougie, a slit half an inch long is to be made in its low- er end, after which the part rolled up, is inserted into the catheter, and the other half is wrapped round its out- side and fastened by tying a cambric thread neatly round it. In order to secure still more effectually the bougie . point from slipping off, and to extract it, in case this ac- A cident should happen, a strong thread is passed through the bougie and fastened to the outer extremity of the catheter, The opposite plate illustrates the construction of the instrument. A. Represents the waxed linen or bougie plaster, cut into the proper form. B. Represents the same plaster rolled so as to form a plug to enter the extremity of the catheter. C. The bougie point rolled around and attached to the catheter. . vol. 11. jC t 138 ELEMENTS OF SURGERY. The string d, is intended to give greater security to the instrument, and in case of a separation of the point from the catheter it would serve for the extraction of the former. Dr. Wistar generally passes the string through Jhe catheter in the manner represented at e, which is equally secure and much neater than the other mode. The bougie pointed catheter succeeds in a variety of cases in which no other instrument can be introduced. In cases of enlarged prostate gland it is particularly suc- cessful, and where a considerable portion of the urethra is tortuous from strictures, it can be passed with more ease than any other catheter. If, however, every attempt to pass a catheter fail, another mode of gaining access to the bladder is occa- sionally in our power by perforating the stricture in the manner already mentioned. The instrument for performing this operation is a ca- nula or catheter, curved in such a manner as to pass rea- dily as far as the stricture; in this canula is concealed a lancet capable of being protruded when necessary. The operation is to be performed by introducing the instru- ment as far as it will go, and then the lancet is to be protruded. In some cases the obstruction is situated beyond the bend of the urethra and in these cases, in or- der to guard against all danger of wounding any other parts except those intended, the handle of the instrument is to be depressed as low as possible, and when it is push- ed onward, it will be found to have divided the stric- ture and urine will generally escape through the ca- nula. The lancet is immediately to be retracted and the urine evacuated. A catheter must afterwards be intro- duced and left in the bladder until the new passage heals up. This very important operation which was contrived and has beenrepeatedly performed by Dr. Physick, has never been followed by any unpleasant consequences, and it has in several cases obviated the necessity of ELEMENTS OF SURGERY. 139 puncturing the bladder, an operation which Dr. Physick has never been obliged to perform, having always suc- ceeded by some of the preceding methods in drawing off the water. The success of Dr. Physick in this particular, during twenty years of extensive practice is a strong argument in favour of Mr. Abernethy's opinion that the tapping of the bladder is very rarely necessary. Mr. John Bell in his principles of surgery expresses great indignation against such an operation as I have described. He says "if so rash a thing has been done, I protest against it as a sword put into the hands of a fool; such an instrument (a trochar-pointed catheter) would soon be in the hands of every young man, and would prove, what the crotchet is in midwifery, a merciless resource." If that excellent anatomist had only paused long enough to investigate the probable consequences of the operation, he could have convinced himself that no such terrible effects were to be dreaded, as his ima- gination, fruitful in the invention of horrors, has antici- pated, and I am happy in the opportunity of attestingiitg perfect safety, at the same time that I would urge extreme caution in performing it. No one should under- take it who is not well acquainted with the anatomy of, the parts. Mr. Bell censures with comparative mildness (if his language can even be construed into censure) a much more dangerous expedient, that of forcing onward the catheter till it reaches the bladder. This operation is surely terrible. In Dr. Hunter's hands it proved" fatal, and though Mr. Dease succeeded in some cases by this uncertain mode, it is one which no surgeon at the pre- sent day will venture to recommend. , The introduction of the ^atheter in the female subject is an operation of no difficulty to a person acquainted with the anatomy of the parts. Before the operation the 110 ELEMENTS OF SURGERY. room should be darkened, and from motives of delicacy every exposure^ should be carefully avoided. The ca- theter is to be held in one hand, and the fore finger of the other is to be placed upon the clitoris, from which-a smooth surface'extends backwards a small distance and terminates at the orifice of the urethra; the finger passed along this smooth surface soon distinguishes the precise situation of this canal, and the catheter is then to be in- troduced and passed into the bladder. In the opposite plate are represented, Fig. 1. A straight canula and lancet for dividing the stric- ture at or anterior to the bend of the urethra. 2. A curved canula and lancet for the purpose of dividing the stricture when beyond the bend. 3. The lancet separated from the canula. It is best to have it made with a thin wire stem, because it will be found to move more readily in the canula. 4. Forceps for extracting calculi from the urethra. PLATE XTJ * '.S.Dorsey M tScuJp. J ELEMENTS OF SURGERY. 1*1 CHAPTER XX. Of Tapping the Bladder. This operation becomes necessary when all other means of evacuating the urine are found ineffectual. In itself it is by no means a dangerous operation, but it is very frequently followed by death, in consequence of being performed too late. Mr. John Bell remarks that in this case, as in strangulated hernia and lingering labours, delay is the greatest danger, and yet a remark which follows soon after is of equal importance, "the worst signs are no sure proofs of gangrene. In the most hopeless cases let the patient have his chance for life." Mr. Charles Bell considers the fourth day after a to- tal obstruction to the urine as the most favourable pe- riod for the operation. The bladder may be tapped from the perineum ;-above the pubes-and through the rectum. The difficulty of the first of these operation is considerable, and the extent of incision comparatively great. It has nearly gone into Misuse, but I have been informed that it has lately been performed in London; Mr. Astly Cooper plunges a lancet boldly into the bladder from the perineum, an operation formerly performed by Dr. Jones of this city. of the puncture above the pubes. In many cases of retention of the urine the bladder may be very distinctly felt rising nearly to the umbilicus. In such cases there is no danger of wounding the peri- toneum in puncturing above the pubes. 142 ELEMENTS OF SURGERY. An incision is to be made with a scalpel about an inch in length, through the skin and fat which cover the lower part of the linea alba; this incision should be made about half an inch above the pubis, and should extend between the pyramidal muscles down to the li- nea alba. A curved trochar (the curvature of which forms a segment of a circle seven inches in diameter) is now to be pushed into the bladder, the stilet being with- drawn, and at the same time the canula pushed further inward, the urine will flow freely through it. The ca- nula is now to be fastened by tapes to a bandage passed round the body, care being taken to leave the orifice free, and to this should be adapted^ plug of cedar, to be removed from time to time. A short catheter bent so as to fit the canula should be passed through it, in order to prevent the edges of the instrument from irritating the inner coat of the bladder. After a few days the adhesive inflammation will con- solidate into a perfect canal the aperture through which the canula has passed, and then the instrument being re- moved, an elastic catheter of the same diameter may be introduced, and changed once a week, as long as the circumstances of the case may require. The wound is to be healed whenever the natural pas- sage for the urine is sufficiently pervious. This operation I once performed in an old gentle# man in whom the urethra was completely obliterated, and the surgeons in attendance had no hope from the long duration of his disease and the great extent of the stricture, that he would ever evacuate the urine by the natural passage. He survived the operation several months during which time he was not much incommoded by the new method of making water. A fistulous orifice formed round the canula, and every drop of water was discharged through the instrument, the urethra remain- ing impervious. ELEMENTS OF SURGERY. 143 Desault performed the operation frequently with suc- cess. *)F PUNCTURING THE BLADDER THROUGH THE RECTUM. The finger passed into the rectum readily comes in contact with the prostate gland, and immediately above this in cases of retention of urine the distended bladder is perceived lying nearly in contact with the rectum, a lit- tle cellular substance alone intervening between them; at this place a curved trochar similar to that used for the operation last described, can be easily introduced, upon the fore finger of the left hand. The posture of the patient when the operation is performed should be the same as in Lithotomy. This operation is very easy and very safe. The only caution necessary is to avoid the vesiculae seminales which is done by making the puncture considerably above the prostate gland, and exactly in the middle of the tumour formed by the distended bladder. The ca- nula should be left in the wound until the urine resumes its natural course, although in a case where it was acci- dentally removed very soon after the operation, no ill consequences followed. As the canula would prove ex- tremely inconvenient when the patient had an evacuation ^from his bowels, an elastic catheter could no doubt be substituted with advantage. In cases where the prostate gland is greatly enlarged or where the rectum is diseased, the puncture cannot be rea- dily made through the rectum and that above the pubes is to be preferred. The puncture through the rectum ought only to be performed where it is fairly presumed that the natural passage will ere long become pervious. An interesting case of the operation is related by Dr. Hamilton in the Philosophical Transactions, which proves its safety. Dr. Hamilton's patient speedily acquired the 144 ELEMENTS OF SURGERY. power of discharging or retaining his urine at pleasure— a circumstance ascribed by Mr. John Bell and probably correctly, to the action of the levator ani muscle. The testimony of Mr. Home is favourable to this operation. He performed it in four cases. Mr. Charles Bell also recommends it. It is seldom necessary to puncture the bladder in fe- males. When, however, the operation is required, it can be very readily performed by passing a trochar through the vagina into the bladder, where it may be felt forming a large tumour. In case the obstruction in the urethra is permanent, the canula must be left in the bladder, and in that case it should be sufficiently long to project on the outside of the labia, where it is to be secured by means of a T bandage. In all cases in which it becomes necessary to leave a canula in the bladder it should be changed at least once in ten days, in order to remove the calculous mat- ter with which its extremity becomes encrusted. ELEMENTS OF SURGERY. 145 {^CHAPTER XXI. Of Stone in the Bladder. The urine in a healthy state contains the matter which when concreted forms a calculus, and all that seems ne- cessary for the formation of a stone in the bladder or kidney is the presence of a clot of blood, or some solid matter upon which this calculus may crystallize or conso- lidate—whether a nucleus of this kind is always neces- sary it is not easy nor important to ascertain. A stone in the bladder is perhaps as painful as any other disease to which the human body is liable, and it is sufficiently common to demand great attention from the student of surgery. Calculus generally forms in the kidney, and the symp- toms of stone commence with a pain in the loins, which becomes" very acute upon motion, and is often followed by bloody urine, or urine resembling strong coffee in co- lour. The quantity is small and is sometimes totally suppressed. Efforts to vomit take place and the stone is commonly forced into the ureter, temporary relief is ex- perienced, but the symptoms soon return and continue until by degrees the ureter becomes dilated and affords a passage for the stone into the bladder. The warm bath, anodyne glysters, and the copious use of diluent drinks greatly facilitate the descent of the stone, and af- ford much relief to the patient. When complete relief for a time is experienced after the preceding symptoms, there is great reason to believe that a calculus has been formed in the kidneys, and has VOL, n. u 146 ELEMENTS OF SURGERY. descended into the bladder. It is of course small, and at this time the patient should be directed to drink freely of barley water, and when the bladdcms distended with urine, to void it forcibly in a full stream, bending the body forward so as to render the neck of the bladder its most depending part. In this manner small calculi are sometimes discharged from the bladder, and much fu- ture suffering of the patient prevented : but this termina- tion, in the male subject, is not very frequent, and more commonly the size of the stone gradually augments, and the symptoms of stone in the bladder are experienced. One of the most usual symptoms which attends through- out the whole course of the complaint, is an itching of the perineum and glans penis. In order to relieve this the patient pulls the prepuce, and this becomes, especial- ly in children, greatly elongated. Great difficulty is experienced in making water; the urine flowing in a full stream is suddenly interrupted by the stone falling over the neck of the bladder; and when the bladder is nearly emptied, violent pain is felt. The bladder is in- capable also of containing as much urine as in health, and desires to empty it are very frequent. Tenesmus frequently attends; pain is felt in voiding the stools, and a discharge of semen occasionally takes place when the bowels are evacuated. The mucus of the bladder is dis- charged with the urine iu considerable quantity, and very frequently a sandy matter is mixed with it, the smell be- ing extremely fetid. A prolapsus ani occasionally takes place. Violent spasm of the bladder—dyspepsia—loss of appetite—diarrhaea, together with pain in various parts of the abdomen, often attend. The patient expe- riences an aggravation of these symptoms after exercise, or any irritating cause. A violent jolt is generally fol- lowed by bloody urine. Sometimes without any as- signable reason a very severe exacerbation of pain, and all the other symptoms come on, this is called a fit ELEMENTS OF SURGERY. 14tf of the stone and perhaps no sufferings transcend those experienced by a patient under such circumstances. The preceding symptoms seldom exist except the patient have actually a stone in the bladder, and yet as Bromfield remarks, " all together in the same subject they are not sufficient authority to perform the operation, unless the stone be first felt by the staff." Sir James Earle considers the least fallible sign to be the discharge of urine without pain, and violent pain after the bladder is emptied, arising from the contraction of the bladder upon the stone. The introduction of the sound however is never to be neglected when there is reason to suspect a stone in the bladder. The sound is a polished steel instrument, re- sembling a catheter in shape, but not like a catheter hol- lowed ; its point is also lower and straighter that it may touch every part of the bladder. The method of intro- ducing it differs in nothing from the introduction of a ca- theter ; but in searching for a stone, the posture of a pa- tient and the shape of the sound may be varied greatly: if the stone be not found in one posture, another, and another'must be tried. I have seen Dr. Physick in two cases succeed in detecting a stone with the sound, by placing his patient nearly on his head, so that the fun- dus of the bladder became the most depending part. When a difficulty of finding the stone exists, the blad- der should be examined in different states of fulness, and sometimes a silver catheter introduced has discovered a stone when it could not be felt with a sound, the urine in such cases flows through the catheter, the bladder contracts and forces the stone and the instrument in con- tact : the introduction of the finger into the anus often assists in finding the stone, and enables us to ascertain in some measure its size and form. When they come to- gether the sensation is not to be mistaken for any other, it may be distinctly felt and heard. 148 ELEMENTS OF SURGERY. A stone once found, it will be useless to consume time in endeavours to dissolve it. The use of lithontriptic, or as they are now more properly denominated, antilithic medicines are very serviceable in alleviating the symp- toms of stone, and in case of a severe paroxysm, opium, the warm bath, and blood letting, are useful. We are acquainted with a variety of medicines capable of dis- solving stone, when out of the body, but most of them are too irritating to be injected into the bladder. The gastric liquor of many animals possesses solvent powers in a very great degree, and dissolves among other articles, the urinary calculus. In my inaugural thesis published in 1802, are detailed some experiments which prove that this fluid may safely be injected into the bladder of a pa- tient with stone, and that portions of calculus are eva- • cuated after such operations. It is to be feared, how- ever, that the accretion progresses almost as fast as the solution, and therefore unless some more powerful solvent cau be injected, the operation is the only re- source. The most useful of the antilithic medicines, are, the various combinations of carbonic acid ;—the different al- kaline medicines ;—magnesia ;—and uva ursi. The mode of exhibiting these articles, may be found in the different dispensatories. That stoues of considerable size have been dissolved occasionally by the use of these articles, I have no doubt, but that such an event is ex- tremely rare is most certain. I once dissected a gentle- man of this city who had been sounded some years be- fore he died, and a stone was evidently perceived, the sound of the staff striking on the stone was audibly dis- tinct. This gentleman's bladder contained no stone at the time of his decease. Without entering into a history of the operation of lithotomy which would occupy a volume, I shall pro- ELEMENTS OF SURGERY. 149 ceed to describe the manner of performing the operation which I consider most advantageous.* The instruments necessary for performing the opera- tion, arc, strong garters or bands for securing the pa- tients hands and feet,—a grooved staff or director, adap- ted to the urethra,—a scalpel,—a sharp pointed straight bistoury,—a gorget or knife for dividing the neck of the bladder,—forceps of various sizes for seizing and ex- tracting the stone,—scoops or levers of different degrees of curvature,—a sharp-pointed curved bistoury, for en- larging the wound in the bladder, if necessary,—strong forceps with a screw in the handle to break the stone if U be too large for extraction,—a glystering syringe and pipe, together with warm barley water, to wash out any fragments of stone,—sponges, warm water, needles, li- gatures, tenaculum,—a needle and curved forceps, for tying the pudic artery if it be cut, and warm olive oil for the purpose of lubricating the instruments.! All the instruments which the surgeon can possibly need should be at hand, and carefully put in order before the operation. The beak of the gorget should be adapt- ed to the groove of the staff, and should move readily in it. The gorget should have a perfectly keen edge, es- pecially at that part which commences the incision, which is the part immediately connected with the beak of the instrument. There is no method of having this part of tins gorget perfectly keen, but by having the beak and blade separable, and Dr. Physick has accordingly for many years had his gorgets constructed in this manner. * A very excellent account of the various methods of extracting stones from the bladder, and a very good history of the improvements which have been suc- cessively made in lithotomy may be found in the principles of surgery by John Bell, 2 vol. t I have not thought it necessary to represent in engraving, all these instru- ments as the most of them are familiar to every student of surgery. There are some however which it will be proper to delineate because, they are not in gene- ral use. 150 ELEMENTS OF SURGERY. As I consider this an object of primary importance to the success of the operation, I shall describe the gorget of Dr. Physick which is represented in the adjoining plate.* Fig. 1. Gives a perspective view of the gorget; the blade a little open to shew in what manner it is connect- ed to the stem and secured by the screw. a. The blade. 6. The stem. r. The screw. d. The beak. e. The cutting edge. Fig. 2. The stem of the instrument comprehending the shaft, and beak. /. A groove gradually deepening to admit the point of the blade fig. 3. g. A perforation in the direction of, and to admit, the peg k, as a further security, and to pre- vent injuries to the point of the blade by the upper part of the groove b. h. The opening in the handle, admitting the blade. Fis. 3. A back view of the blade as relieved from the stem. i. The point. k. The peg. I. The cutting edge, the curved line shewing the manner of grinding it away to form the edge. m. The female screw. Fig. 4. A section of the gorget of a proper size, de- scribing the angle formed by uniting the blade and stem. Figs. 5, 6, 7> 8, 9,10, represent six blades, of various sizes, adapted to one common beak, whereby the sur- geon is furnished with a gorget proper for patients of * This instrument^ extremely well made by Mr. Bishop, from Savigny's manufactory, London, who published a description of it in Coxe's Medical Mu- seum, in 1804. . PapelfO.m.2. ELEMENTS OF SURGERY. 151 every age, and at an expense not exceeding one fourth the price of a set of common gorgets. The size and angle of the blade and haft of the in- strument should be similar to those of the common gor- get. The length from the beak to the angle four and a half inches; the handle four inches long. The drawing represents the instrument on a smaller scale. The width of the cutting edges in figures 5, 6, 7, 8, 9, 10, are ac- curately copied from Dr. Physick's instruments. Dr. Physick has had a similar gorget constructed with a double blade, but there are very few occasions where the stone is so large as to require its use. The patient about to submit to lithotomy should if practicable choose the spring or autumn in preference to the cold or hot months. The operation should never be performed during a paroxysm of stone. A temperate diet should be directed for some time previously, and if plethoric the patient should be bled. It is well to ad- minister, on the day preceding the operation, a dose of castor oil, and to empty the rectum two hours before the appointed time by an injection. The perineum should be shaved, after which an encema of laudanum and water may be administered, an hour or more before the opera- tion, and the patient should void no urine for several hours before the time affixed for operating. operation. The patient is to be placed on the end of a common dining table, with the leaves down, covered with blan- kets. The staff is to be well oiled and introduced; the different surgeons present take hold of it and satisfy themselves that they feel the stone. A strong fillet or garter is fastened by means of a noose, round each wrist, the patient is directed to grasp his feet with his hands, and by means of the fillets they are securely bound to- gether. 152. ELEMENTS OF SURGERY. The patient is now placed close upon the edge of the table, his head and back being supported by pillows in such a manner as to present the perineum in a conve- nient manner to the operator. In this posture he is to be held by two assistants who stand along side of the ta- ble (which of course should be narrow) and place the knees of the patient in their armpits, separating his limbs and firmly holding his feet. Another assistant.takes hold of the staff* with one hand and with the other raises the scrotum so as to expose the perineum. He is to hold the staff in such a manner that it may.project a little towards the left side of the peri- neum. The usual attempts to make.its convexity .very prominent, are however, attended with risk of forcing the- staff out of the bladder^ and there is no. advantage in it, because the first incision should be made without any re- ference to the staff. '• ' ■ •* / The surgeon being seated conveniently, commences the first incision with a scalpel, the point of which he inserts through the skin, at that part of the perineum wliich is im- mediately opposite the lower end of the arch of the pubis, of course the ineision begins at the'rapho of the perineum just behind we scrotum; the.knife-.is to be carried stea- . dily in a'rrght'line terminating midway between the lower margin of the anus and the tuberosity of the is- chium of the left '.side.. The first incision should be :'• deeper than it is commonly made, as theceis no danger ., to he dreaded at this stage of the operation, except a ; wound of the rectum which is easily avoided. This in- : cisiofl in an*adult should be between three and four, inches in length.' By two Or three successive strokes of ; the knife the incision is to be 'deepened* and "the trans-1 V ' versales .perinei muscles completely divided-^when this ■■;■■/ . is done-the groove of the staff is very readily felt, and • * the prostate gland at the bottom of the wound. The sur- geon now.:exchanges his scalpel for a sharp straight ELEMENTS t)F SURGERY. 153 bistoury thej>oint of which tie inserts with the back to- wards- the rectum into the membranous part of the ure- thra ; with this instrument he slits up the membranous part of the urethra by cutting in the groove of the staff from the prostate gland to the bulb and effects in this manner by one stroke of the knife what I have known surgeons half an hour in accomplishing by re- peated attempts to dissect down to the staff with a scal- pel. It is of no consequence whether the bulb be cut or not by this incision, it is unnecessary to do it, unless the surgeon should have difficulty in seeing or feel- ing the groove of the staff, and in that case, no danger attends his slitting the urethra freely forwards, always, however, cutting from the staff, the point of the bistoury being in its groove. The division of the urethra is great- ly facilitated by the use of the bistoury, and one simple incision is made instead of twenty. The staff is now laid bare to a considerable extent, and is generally visi- ble, but is always readily felt by the surgeon's finger; it only remains now to divide the prostate gland and neck of the bladder, which may be readily effected by a bis- toury, scalpel, or gorget, but far most conveniently by the last named instrument. The surgeon therefore after laying bare the staff places the nail of the left index fin- ger in the groove of the staff and introduces the beak of his gorget previously dipped in warm oil, into the situa- tion where his nail had been, and now rising from his chair he takes the handle of the staff in his left hand and moves the beak in its groove, ascertaining that no membrane or other substance intervenes between the staff and beak of the gorget. He should be certain also at this moment that the staff has not slipped out of the bladder. With a gentle steady motion he passes the gorget along the groove of the staff into the bladder, de- pressing the handle of the gorget in such a manner that the beak may move along the convex part of the staff VOL. II. x 154 ELEMENTS OF SURGERY. nearly at a right angle, and"the beak of the gorget will consequently take a direction nearly iu a line from the anus to the umbilicus. In introducing the gorget Dr. Physick recommends to push the staff* and gorget as far towards the right side of the perineum as possible, in or- der to avoid wounding the pudic artery. The urine gushing from the bladder and flowing along the gorget announces the division of the neck of the^bladder. The gorget is instantly removed (and there is no risk of ma- king a Wound in withdrawing it unless by great care- lessness) and the fore finger of the left hand introduced and brought in contact with the stone. Thfe staff may now be taken out, and the forceps introduced, or if the sur- geon have any fears from the smallness of his opening into the bladder, that he will not readily find the passage, he may leave the staff in as a guide for the forceps, but this ought never to be necessary. When the forceps dipped in warm oil are introduced, the surgeon should touch the stone before he opens them, and then with one handle in each hand he separates the blades and grasps the .-tone. It is best to use small forceps at first as they enter more easily, and in general, answer as well as the large ones. This part of the operation is sometimes very embar rassing. Surgeons have been baffled in their attempts to find a stone with the forceps which with the staff they could readily touch, and sometimes an hour has been consumed in fruitless searches for the calculus. In ge- neral the most depending part of the bladder contains the stone, and this is commonly immediately on the rec- tum, or a little to one or the other side of it, the elevation of the handles of the forceps, therefore commonly brings them in contact with the stone. The introduction of a finger into the rectum frequently facilitates very much this part of the operation. In some cases the stone is situated near the fundus of the bladder; in these cases ELEMENTS OF SURGERY. 155 a scoop may be used to draw it towards the wound in the bladder. In all cases of difficulty in finding the 'stone, it is better to search with a finger or a female ca- theter, than with the forceps. The bladder is often fill- ed with clotted blood, this should be rinsed out with warm barley water if it prevent the extraction of the stone. The surgeon having grasped the stone with his for- ceps, should be careful that he has taken hold of it in the shortest diameter so that it may occasion as little lacera- tion as possible whilst it is extracted. The use of a simple lever which is contained in all lithotomy cases, assists greatly in placing the stone in a position conve- nient for extraction. When this is done a regular but forcible effort is to be made and the stone extracted. The extraction may often be facilitated greatly by mov- ing the forceps from side to side, using in this manner each blade as a lever. It sometimes breaks in the grasp of the forceps, and then the larger fragments are to be successively taken out by the forceps, the smaller ones by means of a scoop, and the detached sandy matter is to be washed out by injecting forcibly a stream of warm barley water into the bladder, which will be evacuated through the wound, pleno rivo, and with it all the smaller particles of calculus. Sometimes the stone is too large to be extracted, and then it is to be broken, by means of a strong pair of for- ceps with a screw in the handles, and the pieces extract- ed as we have just directed, but if a small enlargement of the wound in the neck of the bladder will enable the surgeon to effect the extraction without recourse to this expedient, it will be better to introduce the index finger of the left hand into the bladder, and then a curved bis- toury with a sharp point may be used in suc'h a manner as to enlarge the wound, the surgeon cutting down upon his finger, runs no risk of wounding any important part, 156 ELEMENTS OF SURGERY. the prostrate gland may be thus- divided with great facili- ty to any necessary extent, and the extraction of a very large stone may in this manner, in general, be conveni- ently effected. The surgeon should always remember, that it is better to cut than to tear, and the maxim of Celsus should never be forgotten "plaga, paulo major quam calculus sit." The surgeon should next examine if any other stone remains. If the stone have a rough surface it is general- ly considered a proof that no other remains, the finger however or a female catheter should be introduced for the purpose of ascertaining this fact. One of the chief subjects now demanding attention is the hemorrhage. It always happens that some consi- derable blood vessels are divided and bleed freely in this operation. The arteria transversalis perinei is always cut, as it runs directly across the perineum iu the course of the incision. This artery is easily secured with a li- gature if it bleed freely, but commonly it stops after the operation is completed. The artery of the bulb of the urethra is occasionally divided, and sometimes it is necessary to tie it up, but the chief danger arises from the pudica interna, a very large artery running along the ramus of the ischium whioh is sometimes wounded by the edge of the gorget. When this happens the hemorrhage is profuse, and in many ca- ses has proved fatal. I am happy in being able to de- scribe a method of securing this vessel which obviates in great measure this danger from lithotomy, In the year 1794 I assisted Dr, Physick in his first operation for stone, and it happened that in passing the gorget he divided the pudic artery. He immediately placed a finger upon the spot, the bleeding ceased, and he felt distinctly the trunk of the vessel pulsating be- tween his finger and the ramus of the ischium. It Mas evident that if the flesh between his finger and the bone I'la '''■: ~£i- nutel5lM-*- t- i$L*-'\ „ S.Vursey deb- X SaUp. ELEMENTS OF SURGERY. 15/ could be compressed, the hemorrhage would be com- manded. He accordingly passed a tenaculum under the trunk of the artery, the point of which came out near the bottom of the wound. A strong ligature was then pass- ed under the projecting point and handle of the tenaculum, and was firmly tied, it included consequently a portion of ftesh, in which the wounded artery was contained, and effectually stopped the bleeding. This measure, which was contrived and executed in as short a time as I have consumed in describing it, can no doubt be applied in similar cases with equal advantage : the opposite plate Fig. 1, conveys an idea of the manner in which this was effected. Another mode however which promises to be more easily executed, consists in passing an armed needle contained in a curved forceps (Fig. 2) under the artery, bringing it out near the bottom of the wound and then tying the ligature. This operation I have never seen performed, but have no doubt that it could easily be done. After the operation is completed, the patient is to be placed on his side in bed, without any dressing to the wound, a folded sheet being laid under him in such a manner, that as fast as it becomes wet by the urine, a dry part may be substituted. A low diet and rest are the only remedies necessary. In some cases the patient has no unpleasant symptom in consequence of the operation, and in other instances death results without any evident cause. Mr. Charles Bell says he has known " the violence of the operation, without hemorrhagy or inflammation, to kill the patient in about ten hours." I have seen patients die in three or four days without inflammation. Sometimes gangrene results from the escape of urine into the surrounding cel- lular texture, and sometimes the bladder inflames violent- ly and death results from this cause. Peritoneal inflam- mation in some instances comes on, terminating very speedily in death. In cases where inflammation runs 158 ELEMENTS OF SURGERY. high, bleeding, and evacuating remedies are to be used and large blisters are to be applied over the abdomen. In general the urine flows for the first few days af- ter the operation through the wound, but in two in- stances in which I performed lithotomy it was my good fortune to witness the healing of the neck of the bladder by the first intention. In the first case (which occurred in private practice) not one drop of urine ever flowed through the wound after the operation was com- pleted, a circumstance which I ascribed to the small- ness of the stone, and the consequent absence of contu- sion. This patient walked about in two weeks, and his wound was healed before three weeks had elapsed. The other case occurred in the Pennsylvania hospital, the stone was much larger, and it required great force to extract it. The urine in this patient flowed during the afternoon and evening of the day on which I operated, through the wound, but never again, and the wound healed as if in one of the limbs.* I have no he- sitation in ascribing the successful termination of these cases to the use of a gorget which is so perfectly keen, as to pass without any resistance through the prostate gland and neck of the bladder. 1 have purposely avoided noticing the various modes of operating, now in use in Europe. The knife has ma- ny advocates, and the lithotome cache some. I have seen a very celebrated surgeon in Paris, cut off an arm ; cut out an eye, and perform lithotomy with the same bistourie, but I confess this simplification of apparatus is carried farther than I approve, and since 1 am persuaded that most of the objections to the gorget have originated from the use of bad gorgets, I have no hesitation in recom- mending a sharp gorget as the most convenient knife with which the bladder can be opened in lithotomy. • Copeland in a note contained in his work on the rectum, mentions a case where the wound made in lithotomy healed by the first intention. Dr. Physick once met with similar success. ELEMENTS OF SURGERY. 159 An operatiou called nephrotomy has been proposed lor the extraction of stones from the kidney. It consists in making an incision through the integuments and mus- cles immediately over that gland, and afterwards expos- ing and opening the pelvis of the kidney, sufficiently to allow the extraction of the stone. This operation has never I believe been performed, and probably never ought to be. It is in almost every in- stance doubtful, whether there exists a stone in the kid- ney, because every symptom resulting from such a cause occasionally occurs, when there is no reason to believe the existence of a calculus, and on the other hand where these symptoms have been ascribed with great probability to that cause, a speedy and permanent relief has been obtained without recourse to an operation;—circum.' stances which render the performance of so dangerous an operation highly unwarrantable. There is however one case in which it would be pro- per to make an incision in the vicinity of the kidney for the extraction of a stone, and that is when suppuration has taken place, and an abscess has formed; as soon as the tumour becomes prominent it would be practicable and safe to make an incision into it, and extract the stone. The great blood-vessels being in this case anterior to the abscess would not be endangered. 160 ELEMENTS OF SURGERY. CHAPTER XXII, Of Fistula in Ana. When abscesses form in the vicinity of the anus, they- are generally very difficult to be healed, and become fis- tulous. The complaint generally commences with a phlegmo- nous tumour near the anus, attended with considerable pain and hardness. In this stage it is often mistaken for a hemorrhoidal affection, and this mistake prevents the application of the necessary remedies. The tumour ad- vances gradually to suppuration, and matter is formed. In some cases the disease proceeds thus far with but little pain, and I have known a patient with fistula, utterly ignorant of the time when the disease formed. In other instances it is attended with extreme pain; with great swelling, and with extensive suppuration, with disury and even suppression of urine from the pressure of the tumour upon the neck of the bladder or the urethra. Fistula in ano sometimes results from an erysipelatous affection of the nates, and in these cases the disease is generally extensive, in consequence of the mortification which takes place in the surrounding cellular texture. I have also known a psoas abscess to point near the but- tock, and when opened more than a gallon of pus was evacuated. The patient recovered and the upper part of the abscess healed, but a fistula formed which requir- ed a surgical operation. I have witnessed so many ca- ses of fistula, in patients affected with pulmonary con- sumption, that I am disposed to consider it, frequently svmptomatic of that disease. In all the instances I have ELEMENTS OF SURGERY. 161 met with, the patient has died soon after the healing of the fistula. TREATMENT. The treatment of the disease depends upon the stage at which the surgeon is called. Should he b» sent for before suppuration has taken place, the usual remedies for inflammation are to be prescribed, with a view of pre- venting it. I shall not detail them, but simply remark that leeches in addition to the other evacuations are of great use in the present case, fifty or sixty may safely be applied to an adult, with an inflammatory tumour near the anus. Nothing is more ridiculous than the manner in which leeching is directed by the British surgeons; they speek of a leech, or two, as beneficial. To obtain advantage from leeches, in cases like the present, from eight to sixteen ounces of blood should be drawn by them, and this quantity can only be evacuated from an * inflamed part by applying from twenty to sixty leeches. If the surgeon be called after suppuration has taken place, or if notwithstanding his exertions the abscess point externally, it should be opened early with a lancet in order to prevent an extension of the disease by ulce- ration. When this is done, a poultice is to be applied, and a free discharge of matter takes place, after which the abscess sometimes (though rarely) heals, as in any other place. More commonly the sore remains open, discharging matter by an aperture near the anus, and a fistulous sinus forms. The disease in this state has no communication with the rectum, and is called an incom- plete fistula. In some cases beside the external open- ing, another is formed into the rectum, and a probe pass- ed by the external aperture comes in contact with a fin- ger in the rectum, this constitutes a complete fistula, from which flatus and faeces mixed with pus are often VOL. II. y 163 ELEMENTS OF SURGERY. discharged. An occult fistula is that in which the abscess opens into the rectum, but not externally ; an event which sometimes happens. The treatment of all these cases consists in laying open the fistulous ulcer in such a manner that the rectum and the fistula may form one cavity, with a free external aperture. The mode of performing the operation is to place the patient bending over a table, the nates being separated by an assistant. The depth and course of the sinus being previously ascertained by careful examina- tion with a probe, the surgeon passes the index finger of his left hand, well oiled, into the rectum, and a narrow curved bistoury down to the very extremity of the sinus. If the fistula be complete, his bistoury and finger will come in contact, and they are to be drawn out together in such a manner as to divide the rectum from one end of the fistulous ulcer to the other. If the fistula be in- complete, a hole must be made through the rectum, by means of the bistoury, and the operation finished in the same manner. In the former case a blunt pointed or probe-pointed bistoury answers best; in the latter it is necessary to have the point of the instrument sharp, to puncture the rectum. Dr. Physick has constructed a bistoury, which combines, to a certain extent, the advan- tages of the blunt and sharp pointed bistouries, and pos- sesses some advantages over both. The annexed plate represents this instrument. -v Fig. 1. The instrument in the handle half open. Fig. %. The silver guard, a. a. a small button on each side of the guard to relieve it from the blade. b. A notch or slit in the guard which slides upon the screw c, to secure it upon the blade. Fig. 3 and 4. The extremities of the blade and of the guard to shew the manner of their connexion. When the instrument is furnished with the guard it resembles a probe, and may be passed down to the bot- Flats xjj Feufe 142. Guarded Sistoury ELEMENTS OF SURGERY. 163 lorn of the sinus, and by pressing forward slightly the guard it is detached, and the naked blade remains very nearly in the same spot where the probe had been. The guard defends the sinus from all the irritation which re- sults from the sharp edge of the common bistoury. This instrument combines all the advantages of the probe pointed and sharp pointed bistouries except one, which is that the sharpness of the point when the guard is de- tached, is apt to prick the surgeon's finger in the rectum, an inconvenience which it possesses in common with the sharp pointed bistoury, and which can only be obviated by defending the end of the finger. This may be done with a piece of thin lead, or a common thimble secured by a string fastened to the wrist. I have often used the instrument, however, and have preferred the trifling puncture to the trouble and inconvenience of the thimble. The bistoury is extremely convenient for open- ing other sinuses, for dividing the prepuce in cases of phymosis, and for many similar surgical purposes. A variety of guarded bistouries have been contrived. I think this the simplest and best. After the operation, a dossil of lint should be intro- duced between the edges of the wound from one end of the incision to the other, in order to prevent the reunion of the cut surfaces. After the first dressings come away either with a stool, or by suppuration, light dressings of lint are to be applied. When several sinuses exist they are to be treated in the same manner, and laid open into the rectum. In cases of occult fistula the surgeon can commonly perceive a tumour formed by the collection of pus, or fae- ces in the sinus, and this he opens externally with a Ian- cet, after which the treatment is similar to that of a com- plete fistula. But I have seen a kind of occult fistula, formed just within the verge of the anus, and seated un- der the skin at this place, which discharges pus and oc- 164 ELEMENTS OF SURGERY. casions much irritation; in this case the sinus is to be sought by means of a bent probe, and the whole sac is to be removed with scissors. I have seen several cases of this disease, and all have been cured in this manner. There are some cases of fistula in which the sinus ex- tends beyond the reach of the finger, and other cases in which arteries of considerable size are situated in such a manner as to be wounded by the common operation. In such cases it has been the practice of Desault, in which lie has been followed by other surgeons, to pass a leaden wire through the fistula and out at the anus. This wire is to be twisted from time to time in such a manner as to compress the part of the rectum usually divided by the bistoury, so as to occasion ulceration and an absorption of the part. In this way the sinus gradually heals above the leaden wire, and by the time the parts are ulcerated through, the cure is nearly completed. When the fistula is incomplete, a perforation must be made through the rectum by means of a stilet adapted to the canal, which is to be received upon a piece of wood introduced into the anus, after which the wire passed through is to be drawn down by forceps; for a more particular account of this mode of treatment I refer to Desault's posthumous works published by Bichat. It often accelerates the cure to commence it by De- sault's plan, and after the wire has acted long enough to bring the sinus down within the reach of the bistoury, to divide it with this instrument. ELEMENTS OF SURGERY. J 65 CHAPTER XXIII. Of Hemorrhoids. A varicose or preternaturally distended state of the veins in the vicinity of the anus constitutes the dis- ease called Piles or Hemorrhoids. Tn some chronic cases the tumour appears to consist of a solid fleshy mass without any enlarged bloodvessels. A patient af- flicted with this disease is subject to copious discharges of blood from a rupture of the veins whilst evacuating his bowels, and fatal hemorrhage has occasionally re- sulted. The founder of the Arian heresy, and the phi- losopher Copernicus, are celebrated characters said to have perished in this manner. The inconveniences at- tending the complaint are often extremely great and a variety of dvspeptic symptoms are occasioned. Extreme pain is experienced m going to stool, followed by violent tenesmus, by profuse bleedings, and by a prolapsus ani, or descent of a large mass of hemorrhoidal tumours, which sometimes remain obstinately enlarged and irre- ducible. The tumours are generally internal and are covered by the lining membrane of the rectum, but sometimes external tumours exist formed of the common integu- ments. The disease is peculiarly frequent in sedentary men whose digestion is impaired, and it also occurs in others of costive or irregular habits of body. Pregnancy, en- larged abdominal viscera, and other circumstances which 166 ELEMENTS OF SURGERY. interrupt the circulation of blood through the bowels are frequent causes of hemorrhoids. At times the symptoms are mild, and at other periods they are greatly aggravated. An attack of piles is gene- rally treated by bleeding, laxative medicines, leeches, and cold and astringent applications to the part; when the tumour remains externally, and is constricted by the sphincter ani, leeches and cold applications are extreme- ly useful, and a variety of astringent lotions and oint- ments have been contrived for the purpose of affording relief. Those which I prefer, are the common ointment prepared by mixing very finely powdered galls with hog's lard, and another ointment formed of white lead mixed into a paste with laudanum, and then incorporated with simple cerate. The ingredients of this ointment, though they by no means form a neat chemical compound, can yet be sufficiently well combined for use, and they form a very comforting application to the part. A radical cure, however, should always be attempted by extirpating the hemorrhoidal tumours, either with a ligature or knife. Mr. Abernethy has of late highly commended the latter, as an operation equally safe and much less painful than the former," but the accidents which have resulted from wounds of the hemorrhoidal veins induce me to prefer very decidedly the ligature. It" is unquestionably painful, but is safe and certain. The operation consists in affixing a strong ligature upon the protruded tumour, whilst the patient strains as if at stool in order to propel them as much as possible. A parti- cular description of such an operation is unnecessary. The only cautions I would urge, are to tie only one tu- mour at a time, and to tie it so firmly as to intercept completely all circulation, so that the part may mortify and drop off. A low diet should be observed, and if ELEMENTS OF SURGERY. 167 great pain result from the operation opium should be ad- ministered. The best local application is a cold poul- tice supported by a T bandage. When the tumour falls off a second can be tied, and all may be thus removed in succession. Where the base of the tumour is too large to admit the application of a ligature, a needle armed with a double ligature must be passed through its base, and one string tied round each half of the tu- mour. Mr. Ware thinks it unnecessary in general to remove all the hemorrhoidal tumours, he believes the pain to proceed chiefly from one or two more inflamed and irri- table than the rest, but smaller and less prominent, pro- truding just low enough to be compressed by the spinc- ter mucsle. He advises the removal of these hardened, inflamed, painful tumours by means of a hook and scis- sors, and supposes that those which remain will collapse and disappear. This practice, however, is by no means safe, and Mr. Petit records an instance of fatal hemor- rhage from cutting off some internal hemorrhoids. The only hemorrhoidal tumours which I think it safe to cut off, are those which are completely external, and these should always be removed by the knife. 168 ELEMENTS OF SURGERY. CHAPTER XXIV. Of Prolapsus Ani. A protrusion of a portion of the rectum, or of its in- ternal coat, out of the anus, is denominated a prolapsus, or procidentia ani. In some cases a considerable por- tion of the intestine protrudes in this manner. The causes of the complaint are such as tend to weak- en the action of the muscles which support the intestine, and the violent exertions of the rectum in consequence of certain irritations. The frequent use of cathartics, es- pecially those which contain aloes,—the presence of as- carides in the lower part of the alimentary canal,—habi- tual costiveness, and hemorrhoids, have all occasionally produced prolapsus ani. I have known it a consequence of the tenesmus attending dysentery. In some instances the intestine remains a considerable length of time unreduced without any ill consequences, but more commonly it swells and inflames very speedily. It is therefore right to attempt as soon as possible the re- duction of the prolapsed part, and this can be best done with the fingers of the surgeon, the patient being placed on his back with the nates elevated. If the surgeon however be not called until the protrud- ed intestine is swollen and inflamed, the attempt at re- duction will be abortive; in which case the usual re- medies for inflammation are to be employed. Bleeding, general and local, here become necessary. Leeches are to be applied to the swelling, after bleeding from the arm, and a soft poultice with lead water is to be applied to the part. The bowels if disordered are to be compos- ELEMENTS OF SURGERY. 169 cd by opium. By these means the protruded rectum may in general be replaced, but the complaint is unfor- tunately very apt to return, and the chief difficulty is to prevent its recurrence. Numerous bandages and machines have been contrived for this purpose; one of the most ingenious is that of Mr. Bernard of Paris, who has constructed of the same mate- rials as those which form the elastic catheters, a perforated pessary, which when introduced within the sphincter ani, prevents the prolapsus of the intestine, and permits the evacuation of the faeces. This instrument should be in- troduced after the reduction of the protruded gut, and kept in its situation until the irritation occasioning the prolapsus shall have subsided, after which it may be re- moved ; the softness of its texture, the smoothness of its surface, its elasticity and lightness, prevent it from giv- ing much irritation. I have never had an opportunity of trying this instrument. To affect a permanent cure, the use of tonic and astringent remedies becomes necessary, and a careful abstinence from all those circumstances which produce the complaint. Dr. Physick has succeeded in some cases in complete- ly curing prolapsus ani, by confining his patients exclu- sively to a diet of rye mush and sugar, and the same re- medy has proved equally beneficial in the hands of other practitioners. During the use of such a diet, the bulk of the abdomen becomes considerably diminished, the bowels are kept constantly in a state somewhat loose, and all the faeces which are evacuated are of very soft consistence, cir- cumstances which combine to lesseu the effort of the abr dominal muscles, and thereby to prevent the bowel from being protruded with the faeces. Cases are recorded in which large portions of the ali- mentary canal have protruded at the anus. In the Me- moirs of the French Academy, the case of a child is vol. n. z 170 ELEMENTS OF SURGERY. related, in whom a complete eversion of the colon took place; it began eleven inches from the anus, and termi- nated five or six inches outside of it. The eversion ap- peared to commence at the coecum, and passed through the whole tract of the rectum. Other cases nearly simi- lar have occurred. These however are instances of in- tus-susceptio, in an inordinate degree, and probably ad- mit of no cure Prolapsus ani is most frequent in children, but some- times occurs in adults. Mr. Hey has in some cases re- moved by the knife the pendulous portion of the rectum, and has in this manner effected a cure. The operation is however a severe one, and I would therefore recom- mend a long continued trial of Dr. Physick's method, "before it is resorted to. Should this prove as successful in grown persons, as it has hitherto in children, there will be no necessity for so serious an operation as that performed by Mr. Hey. Where prolapsus ani is produced by liemorrhoidal tumours, these ought certainly to be removed in the man- ner already directed. ELEMENTS OF SURGERY. 174 CHAPTER XXV. Of Aneurism. An aneurism is a morbid dilatation of an artery. This definition does not, however, include a species of aneu- rism denominated spurious or false, which arises from a wound or rupture of an artery whereby a cavity con- taining arterial blood is formed in the cellular texture surrounding the vessel. This general division of aneurisms into true and false, has been unnecessarily complicated by subdivisions, which I shall not here enumerate, but shall describe in succession such varieties as are important to be known. It was formerly a current opinion that whenever the coats of an artery became weakened at a particular spot, the usual force of circulation would dilate into an aneu- rism the debilitated vessel, and Dr. William Hunter imagined that if the external coats of an artery were cut through, the inner coat might be protruded and gradual- ly dilating become an aneurismal tumour. This erro- neous theory has, however, been completely subverted by the experiments of Mr. J. Hunter and Mr. Home, who dissected off the outer coats and adventitious sup- port, of an artery, and the internal coat alone being left, was fouud sufficient to continue the circulation without acquiring any increase of volume at the injured part. To prevent any accession of strength to the denuded vessel, it was prevented from contracting adhesions to the sur- rounding substance. The experiments therefore prove that aneurism does not depend upon simple debility of an arterial trunk. i7<3 ELEMENTS OF SURGERY. Within a few years professor Scarpa has published a very interesting volume on aneurism, and has attempted to refute the received opinions respecting the nature of the disease, and to substitute in their room a doctrine of his own. He boldly declares, that all aneurisms arise from a wound or rupture of the inner coat of an artery, and consequently, that no such disease as true aneurism is to be found. The opinion of the learned professor, is delivered with an air of confidence, extremely imposing, and many surgeons have adopted it. " I have ascertain- ed (says Scarpa) in the most certain and unequivocal manner that there is only one kind or form of this dis- ease, viz. that formed by a solution of continuity or rup- ture of the proper coats of the artery with effusions of blood into the surrounding cellular substance, which so- lution of continuity is occasioned sometimes by a wound, a steatomatous earthy degeneration, a corroding ulcer, or a rupture of the proper coats (the internal and muscular) of the artery without the concurrence of a preternatural dilatation of these coats being essential to the formation of this disease, and therefore that every aneurism, wheth- er it be internal or external, circumscribed or diffused, is always formed by effusion." The only argument advanced by Scarpa in defence of his novel opinion, is, the result of his individual observa- tions ; a very slender foundation certainly, upon which to ground so strong a conclusion. At most the dissections of the industrious anatomist only give a colour of plausi- bility to his doctrine, and by no means establish its cor- rectness. After a very attentive examination of his cases and his remarks, I shall venture to record my total dis- sent from his opinion, which I cannot but believe to have originated in very imperfect views of the physiology and pathology of the absorbent system. From Scarpa's dissections, from the observations of other anatomists, and from the dissections I have myself ELEMENTS OF SURGERY. 173 made and witnessed, I have no doubt that aneurism is a disease seated in the proper coats of an artery, and that this disease speedily produces a change in the structure of the artery, generally, though not always attended by an enlargement at the diseased spot. The nature of the change I do not profess accurately to comprehend, but Mr. Hunter has proved that it precedes the dilatation of the vessel. I have a preparation at this moment before me, taken probably at a very early period of the disease3 shewing in the clearest manner, an alteration in the struc- ture of a large extent of vessel, which alteration Scarpa would doubtless call, a " steatomatous, earthy degenera- tion," but which in my mind evinces morbid action in the substance of the vessel, the coats of which are not absorb- ed, but are morbidly changed in texture. Scarpa is unquestionably correct in stating the occa- sional ulceration of the vessel, and the removal of its coats by absorption, but this I maintain is a consequence of aneurism, and is to be considered an evidence of a previously morbid state. I have now on my table a pre- paration in which an aneurism of the aorta has occasion- ed an absorption of part of the sternum, of the cartilages, of several ribs, and of almost every solid part in the vi- cinity of the vessel, and such cases are by no means rare. Now Scarpa's dissections have been made at a point of time when this business of absorption was com- mencing, and very probably he is correct in observing that sometimes the first part absorbed, is the inner coat of the artery, but assuredly if this be the case, that coat was in a diseased state, and was removed like any other dead or morbid matter. All therefore which the learned anatomist has proved, is, that the proper coats of the artery are absorbed in aneurisms, but this, I have no doubt, is a consequence, and not a cause, of the disease, and I think it probable that the removal of the inner coat by absorption, does 174 ELEMENTS OF SURGERY. not take place until it has been considerably distended and augmented in diameter. Mr. Richerand in commenting upon Scarpa's doc- trines, pronounces them utterly unworthy of his high character, an opinion in which I fully concur, and am led to retain the usual division of aneurisms into true and false; and 1 honestly think, that nothing can be more obvious than the totally distinct nature of the two cases; the one consisting in disease; the other resulting from accident. A true aneurism commences with an unusual throb- bing, and a small tumour at the affected part; by pres- sure the swelling disappears, but returns immediately when the pressure is removed. If the artery be com- pressed between the aneurism and the heart, the tumour also subsides, and is reproduced by taking off the pres- sure. The tumour is unattended with inflammation, no pain or redness being visible. Gradually augmenting in size it attains a very great volume, and the pulsations ge- nerally become less evident, and in some cases they are quite obscured, a circumstance generally ascribed to the diminished action of the distended vessel, and to co- agulated blood, of which a considerable portion is con- tained in the aneurismal cavity, through which the pulsa- tions of the vessels are less readily felt. In a large aneurism it is generally impracticable entirely to remove the tumour by pressure, in consequence of the coagulated blood lining its cavity. The circulation of blood through the branches of the aneurismal vessel becomes enfeebled, and these branches are sometimes found of a smaller size than natural. In the progress of an aneurism, oedema is sometimes occasioned, and caries of the neighbouring bones. The disease, when seated in a large artery and left to itself, terminates in death. The substance surrounding the tu- mour becomes absorbed in consequence of pressure, car- ELEMENTS OF SURGERY. 175 tilages, and even bones, in contact with the aneurism, are removed, and in many cases upon dissection the cavity of the aneurism appears to be formed by the surrounding parts, all vestige of arterial structure being lost, and a large portion of the neighbouring texture destroyed. At length the integuments become thinned, and the aneu- rism bursts, either from some unusual exertion, produc- ing a rupture of its parietes, or from the formation of a slough or gangrenous eschar at the external part of the tumour, an immense flow of blood follows, and terminates the existence of the patient. All the arteries are subject to aneurism: it is frequent- ly seated at the curve of the aorta, and the larger arteries are much oftener affected with it than the smaller, but not in strict proportion to their size; next to the aorta, the popliteal artery is perhaps most subject to aneurism. The causes of aneurism are not very clearly known. It is not uncommon for an arterial trunk to be found af- fected with aneurism in several situations, and in these patients the vessel, when it is not yet dilated, is seen spotted, in various places, as if with small masses of car- tilage. Mr. Pelletan has counted sixty-three, of various sizes, in one man.* OF THE TREATMENT OF TRUE ANEURISM. Scarpa with his usual confidence states it as " a cer- tain and incontrovertible fact in practical surgery that a complete and truly radical cure of aneurism cannot be ob- tained in whatever part of the body this tumour is situat- ed, unless the ulcerated, lacerated, or wounded artery, from which the aneurism is derived, is by the assistance of nature, or of nature combined with art, obliterated, and * " J'en ai compte soixante-trois sur un seul homme depuis le volume d'une aveline jusqu'a celui de la moitie d'un oeuf dc poule." Cliniqut Chirur. torn. h. 176 ELEMENTS OF SURGERY. converted into a perfectly solid ligamentous substance, for a certain space above and below the ulceration, lace- ration, or wound." This fact asserted by Scarpa with respect to all aneurisms is perhaps true with respect to true aneurism, and it has been the custom to consider these cases as beyond the reach of surgery, unless in cases where the diseased artery can be secured and its cavity obliterated by the application of a ligature; a low diet and occasional bloodlettings were considered as remedies likely only to palliate the complaint. Valsalva, however, appears to have entertained more sanguine expectations, and has accordingly carried this plan to a greater extent by copious and repeated blood- lettings and by a very abstemious diet. I have not been able to see his work, but in the valuable memoir of Mr. Pelletan upon internal aneurisms several cases are recorded, which the author pronounces positive cures, effected by the mode of treatment recommended by Val- salva. Some idea may be formed of the extent to which depletion was carried in these cases from the following passage. "During the first four days I prescribed eight bleedings of three bowls* in the morning and two in the evening. The fifth day the pain and pulsation were much diminished, but the pulse preserved its fulness and two bowls of blood were taken at one bleeding. The pulse remained in a favourable state of weakness till the seventh day, when it became more tense, and the patient lost one bowl of blood in the morning and one in the evening."f During this time the patient was kept to a very ri- gorous diet. In twenty-eight days the patient left the hospital (contrary to the advice of his surgeon) but he never after had a symptom of aneurism. * The term palettes which I have translated bowls, generally signifies four cunces, so that three bowls or porringers, implies twelve ounces. f Clin. Chir. torn. 1. p. 73. ELEMENTS OF SURGERY. 177 Although I would not be sanguine in my expecta- tions of curing an aneurism of the aorta, yet the testi- mony of Mr. Pelletan is so respectable that his treatment is unquestionably worthy of imitation. The general indication to be regarded in the treatment of aneurism is to effect an obliteration of the diseased vessel. This has been done occasionally by pressure, and in some instances a spontaneous cure of aneurism has taken place in consequence of the pressure from the tumour which has effectually precluded fresh blood from the aneurismal cavity, and has produced adhesions in the inner coat of the vessel which have entirely closed up its cavity. Such an event is however very rare, and the effects of pressure are by no means certain. Guattani unquestionably succeeded in many cases by compression, and Mr. Freer in his experiments on horses has proved that compression, may be so applied as to effect the ob- literation of a healthy artery. He recommends pressure upon a sound part of the artery above the aneurism. The best mode of treatment, however, is to tie up the artery at such a distance above the aneurism that the ligature may act upon a healthy portion of the vessel, and thus produce adhesion at that spot; a practice introduced by Mr. Hunter, and founded upon the ill success attending the application of ligatures upon the diseased vessel and the frequent and fatal hemorrhages resulting from that imperfect mode of treatment. He expected that if the artery were tied above the diseased part, the aneurismal tumour would cease to enlarge, and be ultimately re- moved by absorption. Mr. Hunter's first operation was performed in 1785, in a case of popliteal aneurism, and we shall therefore describe this particular aneurism first. It is the most frequent case demanding the surgeon's attention, and the principles which direct his practice in this can readily be applied to aneurisms in other situations. VOL. n. a a 178 ELEMENTS OF SURGERY. OF POPLITEAL ANEURISM. In this case the tumour may be felt pulsating strongly in the space between the hamstrings. It occurs most commonly in coachmen, and the general character of aneurism is distinctly evident. When the operation is to be performed the patient is laid on a table, and a tourniquet placed round the upper part of the thigh; an incision four inches long is then made on the anterior and inner part of the thigh rather below its middle, and this wound is continued obliquely across the inner edge of the sartorius muscle. The fas- cia covering the artery is next to be laid bare, and the vessel can then be very plainly felt. The fascia is now to be cut through along side of the artery, and the ves- sel is thus completely exposed. An aneurismal needle (a small blunt silver bodkin, curved to the shape of the common needle) armed with a strong double ligature of waxed thread, or strong bobbin, is to be passed round the artery. The ligature being cut at the eye of the needle, two strong ligatures are left round the artery, and both these are to be firmly tied the one an inch higher than the other, after which the artery is to be divided with a bistoury between the two ligatures, an improve- ment introduced by Mr. Abernethy, for reasons to be no- ticed presently. This operation differs in some respects from Mr. Hun- ter's, but I have preferred a description of what I con- sider the best method, to a long detail of each successive improvement which the operation has undergone. The wound is to be dressed with adhesive plaster and the patient confined to bed. In general the liga- tures come away between the twelfth and twentieth days and the aneurismal tumour is gradually absorbed, or forms an abscess, and after a free suppuration gets well. ELEMENTS OF SURGERY. 179 The operation of Mr. Hunter for popliteal aneurism, in some instances terminated in fatal hemorrhage, and Mr. Abernethy ascribed this unfortunate event first to the inflammation and ulceration of the artery, and se- condly to the want of union between the sides of the ves- sel. From observing that the bloodvessels of an ampu- tated limb were less apt to bleed than the femoral artery when tied for the cure of popliteal aneurism, Mr. Aber- nethy was led to place this artery in the same situation, by applying two ligatures and dividing the vessel be- tween them. In this manner the tension of the vessel is lessened, a retraction takes place, and the vessel con- tracts adhesions to the surrounding parts, and in the opinion of Dr. Jones founded upon very numerous expe- riments on brutes, the plan of Mr. Abernethy is safest and best. We should recollect in tying so important a vessel, the doctrines of hemorrhage developed by Dr. Jones, and never neglect to tie the artery as closely as possible to its natural connexions, and never to apply a ligature upon the vessel in a situation in which it is de- nuded to any considerable extent. Mr. Astly Cooper in performing the operation in the manner of Mr. Abernethy, found that both the ligatures were forced off, and the divided artery was left which would have inevitably occasioned fatal hemorrhage had the surgeon been absent. Mr. Cline met with a similar case, and his son, Mr. Henry Cline, contrived a plan for preventing the recurrence of such an accident, which consists in passing each ligature, by means of a curved needle, through the cut extremity of the artery. I doubt very much the necessity of this refinement, and believe that wherever the ligatures are tied suffi- ciently tight to divide the inner coat of the artery there will be no reason to dread the slipping off of the liga- ture. At least I have never seen a case in which the accident has occurred. 180 ELEMENTS OF SURGERY. OF FEMORAL AND INGUINAL ANEURISMS. The operation last described may be performed in cases where the aneurism is situated near the knee, but the femoral artery is occasionally diseased considerably higher up, aud in these cases it is equally necessary to tie the artery in a situation remote from the disease. If this can be done in any place below the groin the opera- tion differs in nothing essential from the one just de- scribed. It, however, in some cases happens that the aneurismal tumour is situated in the groin, and then it becomes necessary to tie up the trunk of the external iliac artery within the pelvis, an operation first perform- ed by the intrepid Abernethy, and subsequently by se- veral other surgeons. As I have myself met with such a case and treated it successfully I shall copy, the account of it published in the Eclectic Repertory, as the best method of describing the operation. With respect to the proper time for performing the operation, in this antl most other instances it is safest to operate early, because the advantages wliich some sur- geons have expected from delaying it until the anasta- mosing vessels are enlarged, is more than counter-bal- lariced by the danger of an extension of the disease. CASE. On the 15th of August 1811, I was consulted by Alexander Patton, on account of a tumour in his right groin. The patient was a native of Aberdeenshire in Scotland, aged about thirty years, the last ten of which he had passed in America. He followed the trade of a cooper; was accustomed to hard labour, and to athletic exercises, jumping, running and the like. He was six feet in height, of a robust but not corpulent habit. Two years ago he perceived, for the first time, a small tumour in the right groin. Having never had the vene- ELEMENTS OF SURGERY. 181 real, nor indeed any other disease, and not havins: met with any accMent, he was at a loss to*account for this appearance. From its commencement it throbbed with considerable violence. For a year and four months it increased very slowly; during the last weight months much more rapidly. In January it was no bigger than a walnut; in August its shortest diameter was four in- ches, its longest, nearly five. It occasionally gave him severe pain, and at length incapacitated him from all la- bour. In June last (1811) he applied to Dr. Irwin of Easton, the place of his residence, who instantly apprised him of the nature and importance of the complaint, and advised him to come to Philadelphia. He arrived here the 14th of August, and was admitted next day into the Pennsylvania hospital. On examination, an aneurism was found, situated im- mediately below Poupart's ligament, forming a regular tumour in the groin, nearly hemispherical, with a kind of apex, where the skin appeared extremely thin, and discoloured as if by ecchymosis. The patient had used a good deal of exercise previously to his admission into the hospital, and had taken a drink of rum, in conse- quence of which his arterial system was greatly excited, and the tumour pulsated so violently that the bed clothes were bounced up with great force. He was confined to bed, was purged, and kept m a low diet. A consulta- tion was called; and the surgeons of the house concur- red in recommending the operation of tying the artery as high as practicable above the tumour. It was determin- ed to perform the operation promptly; as the disease was progressing, and no benefit was to be expected from delay. On Monday 19th of August, at noon, in presence of Dr. Physick and Dr. Hartshorn, surgeons to the hospital, and a number of medical gentlemen, I proceeded to the operation. The patient, having previously taken fifty drops of laudanum, was placed on the table. An inci- 18£ ELEMENTS OF SURGERY. * sion, three inches and a half long, was made, beginning an inch and a half higher than the superior anterior, spi- nous process of the ilium, and one inch distant from that process internally ; being also four inches and a half dis- tant from the umbilicus, extending obliquely downward and terminating about one inch above the basis of the tu- mour. This incision, which was nearly in the direction of the fibres of the tendon of the external oblique muscle, divided the skin and adipose membrane, and exposed that tendon, which was next cut through, the whole length of the external incision. The internal oblique muscle now protruded at the wound and was carefully cut through; the inferior edge of the transversalis ab- dominis was next divided, but not so far upward as the top of the external wound. My finger was then intro- duced, and the cellular texture readily yielded it a pas- sage to the external iliac artery, the trunk of which I distinctly felt pulsating very strongly. With my finger I separated it gently from the neighbouring parts; but took care to denude only a very small portion of the ves- sel. The peritoneum I was equally careful to detach as little as possible; and not more than a square inch of it was disturbed. The only remaining difficulty in the operation was to pass the ligature round the vessel; and this having been anticipated, was readily surmounted. Before commencing the ^operation, I had secured an aneurismal needle (a blunt bodkin of silver properly bent) in a pair of curved forceps, by tying the handles of the forceps firmly together. The needle was armed with strong bobbin; and thus connected with the forceps, resembled a tenaculum, which could easily be managed outside of the wound. With one finger in the wound I found it very easy to direct the extremity of the needle, and with the forceps in my other hand, to push it through the fascia surrounding the vessel. The string connect- ing the handles of the forceps was now cut, and the ELEMENTS OF SURGERY. 183 needle was left under the vessel. The forceps being removed, the needle was drawn out, leaving the ligature round the artery. Convinced, by careful examination, that nothing but the artery was included in the ligature, and that it was, to the best of my judgment, natural in size and texture, I tied it very firmly, as high up as pos- sible. The pulsation of the tumour instantly ceased. Three knots were made, and the ends of the ligature were left out at the external wound. No blood-vessel of magnitude was divided, and not half an ounce of blood was lost. No stitches were employed to close the wound; a strip of adhesive plaster effectually answered this pur- pose. A pledget of lint was applied, and the patient was put to bed, his thigh being moderately flexed upon the pelvis. He complained of extreme pain during the latter part of the operation, the whole of which occupied eleven minutes. The patient's pulse, for several days before the opera- tion, was 80 : after the operation it was 88, and rose in the afternoon to 100. At four o'clock* he was bled ten ounces. At seven be complained of extreme pain in the back and belly, and also of some pain in the limb. He was not permitted to take any sustenance except toast and water. The superficial veins of the leg and foot were filled ; and the whole of the limb was covered all the evening with perspiration. Its temperature was ex- amined repeatedly by a thermometer, and was five de- grees colder than the other. It was covered with flannel and carded wool. Tuesday SOth. Passed a restless night, in great pain. To use his own language, in expressing his sensations, "he felt as if his loins were tearing apart." He was also troubled with pain of the bowels. Three grains of calomel and ten of rhubarb were given, but without pro- curing a stool. In the afternoon he was bled ten ounces. and a purgative injection was ordered; after which his 184 ELEMENTS OF SURGERY. bowels were freely opened, and his pain subsided. An enema, consisting of a hundred drops of laudanum and two ounces of water, was administered, and he soon af- ter fell asleep. The weather, on the dav of the opera- tion and seve^il days after, was very hot. The mercury of the thermometer in the patient's room stood at 86° Fahrenheit. Placed between the toes of the aneurismal limb, it rose to 88°; between those of the sound limb 90°; at both knees it stood at 92°. His pulse was 100 and tense. Wednesday 21st, third day after the operation. The sleep procured by the anodyne injection continued all night. In the fore part of the day he was easy ; but in the evening his pain returned with considerable fever. He was bled ten ounces and took ten grains of magnesia and as much rhubarb: this with the assistance of a clys- ter, brought away a large quantity of fasces and flatus, and procured relief of all his pain. The anodyne injec- tion was again administered, and he soon after slept. His pulse 100. and somewhat tense. Thursday, fourth day. He slept all night, and was much better; being quite free from pain and fever. His pulse 90. He ate some boiled rice with great relish. The wound was examined, and it was found that nearly all of it had united: a little healthy pus surrounded the ligature. The limb was four degrees colder than the sound one. From this time no change of importance occurred un- til Sunday, 1st Sept. when the ligature came away; viz. on the fourteenth day after the operation. In a few days more the wound cicatrized, without the occurrence of a single unpleasant symptom. On the twentieth day after the operation, his nurse being absent, he arose from bed and walked across the room, and has taken exercise every day since without inconvenience. The tumour in ELEMENTS OF SURGERY. 185 the groin diminishes slowly, and at this time is much re- duced in size. ^ Remarks. The operation of tying up the external iliac artery above Poupart's ligament was first performed by Mr. Abernethy, under circumstances in which imme- diate death was the only alternative. He repeated it af- terwards in cases of aneurism seated so high in the fe- moral artery as to preclude all prospect of a cure by any other means. He performed the operation four times. In the first two instances his patients died; in the suc- ceeding cases they recovered.* Mr. Freer, in the Bir- mingham hospital, performed the operation in a case of inguinal aneurism with complete success; and soon after another case was treated successfully by Mr. Tomlinson, of the same hospital, f These six cases are all that I have seen related, in which the operation has been tried. The case I have now detailed is the seventh; and it has failed in only two of these. In every instance the limb has been supplied with blood, which does not uniformly happen after the operation for popliteal aneurism. I wish, before closiug this paper, to call the attention of those surgeons, who may have occasion to perform the operation, to the forceps, of which an engraving is annexed. This instrument was contrived several years ago by Dr. Physick for the purpose of passing a needle under the pudic artery, when wounded in lithotomy, and has since been used by him for securing bleeding arte- ries in deep narrow wounds. Mr. Abernethy complains of "the great difficulty of turning a common needle in a deep narrow wound;" and Mr. Freer was unable to pass his aneurismal needle round the iliac artery, until he punctured the fascia surrounding it with his knife, which he confesses was the most "difficult and dangerous part of the operation." These dangers and difficulties are • Abernethy's Surgical Observations. f Freer on Aneurism. VOL. II. B b 186 ELEMENTS OF SURGERi. entirely obviated by means of the curved forceps: and I think the operation greatly simplified by the use of this contrivance. Should this paper meet the eyes of Mr. Abernethy, I hope he will be gratified with the additional testimony of the importance of an operation for which the world is indebted to the intrepid efforts of true genius; and he will no doubt learn with pleasure, that one individual on this side the Atlantic owes to it, his life.* To this account I have only to add that the operation has been since performed in Dublin and in London with success ; it certainly affords a strong proof of the courage derived from our increased knowledge of the resources of the animal ceconomy. The extent to which anastomo- sing vessels are capable of enlarging when a main ar- tery is obliterated, is perhaps not yet fully developed. Mr. Astly Cooper has made some experiments upon dogs, by which it appears that the aorta, both caro- tids, and the subclavian arteries may be tied up with- out destroying the life of the animal. OF ANEURISM OF THE CAROTID ARTERY. In November 1805, Mr. Astly Cooper tied up the ca- roticj, artery in a case of aneurism, and though the pa- tient died on the twenty-first day, she had lived long enough to prove that her death did not result necessarily from the operation. Mr. Cooper repeated it there- fore on a porter aged fifty, upon whom it succeeded completely, and tbe patient was cured. Dr. Baillie and Mr. Hunter many years ago thought the success of this operation not improbable, but protested against it except in cases of absolute necessity. • The adjoining sketch is intendecPto point out the paft where the operation was performed, and the instrument used to convey the ligature* round the arte- ry. It needs no particular expfanation. Pi,ATE JTX/II :u;. /;-/ J),.**"' "L'fn-9' Inguinal* A^eitrism. ELEMENTS OF SURGERY 187 The following case extracted from Mr. Cooper's pub- lication will prove sufficiently descriptive of the disease and operation; The dilatation of the carotid artery was seated just below the angle of the jaw, and about the acute angle which is made by the great division of the common caro- tid. The tumour was about the size of a pullet's egg, and prominent in its middle. The pulsation of the aneurism on the day of the ope- ration was remarkably strong; when the sac was emp- tied by pressure on the artery below, the tumour sprang to its original size with one contraction of*the heart. Mr. Cooper proposed to tie the common carotid below the dilated part, and the operation was performed at one o'clock on the twenty-second of June, 1808, at Guy's Hospital. He began his incision opposite the middle of the thy- roid cartilage from the base of the tumour, and extended it to within an inch of the clavicle, on the inner side of the mastoid muscle. On raising the margin of this mus- cle, the omo-hyoideus could be distinctly seen crossing the sheath of the vessels, and the nervus descendens noni was also exposed. He next separated the mastoid from the omo-hyoideus muscle, and the jugular vein be- came apparent, which, being distended at every expira- tion spread itself over the artery. Drawing aside the vein, the par vagum was evident, lying between it and the carotid artery, but a little to its outer side. This nerve was easily avoided. A blunt iron probe constructed for the purpose was then passed under the artery carrying a double ligature with it. Two ligatures being thus conveyed under the artery the lower was immediately tied. Mr. Coopei* next detached the artery from the surrounding parts, to the extent of an inch above the lower ligature, and then tied the upper. Lastly a needl#and thiead Vvere passed 188 ELEMENTS OF SURGERY. through the artery above one ligature and below the other. The division of the artery was then performed. Nothing now remained but to dress the patient and this was done by drawing the parts together by adhesive straps, the ligatures hanging from each end of the wound, and by laying on a piece of lint retained by straps of ad- hesive plaster. After the operation the patient felt relieved from a headache which had accompanied the formation and growth of the tumour, and which never afterwards re- turned. The pulsation of the tumour, however, did not entirely cease in consequence as Mr. Cooper supposed, ofvthe return of blood by the internal carotid artery from the brain. This patient happily recovered ; a cough and hoarse- ness came on and continued a long time; on the twenty- third day the upper ligature came away, and on the twenty-fourth the lower, and soon after the wound heal- ed, the patient was discharged cured, and the tumour gradually disappeared. Mr. Cooper thinks that the aneurism in the preceding case was situated in the internal carotid artery, a circum- stance which led him to hope that the regurgitation of the blood, although at first sufficient to excite a slight pulsa- tion in the tumour, would not continue to support its growth, because as the internal carotid artery passes through a foramen in the skull, a little above where the swelling was situated, it could not dilate at that part to bring down any additional quantity of blood into the sac, so that its first effect was likely to be as great as any it could produce. But if the aneurism had been of the ex- ternal carotid artery, owing to the number of communi- cating vessels, he would not have been equally sanguine in his expectation that the pulsation would have ceased. ELEMENTS OF SOtffeERY, iS*| 1 have great pleasure in subjoinitig the following very interesting case in which the carotid artery was tied up successfully by Dr. Post of New York, a gentle- man long distinguished as one of our ablest surgeons. Peter Thomas aged thirty-five, a native of the West Indies, was admitted into the New York Hospital Ja- nuary fifth 1813, with a large aneurism of the carotid ar- tery, situated immediately below the angle of the jaw on the right side. The account which he gave of himself was as fol- lows. In March 1812, he first experienced a pulsa- tory sensation in the neck, but at this time there was no visible tumour. A tumour was, however, soon after discovered on examination, which very slowly and gra- dually increased in size, until about two months since, when it began rapidly to enlarge. Previously to its last enlargement, he experienced no pain in it; but now com- plains of an unpleasant throbbing sensation, and has lately had several attacks of vertigo. He had been bled from the arm sometime before his admission into the Hospital, and by some ignorant prac- titioner, had had several blisters applied to the tumour. He had never laboured under any severe indisposition, and his constitution was robust and plethoric. For some considerable time before the discovery of the tumour, he had been occupied as a labourer to attend upon masons, and of course in this capacity, was frequently necessi- tated to carry very heavy loads upon his shoulders to a great height. In this employ too, the frequent inclina- tion of the body forward would greatly favour a deter- mination of blood to the head. The tumour upon being accurately measured at this lime was found to possess the following dimensions. 19^ ELEMENTS OF SURGERY. INCHES. Length ...... 6£ Breadth......4 Height or projection from the neck more than......% Half circumference - 83 Being of a full habit of body with a strong pulse, he was bled from the arm to 5 xvj, took some cathartic me- dicine, i and was ordered to live upon a light diet, to di- minish arterial action. On the seventh of the month a consultation was held, when it was agreed to take up the carotid ajtery below the tumour, as affording the best chance of success in the case. The patient, anxious to be relieved, willingly sub- mitted to the operation, and it was performed on the ninth at IS o'clock, by Dr. Post, in the presence of a large number of professional gentlemen in the following manner: An incision was made from the lower part of the tu- mour to within a very small distance of the clavicle, of about. three inches in length. This laid bare the inner edge of the sterno-mastoid muscle, and by cautiously di- viding the cellular substance, the sterno-hyoideus and the sheath containing the vessels, were exposed. The sheath was then divided, and the artery separated from the vein and par vagum. This part of the operation was done with great caution, sometimes using the edge and sometimes the handle of the scalpel, to avoid inju- ring either of these important vessels. An eyed probe properly curved and armed with a round ligature, was passed under the artery. The ligature was then divided, and the lower one tied, and after detaching the artery about three-fourths of an inch from the lower ligature, the upper one was tied. Both ligatures being previous- ly armed with a small crooked needle, the lower one Mas ELEMENTS OF SURGERY. 191 passed through the artery above the ligature, and tied a second time as recommended by Henry Cline jun. of London. The artery between the ligatures was then divided with a bistoury. It was not deemed necessary to pass the upper ligature through the artery, as there could be but little or no dan- ger of its slipping off; the force of the circulation being altogether resisted by the lower one; though the arte- ry was at least one third larger than natural, and the coats uncommonly thickened. As soon as the first ligature was applied, the pulsa- tion in the tumour entirely ceased; but in the course of an hour afterwards, upon being attentively examined, an obscure pulsatory or undulatory motion was discover- able. About two minutes aftqp" the first ligature was applied, one of the gentlemen present having his fingers upon the pulse at the wrist from the commencement of the operation, observed a sudden diminution both of fre- quency and force in the stroke of the artery, so that it could scarcely be felt at all, and yet there was no ap- pearance of syncope. In about five minutes, however, it was restored to its former standard. The patient com- plained at this time, of a pressing, or sense of weight in the right inferior extremity, the right arm Mas very much relaxed, fell from the side of the body, and seemed de- prived of the power of motion. These symptoms, how- ever, immediately disappeared with the return of the energy of the circulation. The wound was dressed by drawing the parts accu- rately together by straps of adhesive plaster, with the ligatures hanging from each angle of it; and over these a piece of lint retained by adhesive plaster. No ban- dage was applied. The man was then carried to his bed, and had his head and shoulders considerably ele- vated. 19& ELEMENTS OF SURGERY. About three hours after the operation he complained of oppression about the upper part of the chest, and some pain in the right side of the head, though not of the throbbing kind wliich he felt before the operation. As he complained also of chilliness and cold feet, accompa- nied with a small and feeble pulse, he was ordered a draught of Aq. Ammon. Acetat. and Tinct. Opii—to drink freely of tepid drink, and have warm applications to his feet. By 10 o'clock in the evening he felt very comfortable, except a little pain in the head—Pulse 70, full and soft. Next day, January tenth—Morning. Slept very well during the latter part of the night, and at present feels no uneasiness except a little in the head—Pulse 70 and full—was bled to §xij—Four o'clock P. M. pulse 80, and full, in other respects much as in the morning. At ten in the evening his pulse being 84, strong, full and in «ome degree hard, with white tongue, and an increase of temperature of the skin, he was bled to ^x more. January eleventh. Complains of stiffness and some uneasiness about the throat, but has no pain. Having had no alvine evacuation since the operation, was or- dered the Tart. Potas. and Sodae in divided doses— Pulse 86. January twelfth. The purgative operated very well. Early this morning after an attack of coughing, he fell into a state of syncope, which lasted several minutes; on recovering he complained of an uneasiness about the throat, and a difficulty in throwing up the mucus from the fauces—Pulse frequent and feeble, skin cold and covered with a copious perspiration—Ordered a more nourishing diet—Evening—Pulse 94 and moderately full—feels no pain except in the wound—Tumour does not appear quite so prominent as before, is harder to the feel—pulsation very obscure. . ELEMENTS OF SURGERY. 193 January thirteenth. Passed a comfortable night—Is troubled occasionally with fits of coughing, for which he was ordered Tinct. Opii. gtt. x in ^fs. Sol. Glycyrrh. every two hours. The frequent fits of coughing have so deranged the dressings, (though they have been fre- quently re-applied) that no union by the adhesive in- flammation has taken place, but suppuration is coming on. Pulsation almost imperceptible. January fourteenth to twentieth. The cough was at times very harrassing. The pain in the right side of the head, and on the lower part of the neck continued to be more or less troublesome. The bowels were kept free with saline cathartics, and the cough moderated by ano- dynes and demulcents. January twenty-second. The wound is granulating and healthy—the cough less troublesome. The dimen- sions of the tumour are as follows: inches. Length......5\ Breadth......3? Projection ..... 2 2 Circumference .... 71 January twenty-fourth. The upper ligature came away with the dressings. January twenty-sixth. The lower ligature came away. The sore has very much contracted, and discharges but little. February second. The patient's general health is good. There is no pulsation in the tumour except at one part, where it is softer, and here it is very indistinct. Fehj|iarv twenty-second. The wound is reduced to a small Wnus of an inch and an half in depth—At a soft prominent point, near the lower part of the tumour, an obscure pulsation is still perceptible. VOL. TL C C ■* 194 ELEMENTS OF SURGERY. March twenty-third. Injections have been made of Sulphate of Zinc and Sulphate of Copper into the sinus, which is now very much contracted. The measurement of tire tumour to day gives the following result. INCHES. Length ------ 4£ Breadth ... - - 2| Projection ----- 1| I Circumference - 6| May seventeenth. The sinus has been well for some days—Discharged cured. Dr. Post saw the patient on the fifth of June when the general prominence of the tumour did not appear to have diminished since the last measurement; the upper part was lessened, so as to leave a considerable space be- tween it and the angle of the jaw—the lower part had approached so near the clavicle as to have the cicatrix in part upon it. Dr. Post was of opinion that had the tumour been situated as close to the clavicle before the operation, there would not have been room enough to have taken up the artery. ANEURISM OF THE AXILLARY ARTERY. Another situation in which aneurism sometimes occurs is in the axillary, or high in the brachial artery. The usual symptoms of aneurism generally attend this case, but Mr. Pelletan relates an instance in which no arterial pulsation could be discovered, and the tumour was mis- taken for an abscess; a puncture being made a gush*of arterial blood announced the nature of the disea&e, and though the puncture was healed yet the mistake had nearly proved fatal. Of late years the success of those daring operations already described has encouraged sur- ELEMENTS OF SURGERY. 195 geons to tie up the subclavian artery in cases of axillary aneurism. In the year 1786, before the successful performance of any of these operations, however, a case of axillary aneurism occurred in the practice of Mr. Pelletan, who received the patient "more with a view to study his dis- ease than with a hope of curing it." He found after many examinations of this patient, that upon raising the arm and clavicle he could distinctly feel the subclavian artery, in a manner insulated, and by compressing it with the finger the pulsations of the tumour were imme- diately stopped. He accordingly determined to tie up the artery in this situation. It appears from Mr. Pelletan's candid and very inte- resting account of his operation that he was prevented from carrying his own plan into effect, and therefore he made an unsuccessful attempt to take up the vessel, and the patient soon after expiring, gave him an opportunity to prove by dissection the practicability of tying up the subclavian artery in such a situation as to have cut off all access of blood to the tumour. Mr. Pelletan suggests the propriety, in cases where this is totally impracticable, of tying the artery below the tumour, under an expecta- tion that the course of the blood being interrupted through the main channel, another route would be established and the progress of the disease arrested—an idea total- ly improbable, and an operation by no means likely to succeed. Desault also tied the axillary artery without success. That the mere obstruction of the subclavian artery will not necessarily occasion gangrene of the arm is de- monstrated by a case recorded by Mr. Hall, in which this artery was divided by a sithe and being taken up the patient recovered, and regained the use of his arm. Mr. Keate has detailed so far as 1 know the first case in wliich an axillary aneurism has been successfully 196 ELEMENTS OF SURGERY. treated by a ligature on the subclavian artery. This pa- tient was a soldier twenty-five years of age. In Octo- ber 1799 he was wounded in the hand, and three fingers were amputated. The stumps did not soon heal and collections of matter formed near his wrist—an aneuris- mal tumour was soon after found in the axilla which be- came very prominent and was attended with a strong pulsation. The parietes of this aneurism became ex- tremely thin, and at length were ruptured, and the he- morrhage for a time was commanded by pressure. In this situation Mr. Keate determined to take up the ar- tery in its passage over the first rib. Accordingly he made an incision obliquely downwards, divided the fibres of the pectoral muscle that lay in his way, and when he came to the artery he passed a curved blunt pointed silver needle armed double, as he conceived under the artery, and tied two of the ends ; after a care- ful examination he found that the artery pulsated below the ligature, and he determined to pass another ligature higher up and nearer to the clavicle. He accordingly passed the needle deeper evidently including the artery. This operation proved completely successful, no gan- grene resulted, and the patient gradually acquired the use of his arm as well as before the accident. Mr. Ramsden of London has published a case in which the subclavian artery was tied up, and although the event was fatal yet the mode of operating is des- cribed so clearly that I shall relate the principal circum- stances of the case. The patient was twenty-two years of age—a perfect sot. The tumour was as large as half of an orange. Pulse and temperature in both arms similar. He had not remained long in St. Bartholomew's Hospital before a dark spot appeared on the centre of the tumour in- dicative of gangrene, and the operation was accordingly performed iu the following manner. ELEMENTS OF SURGERY. 197 The patient being placed upon an operating table with his head obliquely towards the light and the af- fected arm supported by an assistant at an easy distance from the side; I made" says Mr. Ramsden " a trans- verse incision through the skin and platysma myoides along and upon the upper edge of the clavicle of about two inches and a half in length, beginning it nearest to the shoulder, and terminating its inner extremity at about half an inch within the outward edge of the sterno-cleido- mastoideus muscle. This incision divided a small su- perficial artery, which was directly secured. The skin above the clavicle being then pinched up between my thumb and finger and those of an assistant, I divided it from within outwards and upwards in the line of the outward edge of the sterno-cleido-mastoideus muscle to the extent of two inches. "My object in pinching up the skin for the second in- cision was to expose at once the superficial veins, and by dissecting them carefully from the cellular membrane to place them out of my way without Mounding them. This provision proved to be very useful, for it rendered the flow of blood during the operation very trifling com- paratively with what might otherwise have been ex- pected ; and thereby enabled me with the greatest faci- lity to bring into view those parts which were to direct me to the artery. " My assistant having now lowered the shoulder* for the purpose of placing the first incision above the clavi- cle (which I had designedly made along and upon that bone), I continued the dissection with my scalpel until 1 had distinctly brought into sight the edge of the anterior scalenus muscle, immediately below the angle, which is " * In my first incision I intentionally cut down along and upon the clavicle as a security against wounding any superficial vessels, a very little lowering of the shoulder therefore placed the incision in the situation I wished to have it for the purpose of proceeding widi the operation." 198 ELEMENTS 01 SURGERY. formed by the traversing-bellies of the omohyoideus and the edge of the sterno-cleido-mastoideus, and having placed my finger on the artery at the point where it pre- sents itself between the scaleni, I found no difficulty in tracing it, without touching any of the nerves, to the lower edge of the upper rib, at which part I detached it with my finger nail, for the purpose of applying the liga- ture. " Here however arose an embarrassment which (al- though I was not unprepared for it) greatly exceeded my expectation. I had learned from repeatedly performing this operation many years since on the dead subject, that to pass the ligature under the subclavian artery, with the needle commonly used in aneurisms would be impracti- cable; I had therefore provided myself with instruments of various forms and curvatures to meet the difficulty, each of which conveyed most readily the ligature un- derneath the artery but would serve me no farther; for, being made of solid materials, and fixed into handles, they would not allow of their points being brought up again at the very short curvature which the narrowness of the space between the rib and the clavicle afforded, and which in this particular case was rendered of un- usual depth by the previous elevation of the shoulder, by the tumour. "After trying various means to overcome this difficul- ty, a probe of ductile metal was at length handed me, which I passed under the artery, and bringing up its point with a pair of forceps, I succeeded in passing on the ligatufe, and then tied the subclavian artery at the part, where I had previously detached it for that pur- pose. The drawing of the knot was unattended with pain, the wound was closed by the dry suture, and the patient was then returned to his bed." Mr. Ramsden's patient died on the fifth day after the operation, but the practicability of the operation is demon- ELEMENTS OF SURGERY. 199 straled by the case, and there occurred nothing in the sub- sequent symptoms to forbid a similar attempt in a simi- lar instance. With respect to the best situation in which to apply the ligature in the present instance, that must be de- cided by the nature of the case, and the size and situation of the tumour—the most accessible part of the sound artery is to be preferred. To find this spot there are no directions necessary; an accurate knowledge of the ana- tomy of the parts is indispensable, but the surgeon will always recollect one material difference between the living and dead body, too much overlooked, the pul- sation of the artery, which in operations for aneurism is a most important guide. Having never performed the operation upon the living subject I speak diffidently as to the best method, but I have no doubt that the needle in curved forceps such as I have recommended in tving the pudic and iliac ar- teries, would greatly facilitate the passing of a ligature round the subclavian. 200 ELEMENTS OF SURGED. CHAPTER XXVI. Of False Aneurisms. Spurious or false aneurisms are always occasioned by a wound or rupture of an artery, in consequence of which blood escapes out of the cavity of the artery and forms an aneurismal sac in the surrounding parts. The term diffused false aneurism is applied to those cases where the blood forms an irregular swelling extending in dif- ferent directions from the seat of the injury, and the aneurism is called circumscribed, when a regular, cir- cumscribed tumour is formed. These terms are applied also in some cases to true aneurisms without any pro- priety, since the extent of diseased vessel does not occa- sion any change in its nature. A species of false aneurism called varicose w7as first described by Dr. William Hunter.* In this disease the coats of an artery are punctured by an instrument which had previously passed through a neighbouring vein, and by this means corresponding apertures are formed where- by the blood flows out of the artery into the vein. The accident generally happens in the common operation of venesection. Dr. Hunter's account of this affection is very accurate. "In the operation of bleeding, the lancet is plunged into the artery through both sides of the vein, and there will be three wounds made in these vessels, viz. two in the vein and one in the artery, and these will be nearly op- posite to one another, and to the wound in the skin. This is what all surgeons know has happened in bleed- * Scama says by Guattani, ELEMENTS OF SURGERY. 201 ing, and the injury done the artery is commonly known by the jerking impetuosity of the stream, whilst it flows from the vein, and by the difficulty of stopping it, when a sufficient quantity is drawn. "In the next place, we must suppose, that the wound of the skin, and of the adjacent, or upper side of the vein, heal up as usual; but, that the wound of the artery, and of the adjacent, or under side of the vein, remain open (as the wound of the artery does in the spurious aneurism) and, by that means, the blood is thrown from the trunk of the artery, directly into the trunk of the vein. Extraordinary as this supposition may appear, in reality it differs from the common spurious aneurism in one circumstance only, viz. the wound remaining open in the side of the vein, as well as in the side of the arte- ry. But this one circumstance will occasion a great deal of difference in the symptoms, in the tendency of the complaint, and in the proper method of treating it: upon which account the knowledge of such a case will be'of importance in surgery. "It will differ in its symptoms from the common spu- rious aneurism principally thus. The vein will be di- lated, or become varicose, and it will have a pulsating jarring motion on account of the stream from the artery. It will make a hissing noise, which will be found to cor- respond with the pulse for the same reason. The blood of the tumour will be altogether, or almost entirely fluid, because kept in constant motion. The artery, I appre- hend, will become larger in the arm, and smaller at the wrist, than it was in the natural state; which will be found out by comparing the size, and the pulse of the artery in both arms, at these different places; the rea- son of which I shall speak of hereafter. And the effects of ligatures, and of pressure upon the vessels above the elbow and below it, will be what every person may rea«- vol. n. d d 202 ELEMENTS OF SURGERY. dily conceive, who understands any thiug of arteries and veins in the living body. "The natural tendency of such a complaint will be very different from that of the spurious aneurism. The one is growing worse every hour, because of the resist- ance to the arterial blood, and if not remedied by surge- ry must at last burst, the other in a short time comes to a nearly permanent state; and, if not disturbed, produces no mischief, because there is no considerable resistance to the blood, that is forced out of the artery. "The proper treatment must, therefore be very dif- ferent in these two cases, the spurious aneurism requir- ing chirurgical assistance, as much, perhaps, as any dis- ease whatever; whereas, in the other case, I presume it will be best to do nothing. "If such cases do happen, they will no doubt be found to differ among themselves, in many little circumstances, and particularly in the shape, &c. of the tumefied parts. 'Thus the dilatation of the veins may be in one only, or in several, and may extend lower or higher in one case, than in another, &c. according to the manner of branch- ing, and to the state of the valves in different arms. And the dilatation of the veins may also vary, on account of the size of the artery that is wounded, and of the size of the orifice in the artery and in the vein. " Another difference in such cases will arise from the different manner, in which the orifice of the artery may be united or continued with the orifice of the vein. In one case, the trunk of the vein may keep close to the trunk of the artery, and the very thin stratum of cellular membrane between them, may by means of a little in- flammation and coagulation of the blood among its fila- ments, as it were, solder the two orifices of these vessels together, so that there shall be nothing like a canal going from one to the other; and then the whole tumefaction will be more regular, and more evidently a dilatation of ELEMENTS OF SURGERY. 203 the veins only. In other instances the blood that rushes from the wounded artery, meeting with some difficulty of admission and passage through the vein, may dilate the cellular membrane, between the artery and vein, into a bag, as in a common spurious aneurism, and so make a sort of canal between these two vessels. The trunk of the vein will then be removed to some distance from the trunk of the artery, and the bag will be situated chiefly upon the under side of the vein. The bag may take an irregular form, from the cellular membrane being more loose and yielding, at one place, than at another, and from being unequally bound down by the fascia of the biceps muscle. And if the bag be very large, especially if it be of an irregular figure, no doubt, coagulations of blood may be formed, as in the common spurious aneurism." With respect to the treatment of false aneurism, no reliance is to be placed upon any remedy except the li- gature; a free incision is to be made into the cavity of the aneurism, that the bleeding orifice may be seen or felt; a ligature is then to be applied above and another below it, and firmly tied. One of the most serious cases of this kind is a case of aneurism recorded by Mr. John Bell. The injury was occasioned by a fall on a pair of scissors which penetrated the hip opposite the sciatic notch; an aneurismal tumour formed, an in- cision was made into it, and a large quantity of coagu- lated blood was suddenly discharged. The opening was enlarged and the clots evacuated. A torrent of fresh ar- terial blood now jetted forth, and "in a moment twenty hands were about the tumour and the bag was filled with sponges and cloths of all kinds." At this instant a bistoury was run upwards and downwards, and an in- cision two feet in length was made, at which time the patient was apparently lifeless. Mr. Bell now disco- vered with his finger the gush of warm blood, and dis 204 ELEMENTS OF SURGERY. tinctly felt the pulsation of the vessel, which convinced him that the man was still alive. The artery was easily secured; it was the posterior iliac artery which had been cut fairly across, and bled with open mouth; it was cut and tied exactly where it turns over the bone. The pa- tient ultimately recovered. In all such cases it is of primary importance to act with promptness and decision; delay in such cases is not merely dangerous but fatal. In all operations, there- fore, for the cure of false aneurism, if practicable, the loss of blood should be restrained by a tourniquet, or pressure, on the artery supplying the tumour, whilst the operation is performed, and in such cases the surgeon may act deliberately; but where cases occur similar to that described by the dauntless surgeon last quoted, a bold and sudden exertion is absolutely indispensable. Mr. Bell's rules of practice on this subject are so very important that I shall quote them from Dr. Smith's va- luable abridgement of his principles of surgery, and I know no part of Mr. Bell's writings more honourable to the author than his remarks on the present subject. "In great aneurisms, then, of the arm or thigh, when the tourniquet can be applied, do your operation delibe- rately, steadily, slowly, but do not needlessly prolong your patient's suffering. Cut the skin nicely, open the sac freely, dissect your artery very clean, and tie it clear of the nerve, and pass your ligature with a blunt needle or crooked probe; for whenever you are reduced to the necessity of using the sharp needles your patient is in danger. Tie your artery with moderate firmness; tie it in two places (for on several occasions the retrograde blood has flowed out even in the time of the operation;) clean the sac; look now attentively to your two liga- tures, and if you see the upper one moving according to the pulsation of the artery, all is right. Finally, if you approve of my reasoning, cut tfre artery across in the ELEMENTS OF SURGERY. 205 middle betwixt the ligatures. When the tourniquet can- not be applied, do not trust to compression. Your as- sistant may try to compress the artery, but do not lay your account with performing a cool deliberate opera- tion ; expect rather a dash of blood at the first stroke you make into the sac, and confusion and alarm of every kind. Compose your mind for such a scene; bend up each corporeal agent to this attempt; expect safety for your patient from nothing but your own daring opera- tion ; be resolute, bold, and rapid; but let this boldness be the result of serious deliberation, and earnest consul- tation with your friends. And in what does this rapi- dity consist? Is it a dangerous stroke that you are to make? No surely: the rapid movement is merely slit- ting up suddenly the half putrid and tendinous sac, and turning out the clots of blood with your fingers, while the artery, nerve, and all the important parts lie safe at the bottom of the tumour. You are to trust much to your acquaintance with the parts, therefore make sure of your knowledge of the artery that is actually wounded; return to your books, drawings, and preparations; hold consul- tations with your friends; lose no opportunity of making up your mind beforehand; the more you reason upon the case, and revolve the possible dangers, the greater will be your prospect of sustaining yourself with becoming resolution in the moment of operation." . Dr. Smith very judiciously adds to these directions that " there is no necessity for opening the aneurismal sac iu those cases in which you can tie the vessel above where it has been Mounded, unless the sac is very large; operate, in short, as in spontaneous aneurism." The treatment of varicose aneurism depends upon the nature of the case. In a great majority of instances the aneurismal sac is formed by the vein dilated into a pouch over the artery. These cases sometimes occasion very little trouble to persons who do not use the arm violent- S06 ELEMENTS OF SURGERY. ly. Scarpa recommends in such cases to order the pa- tient to abstain from using the arm, and to keep it as little as possible hanging by the side. Perhaps mode- rate compression, absolute rest, and a low diet, would tend greatly to prevent mischief after the puncture of an artery, and in the forming state of varicose aneurism. In some instances a spontaneous cure takes place, and iu others the disease remains without occasioning any great inconvenience. A whizzing noise can be heard by ap- plying the ear to the part, and any thing which excites the circulation occasions a distressing throbbing, but no tumour forms, and the patient prefers the existing evil to an operation. Mr. Pott, Dr. Hunter, and several other surgeons have met with such cases, and a lady of Philadelphia is at present situated in this manner. She has a varicose aueurism which was occasioned by vene- section many years ago, and it remains at present with- out occasioning any inconvenience sufficient to induce her to submit to an operation. In some few cases, however, a very different result takes place, and the vein becomes distended, producing all the dangers and most of the symptoms of other aneu- rismal swellings. In such instances the tumour must be cut open and treated as a common false aneurism, the aperture in the artery being secured by a ligature above and another below the orifice. To obviate all inconve- nience it is surely best as soon as an artery is known to have been opened in the operation of venesection to cut down to and tie it up. Dr. Hunter in his accurate description of varicose aneurism, or as it is now called aneurismal varix an- ticipated the probable occurrence of a case which he never saw, but which has since occurred to Mr. Park of Liverpool, and to Dr. Physick. I have marked in italics the words in which he hints at this case,* and I now pro- ceed to detail such a one; it was published by Dr. Phy • See Page 203. ELEMENTS OF SURGERY. 207 sick in the first volume of the Medical Museum together with the mode of treatment. "A young gentleman from Virginia applied to me last April to undertake the treatment of an aneurism, si- tuated at the bend of the elbow, occasioned by his having been bled in the basilic vein in October, 1801. He in- formed me that the bleeder at the time of the operation experienced no difficulty in stopping the blood, but that a very considerable ecchymosis formed, occasioning a livid colour of the skin about the wound and extending both above and below the elbow. The ecchymosis dis- appeared after a few days, but a pulsating tumour was observed directly under that part of the vein which had been punctured. This tumour gradually increased in size for six months, but afterwards the increase of the tumour, if any, Mas so slow as not to be observed, though the basilic vein running over it began to enlarge. "On examining the arm T found a tumour at the bend of the elbow pulsating very strongly; exactly resembling a true aneurism: there was also two tumours, one si- tuated above, and the other immediately below this aneu- rismal sac, in which the particular thrill always met with in varicose aneurisms was very distinctly felt, These tumours were evidently distensions of the basilic vein, the trunk of which however for about three-fourths of an inch, where it passed over the aneurismal sac, was very little enlarged: by making pressure ou the middle of this last mentioned portion of the vein, the orifice of communication between the aneurismal sac and the vein could be felt; and by applying the finger accurately over it, the flow of blood into the vein could be prevented, and the thrill, while the pressure Was continued, ceased. " The case was now easily understood : the artery had no doubt been punctured by the lancet, pushed into it through ffie vein by the bleeder; the pulsating tumour was a sac formed in the cellular membrane between the 208 ELEMENTS OF SURGERY. artery and vein, by the impulse of the arterial blood: the enlargement of this sac went on until its sides became firm and resisting, and then the blood from the sac was thrown with such force into the vein through the punc- ture in its lower side, as to cause it to distend very con- siderably, for two or three inches above and below the sac; the intermediate portion of the vein however run- ning over the sac being supported by it, was very little enlarged. "As the upper portion of the vein was observed to distend very rapidly, the skin covering it being very thin and every where marked with cicatrices; the pa- tient apprehending a sudden rupture of the tumour, be- came very uneasy in his mind: the fore-arm was much diminished in size, and the hand was constantly cold. These circumstances together with the existence of the aneurismal sac, determined Dr. Wistar and myself to advise the operation of tying the artery above and below the sac. "I performed the operation in April, 1804; within a quarter of an hour after, the pulse of the artery at the wrist was distinctly perceived; in three weeks the wound was cicatrized, and the patient very soon recovered the most perfect use of his hand and arm. It seems unnecessa- ry to describe the operation further than to mention, that after dividing the skin and cellular membrane covering the swelling by a straight incision, 1 dissected round the tumours, then tied the trunk of the vein above and below its enlargement, next tied the artery above and below the sac; the parts comprehended between the ligatures were then cut out, which has enabled me to have the annexed drawing of them made. They are represented of their natural size. * PLATEXXim Page 209Vol.2. Fia / Jfy- ELEMENTS OF SURGERY. 209 EXPLANATION OF THE PLATE. Fig. 1. AA. The basilic vein distended above and be- low the puncture. B. The cicatrix from bleeding. D. The aneurismal sac. CC. The brachial artery. t Fig. 2. AA. The enlarged vein. e. Orifice of communication between the vein and aneurismal sac. D. The inside of the aneurismal sac every where incrusted with bone. E. The orifice of communication between the ar- tery and the aneurismal sac. v *£C. The brachial artery. „F. Dotted lines representing the situation of the artery under the sac. The artery was not enlarged nor in any respect diseased. vol. iju e e 'HO ELEMENTS OF SURGERY. I have lately seen a case of aneurismal varix attended with some very extraordinary circumstances. The pa- tient had received many years before a load of buckshot in his leg. When the parts healed a varicose aneurism was discovered just below the knee, and in a short time the superficial veins of the leg were all enlarged, and the thrill peculiar to this species of aneurism could be dis- tinctly felt. When I saw the patient, twelve years had elapsed after the occurrence of the accident, and the veins of the leg from the toes to the groin were all great- ly distended. The leg was constantly very painful, and ulcers formed on the foot and ankle which resisted every remedy. The patient Mas attended by Dr. Physick and Dr. Wistar. The enormous distention of the vessels of the leg, and the uncertainty of finding the communication between the artery and vein induced them to tie up the femoral artery in the middle of the thiglju. The patient's leg mortified as high up as the middle, and whilst the dead parts were separating a sudden and unexpected"? hemorrhage took place from one of the enlarged veins in¥ the mortified part near the ajikle, which greaftly reduced his strength, and although the bleeding Mras for a time arrested by tying up the vein from which it issued, yet it recurred, unnoticed by the nurse, and he became* gra- dually weaker and finally expired; I dissected the limb and found the whole trunk of the femoral artery as high as the groin in an enlarged and unnatural state—the veins of the limb were all greatly distended, and a bougie readily passed along the popliteal artery into the poste- rior tibial artery, which was enlarged, and out of this into venous pouch situated at the inner part of the leg be- low the knee. % Before concluding the subject of aneurism I shall briefly notice a species of tumour consisting chiefly of en- ELEMENTS OF SURGERY. 211 larged blood-vessels, which has been called by Mr. John Bell, ANEURISM FROM ANASTOMOSIS. This complaint exists in some cases of naevi materni in children, and is congenital. Many cases however occur in which a gradual enlargement of vessels takes place, originating in a pimple or spot, and sometimes appears to result from accidental injtiry. It is attended with constant throbbing, and great turgeseence of the vessels, augmented and diminished in proportion to the rapidity of the general circulation. When the part hap- pens to be scratched hemorrhage takes place very freely from it, and sometimes the vessels burst without any ac- cidental injury and pour forth very considerable quanti- ties of blood. There is but one remedy for this complaint; the total excision of the diseased parts. It is very important to cut completely outside of the tumour; if the sur- , geon inadvertently cut into it, the bleeding will be pro- fuse. The arteries which nourish the tumour are easily taken up, if the external incision is made at a small dis- tance from its margin. This is one of those cases in wliich it is important to remove the parts quickly, as the hemorrhage continues, and is sometimes very profuse during the operation. A very common situation for these tumours is the scalp, and no difficulty attends their extirpation. An in- cision should be made quickly round the swelling down to the bone, and then the diseased portion of scalp is ea- sily detached, and the arteries which supplied it can be secured. Mr. Pelletan relates a case somewhat analagous to this disease, in which all the branches of the temporal artery were morbidly dilated, and 1 have very recently seen a case of aneurismal tumour in which the whole scalp was pervaded by very large arteries. The princi- * 212 ELEMENTS OF SURGERY. pal diseased spot, however, appeared to be formed of a convolution of the branches of the occipital artery. In this case the larger arteries leading to the tumour, some of which were equal in diameter to the brachial, were successively tied up before any operation was attempted on the tumour, and very fortunately, for notwithstanding this precaution, when the circular incision was made round the tumour, so large a quantity of blood was lost that great alarm was occasioned. To prevent the deformity attending the separation of large portions of scalp, Dr. Physick has in some cases cut round the tumour, tied up the bloodvessels, and suf- ferred the parts to remain; lint being interposed between the edges of the wound to prevent immediate union. The tumour after such an operation is in great measure ab- sorbed and much diminished in size. A very excellent account of these vascular tumours may be found in John Bell's Principles of Surgery. ELEMENTS OF SURGERY. 213 CHAPTER XXVII. Of Mammary Abscess. The breasts of women are sometimes the seat of very painful and distressing abscesses. They are some- times seated deeply in the glandular substance of the breast, and at other times in the investing cellular mem- brane. The inflammation commences in the usual man- ner, and the pain, hardness, and swelling, are in gene- ral very considerable. When the glandular structure is affected the secretion of milk is much diminished, and is sometimes totally suspended. The disease in its progress is attended with severe pains shooting up into the axilla, and the axil- lary glands often swell and inflame. The progress of this complaint varies; sometimes it is rapid and suppuration takes place in three or four days, and in other cases it is much slower. Sometimes an (edematous swelling forms, and the nipple appears buried below the level of the skin. In some cases seve- ral distinct hard tumours are found in the breast; and when these suppurate an equal number of separate ab- scesses are formed. It now and then happens that one abscess opens by several small apertures, and sinuses are thus made, communicating with each other under the skin. Mammary abscesses form at different periods after de- livery, and are always attended with more or less fever preceded in general by a chilly fit. They result some- times from exposure to cold-from tight dresses-acci- dental injuries-long retention of milk-and from the 214 ELEMENTS OF SURGERY. usual causes of inflammation; and in other instances no evident cause can be assigned. The remedies for this complaint differ in nothing from the common remedies for inflammation. Bloodletting according to the strength of the patient, purges, and low diet are to be first employed. After general bleeding the application of leeches is extremely serviceable. The best local remedy is a soft bread and milk poultice with lead water. After the use of the preceding reme- dies, if the inflammation continue, a blister should be applied over the inflamed part. When suppuration is established if the abscess should not speedily open, a puncture may be made with a lancet, and the matter evacuated; free incisions have been recom- mended in these cases, but during the existence of acute inflammation they are unnecessary, and the puncture can in general be kept from healing by a soft poultice, or by a piece of linen rag placed in the orifice. When sinuses form they are to be laid open freely. When an oedematous swelling takes place the application of spiritus mindereri, and repeated purges generally carry it off. The indurations which sometimes follow mam- mary abscess have been already noticed in the chapter on cancer; they yield in general to purges, blisters, mer- cury, and cicuta. ELEMENTS OF SURGERY. 215 CHAPTER XXVIII. Abscess of the Hip Joint. This is a well known disease met with in patients of every age, but more commonly in children than in adults. In its commencement it is very insidious, and sometimes is not preceded by any pain; a slight weakness, and some degree of limping generally attend; a loss of ap- petite, and disinclination to motion are observed. A pain in the knee is a common symptom; and this pain some- times misleads patients and their medical attendants, who imagine the mischief to be seated in the knee, and have no suspicion of the hip. In general before the disease has made much pro- gress, pain is perceived in the vicinity of the affected joint, and the limb appears longer than the sound one— a circumstance easily accounted for from the crooked- ness of the pelvis, the patient supporting the weight of the body entirely upon the sound side, the limb becomes diminished and emaciated. Pain is experienced in exa- mining the limb, from pressure upon the parts concerned in forming the joint which are in a state of inflammation. The nates become flattened—the whole form and ap- pearance of the hip is changed, and the natural convexi- ty of the buttock is lost. The knee may be moved with- out pain, but every motion of the hip occasions a very severe pain. When the patient attempts to walk, the thigh is bent forwards, the knee is flexed, and the weight, of the body is almost entirely sustained by the sound limb; great pain is sometimes experienced in attemps to S16 ELEMENTS n. SURGERY. straighten the affected limb. T.ie preceding symptoms characterize the early stage of the complaint. When pus is about to form, the pain is augmented and becomes constant; the soft parts around the joint be- come sore and tender; a degree of tension is perceived ; the skin is hot and red, and considerable fever comes on, sometimes attended with fits of shivering. Shortly after these symptoms the pain abates, and a swelling is per- ceived containing pus. In some instances, however, the inflammation assumes a more chronic form, and no particular increase of pain precedes the formation of pus. It sometimes happens that after the affected limb has been longer than the sound one, it suddenly becomes shorter; this is owing to what has been called a sponta- neous dislocation of the os femoris; the head of the bone is actually protruded from the acetabulum by the inflam- matory swelling of the contents of that cavity. It is said that this dislocation sometimes precedes the formation of pus. The joint then gets well without an abscess, and the parts heal by anchylosis; but this is rare. Hectic fever generally attends the disease of the hip joint. Pus of a thin sanious consistence is continually discharged from one or more orifices. Abscesses form in various parts of the thigh, and the strength of the pa- tient is much exhausted. Carious bone can generally be felt by a probe passed into any of the sinuses. The acetabulum is diseased as well as the os femoris: the cartilages detached by absorption, and the solid bone is also greatly diminished by the same process. In some cases this separation of the cartilages gives rise to an anchylosis between the os femoris and acetabulum, and a cure is effected; but more commonly the disease pro- gresses—every motion is attended with extreme pain: the patient lingers months and even years, and ultimate- ly expires. ELEMENVs Vf SURGERY. 21/ I have known the bottom of the acetabulum absorbed in a case of hip disease and the head of the os femoris pushed through into the pelvis. TREATMENT. The remedies to be successful must be active in the early stage of the complaint—but it unfortunately hap- pens that we are seldom sent for until the disease has made great progress; bleeding, purging, emetics, sea bathing, the various remedies for scrofula, mercury and many others have been used in this disease without ef- fect—Issues which are1 highly recommended, do but little seivice—Dr. Physick has seen a great number of these cases, and has found those succeed best which were treated by very active and long continued purg- ing. The best cathartic is Jallap and Cream of Tartar every day, or every two days—the health and strength of the patient under this mode of treatment greatly im- proves, and in several instances a complete cure has been effected. In addition to this, however, a vegeta- ble diet, and absolute rest are to be enjoined. In chil- dren it is difficult to carry this last prescription into effect, and it is found extremely convenient to Jiave a curved splint to fit the hip and thigh. After suppuration comes on,. little can be done, but to keep open the sinuses till the dead bone comes out. The constitution must be supported by bark, wine, and nourishing diet—and inflammatory fever when it occurs, must be combatted by bleeding, and a low diet—Leech- es and blisters are certainly useful in the early stage of the disease. m The appearances of a diseased hip joint on dissection vary according to the period of the disease at which it is made. Mr. Ford gives an account of two dissections, one in an early and the other in a later stage of the com- VOL. II. r f 218 ELEMENTS OF SURGERY. plaint. In the first the head of the os femoris was in- flamed; the capsular ligaments were somewhat thicken- ed, tbe round ligament retained its usual connection both to the head of the thigh bone, and to the acetabulum; about a teaspoonful of pus Mas contained in the cavity of the joint, and the cartilage lining the acetabulum was eroded, (absorbed) in one place with a small aperture through which a probe might be passed underneath the cartilage into the internal surface of the os pubis on one side, and on the other into the os ischii, the opposite or external part of the os innominatum shewing more ap- pearance of disease than the acetabulum. In the second case the disease was more advanced, and exhibited the usual appearances of a destruction of parts in conse- quence of suppuration. The best writers on this subject are Desault, Boyer, Cooper, Crowther, and Ford. A disease somewhat analogous to that of the hip joint occurs in the knee, and forms one species of white swel- ling; for a very excellent history of that subject, and many other affections of the joints, 1 refer to Mr. Sa- muel Cooper's valuable treatise on the diseases of the joints. ELEMENTS OF SURGERY. 219 CHAPTER XXIX. Lumbar or Psoas Abscess. Of the various abscesses which fall under the notice of the surgeon, there is not one more extensive or se- rious than that which occurs in the loins, and which is therefore denominated lumbar abscess. The matter col- lected in these cases is seated in the cellular texture sur- rounding the psose muscles,, and hence the disease is fre- quently called psoas abscess. These collections of mat- ter are situated posteriorly to the peritoneum, and occa- sion swellings in various situations. The disease origi- nates in many cases in bruises or hurts, but in a variety of instances no evident exciting cause precedes it, and it is ascribed to bruises in bed, slight sprains, or hea- vy lifts, &c. The symptoms often commence with a difficulty in walking, with some sense of weakness or uneasiness in the loins, but without any acute pain. Indeed we some- times find very copious collections of pus in these cases without any pain having preceded. The matter formed increases gradually in quantity, and makes its appearance by a tumour in the upper part of the thigh, or just under Poupart's ligament; some- times it descends loMrer and points at the middle of the thigh, travelling under the tendinous fascia femoris; sometimes in the loins, and sometimes on the^back. It ^occasionally descends into the pelvis and points near the anus, resembling a fistula in ano. I once saw a case in which a gallon of pus was discharged from a psoas abscess which opened within an inch of the anus—my 220 ELEMENTS OF SURGERY. patient very speedily and happily recovered his genera health, though a fistula in ano was the consequence, and this was cured by an operation. Psoas abscess is often connected with a carious state of the vertebrae: sometimes this caries is a cause and at other times an effect of the abscess. Where this is the case the patient is generally uuable to stand erect, and to exert the muscles of the loins, aud paralysis of the lower limbs comes ou. Where the tumour appears in the groin it has been mistaken for hernia; the tumour subsiding when the pa- tient is in a recumbent posture and returning again when he rises erect. The fluctuation being evident, removes any doubt of this kind. TREATMENT. When we are called early in the disease the usual re- medies for inflammation must be used; bleeding, purg- ing, and low diet, leeches to the loins, or cupping, are also useful—Rest and a horizontal posture must be en- joined—Blisters over the lower part of the back are highly serviceable—Issues with caustic are to be resort- ed to if the previous remedies fail. After matter has formed and presented itself by an ex- ternal tumour, it becomes an object of very considerable moment to ascertain whether the abscess should be opened. We need not apprehend any danger of its opening into the cavity of the abdomen, as there are no such instances recorded, although fatal hemorrhage has in some cases resulted from absorption of the great blood vessels in the vicinity of the abscess. The danger of opening the abscess depends upon thevio-* lent fever which invariably follows a wound of any large cavity, unless the opening be healed immediately and the cavity be again rendered perfect. Mr. Hunter first taught ELEMENTS OF SURGERY 221 that the imperfection merely of a large cavity without its exposure to the air, M^ould cause extensive inflammation through its sides, and violent constitutional effects. Mr. Abernethy to avoid the evils of an imperfect cavity, pro- posed to make a puncture through the parietes of the ab- scess in such a manner that the sides of the wound might heal by the first intention. This is effected by making a valvular opening with a sharp lancet, by passing the lancet first through the skin, and then obliquely upwards under the skin, for half an inch or more, then the point of the lancet is to be depressed and pushed into the ca- vity of the abscess. The matter now flows freely through the wound ; if the patient's strength permit, and the ab- scess be not very large, the whole contents may be at once removed; but in cases where large quantities of pus are collected this is dangerous; we therefore remove a pint or more, and complete the evacuation a few hours after—the sides of the puncture arc now to be brought into contact, and kept so by adhesive plaster—they unite readily. In peforming this operation great care is ne- cessary, if the abscess point in the groin, to avoid the large vessels—probes or canulas are never to be intro- duced. After the operation the matter collects in a few weeks, and is to be again opened iu the same man- ner. This operation repeated several times has the ef- fect of gradually contracting the dimensions of the cavi- ty, and when this is considerably diminished a larger opening may be made without danger. In some cases, however, the puncture does not heal by the first inten- tion, and then extensive inflammation supervenes, and often terminates fatally. The disease we are now considering is frequently at- tended with caries of the vertebra;- (of which we shall speak more particularly in the next chapter.) In that case it becomes doubtful whether an opening ought to be made into the abscess for the evacuation of the pus, 222 ELEMENTS OF SURGERY. " because so long as carious bone exists in the spine, so long will suppuration continue, and consequently no rea sonable hope of a cure can be entertained. If it be dis- tinctly ascertained that carious bone does exist, then I believe it will be best not to make a puncture into the cavity of the abscess, except there be danger of an open- ing by ulceration, in which case the puncture should at all events be made, because a very small aperture will be thereby substituted for a larger one, and much of the danger from inflammation in the cavity of the abscess will be prevented. The puncture should be healed as speedily as possible. The mode of treatment when ca- rious vertebrae are discovered will be detailed presently. It is to be confessed, however, that we are not always able to ascertain when the vertebrae are in this state. Mr. Crowther has succeeded in curing some cases of lumbar abscess without puncturing, even after large col- lections of matter had formed; his treatment consists in the repeated application of blisters over the integuments covering the abscess, which are to be kept open by savin cerate. F.LEMENTS OF SURGERY. 223 CHAPTER XXX. Of Curved Spine. By this name is designated a disease, or caries, of the vertebrae, which has long been familiar to surgeons, but was never well understood until the investigations of Mr. Pott rendered its nature intelligible. I shall therefore take the followiug observations from his excellent treatise on the subject. " The disease, of which I am to speak, is a disease of the Spine, producing an alteration in its natural figure, and not unfrequently attended with a partial, or a total loss of the power of using, or even of moving, the lower limbs. " From this last circumstance (the loss of the use of the limbs) it has in general been called a Palsy, and treated as a paralytic affection; to which it is in almost every respect perfectly unlike. " The occasion of the mistake is palpable; the patient is deprived of the use of his legs, and has a deformed incurvation of the spine ; the incurvation is supposed to be caused by a dislocation of the vertebrae ; the displaced bones are thought to make an unnatural pressure on the spinal marrow, and a pressure on that being very likely to produce a paralysis of some kind, the loss of the use of the legs is in this case determined to be such : the truth is, that there is no dislocation, no unnatural pres- sure made on the spinal marrow, nor are the limbs by any means paralytic, as will appear to whoever will ex- amine the two complaints with any degree of attention. 254 ELEMENTS OF SURGERY. " In the true paralysis, from whatever cause, the mus- cles of tbe affected limb are soft, flabby, unresisting, and incapable of being put iuto even a tonic state ; the limb itself may be placed in almost any position or pos- ture; if it be lifted up, and then let go, it falls down, and it is not in the power of the patient to prevent, or even to retard its fall :* the joints are perfectly and easily moveable in any direction; if the affection be of the lower limbs, neither hips, knees, nor ancles, have any degree of rigidity or stiffness, but permit the limb to be turned or twisted in almost any manner. " In the present case, the muscles are indeed extenu- ated, and lessened in size; but they are rigid, and al- ways at least in a tonic state, by which the knees and ancles acquire a stiffness not very easy to overcome; by means of this stiffness, mixed witji a kind of spasm, the legs of the patient are either constantly kept stretched out straight, iu which case considerable force is required to bend the knees, or they are by the action of the stronger muscles drawn across each other, in such man- ner as to require as mucji to "separate them: when the leg is in a straight position, the extensor muscles act so powerfully as to require a considerable degree of force to bend the joints of the knees; and when they have been bent, the legs arc immediately and strongly drawn up, with the heels toward the buttocks: by the rigidity of the ancle joints joined to the spasmodic action of the gastrocnemii muscles, the patient's toes are pointed down- ward in such manner as to render it impossible for him to put his foot flat to the ground: which makes one of the decisive characteristics of the distemper " These are strong marks of the distinction which ought to be made between the two diseases; and fully sufficient to shew the impropriety of confounding them with each other. ELEMENTS OF SURGERY. 223 u The majority of those who labour under this disease are infantfe or young children: adults are by no means exempt from it, but I have never seen it at an age beyond forty. " When it attacks a child who is old enough to have walked properly, its aukward and imperfect manner of using its legs, is the circumstance which first excites at- tention, and the incapacity of using them at all, which very soon follows, fixes that attention, and alarms the friends. " The account most frequently given is, that for some time previous to the incapacity, the child had been ob- served to be languid, listless, and very soon tired; that he was unwilling to move much, or briskly; that he had been observed frequently to trip and stumble, although no impediment lay in his way; that when he moved hastily or unguardedly, his legs would cross each other involuntarily, by which he was often and suddenly thrown down; that if he endeavoured to stand still, and upright, unsupported by another person, his knees would totter and bend under him ; that he could not with any degree of precision or certainty, steadily direct either of his feet to any particular point, but that in attempting so to do, they would be suddenly, and involuntarily, brought across each other ; that soon after this, he com- plained of frequent pains and twitchings in his thighs, particularly when in bed, and of an uneasy sensation at the pit of his stomach; that when he sat on a chair, or a stool, his legs were almost always found across each other, and drawn up under the seat; and that in a little time after these particulars had been observed, he totally lost the power of walking. " These are the general circumstances which are found, at least in some degree, and that pretty uniform' ly in* most infants and children, but there are Hheiv which are different in different subjects. vol. n. g g 226 ELEMENTS OF SURGERY. " If the incurvation be of the neck, and to a consider- able degree, by affecting several vertebrae, the^hild finds it inconvenient and painful to support its own head, and is always desirous of laying it on a table or pillow, or any thing to take off the weight. If the affection be of the dorsal vertebrae, the general marks of a distempered habit, such as loss of appetite, hard dry cough, labo- rious respiration, quick pulse, and disposition to hectic, appear pretty early, and in such a manner as to demand attention: and as in this state of the case there is al- ways, from the connexion between the ribs, sternum, and spine, a great degree of crookedness of the trunk, these complaints are by every body set to the account of the deformity merely. In an adult, the attack and the progress of the disease are much the same, but there are some few circumstances which may be learned from a patient of such age, which either do not make an im- pression on a child, or do not happen to it. " An adult, in a case where no violence hath been committed, or received, will tell you, that his first inti- mation was a sense of weakness in his back bone, ac- companied with what he will call a heavy dull kind of pain, attended with such a lassitude as rendered a small degree of exercise fatiguing: that this was soon follow- ed by an unusual sense of coldness in his thighs, not ac- countable for from the weather, and a palpable diminu- tion of their sensibility. That in a little time more, his limbs were frequently convulsed by involuntary twitch- ings, particularly troublesome in the night: that soon after this, he not only became incapable of walking, but that his power either of retaining or discharging his urine and faeces was considerably impaired, and his penis be- came incapable of erection. " The adult also finds all the offices of his digestive, and respiratory organs much affected, and complains con- stantly of pain and tightness at his stomach. ELEMENTS OF SURGERY. 22? " In infants, the curve is seldom noticed till it has got to such size and state, as to demand attention from the deformity: previous to this, all the marks of distemper wliich appear in the child, pass for the effects of general weakness, and are treated as such; differently by differ- ent people, and under different circumstances, but never with any permanent good effect; some of the adventi- tious symptoms, if I may so call them, are, in some de- gree, relieved, but the principal remain in full force, or, what is much more frequent, go on increasing. " In an adult it passes for rheumatism, or gravel, or a strain, and the defect in the limbs is the first thing that occasions an inquiry into the state of the back bone. " When a curvature is perceived in an infant, it is always supposed to have received a hurt by a blow, or fall, and an adult has always recourse to some exertion in pulling, drawing, lifting, or carrying, by which the spine is thought to have been deranged^ or injured; but which supposition is seldom, if ever true, in either case. " The true cause of the disease, is a morbid state of the spine, and of some of the parts connected with it; which distempered state of parts will, upon careful in- quiry, be always found to have preceded the deformity some length of time; in infants this is the sole cause, and external violence has nothing to do M'ith it. In the adult, I will not assert that external mischief is always and totally out of the question, but I will venture to af- firm what is equal, as far as regards the true nature of the case, which is, that although accident and violence may in some few instances be allowed to have contri- buted to its more immediate appearance, yet the part in which it shews itself, must have been previously in a morbid state, and thereby predisposed for the production of it. I do not by this mean to say, that a violent ex- ertion cannot injure the spine, nor produce a paralytic complaint, that would be to say more than I know; but 22* ELEMENTS OF SURGERY. I will venture to assert, that no degree of violence what- ever is capable of producing such an appearance as I am now speaking of, unless the bodies of the vertebra were by previous distemper disposed to give way; and that no supposable dislocation, caused by mere violence done to the bones of the back, which bones were before the receipt of the injury in a sound state, can possibly be attended with the peculiar symptoms of a curved spine. In which distinction, according to my judgment, consists the very essence of the disease. Violence may easily be supposed to bring the two vertebrae nearer to each other than they ought to be, and by crushing an intermediate one to produce a curvature; but then the body of the vertebrae so crushed, must have been in a distempered state previous to such violence: great vio- lence may also suddenly and immediately displace a per- fectly sound vertebrae from its proper and natural situa- tion, with regard to those annexed to it; but the neces- sary consequences of these two kinds of injury must be so very different, that they never can be confounded to- gether, or mistaken for each other, even by the most in- attentive observer. " The true curvature is invariably uniform in being from within outwards; but it varies in situation, in extent, and in degree; it affects the neck, the back, or the loins; it comprehends one vertebra only, or two, or more; and as few or more are affected, or, as these are more or less morbid, and consequently give way more or less, the Curve must be different; but whatever variety these cir- cumstances may admit, the lower limbs alone,* in gene- « • Since I began to put these papers together, I have seen two cases, in one 6f which the arms only were affected, in the other both legs and arms. " Mr. E. Ford, of < iolden Square, has favoured me with the examination and case of a lad, who lost the use of both legs, and both arms, from a curvature which Mr. Ford cured by means of the caustics. Mr. Park, of Liverpool, has also obliged me with an account of two persons, both under his care, both with Useless arms and legs, and both cured by the same means." ELEMENTS OF SURGERY. 229 ral, feel the effect. Some are very soon after the curva- ture, rendered totally and absolutely incapable, not only of walking, but of using their legs in any manner; others can make shift to move about with the help of crutches, or by grasping their thighs just above' the knees with both hands; some can sit iu au armed chair without much trouble or fatigue, others cannot sit up with any help; some retain such a degree of power of using their legs, as to be able to shift their posture when in bed; others have no such power, and are obliged to be moved upon all occasions. " Weak and delicate children are the most frequent subjects of this distemper; and when in these, it seizes on the dorsal vertebrae, great deformity of the trunk, both before and behind, is the almost inevitable and ne- cessary consequence; this will be different in different persons; but let the difference in this be what it may, it is an adjunct circumstance; and upon due enquiry it will always be found that the curvature from within outward, preceded the other deformity, and Mas, at one time, the only one to be seen. " Before the alteration of figure in the back bone has been discovered, all the attention is paid to the limbs, in which the whole disorder is supposed to reside; and all the applications for relief are made to them: frictions, liniments, embrocations, blisters, &c. to which is gene- rally added cold-bathing and electricity; when the cur- vature has been noticed, recourse is immediately had to back-boards, collars, steel bodice, swings, screw-chairs, and other pieces of machinery, but all to no purpose; the patient becomes daily more and more helpless and unhealthy, languishes for more or less time, and at last dies either in an emaciated state from an hectic, or by a drain from an abscess formed within the body. "That this is the case frequent and melaucholy expe- 230 ELEMENTS OF SURGERY. rience evinces, but why it is so, is perhaps not generally so well understood, or attended to as it ought to be. "The primary and sole cause of all the misehief, is a distempered state of the parts composing or in imme- diate connexion with the spine, tending to, and most frequently ending in a caries of the body, or bodies, of one or more of the vertebrae: from this proceed all the ills whether general, or local, apparent, or concealed; this causes the ill health of the patient, and, in time, the curvature. The helpless state of the limbs, is only one consequence of several proceeding from the same cause; but though this effect is a very frequent one, and always affects the limbs in nearly the same manner; yet the dis- ease not having its origin in them, no application made to them only can ever be of any possible use. "The same failure of success attends the use of the different pieces of machinery, and for reasons which are equally obvious. "They are all, from the most simple to the most com- plex, but particularly the swing and the screw, calcu- lated to obviate and remove what does not exist. They are founded upon the supposition of an actual disloca- tion, M'hich never is the case, and therefore they always have been and ever must be unsuccessful. "To understand this in the clearest and most con- vincing manner, we need only reflect on the nature of the disease, its seat, and the state in which the parts concerned must necessarily be. " The bones are either already carious, or tending to become so; the parts connected with them are diseased, and not unfrequently ulcerated; there is no displacement of the vertebrae with regard to each other, and the spine bends forward only because the rotten bone, or bones in- tervening between the sound ones give way, being unable in such state to bear the weight of the parts above. The most superficial reflection on this must point out to every ELEMENTS OF SURGERY. 231 oue, why attemps of this kind can do no good, and a lit- tle more attention to the subject will show why they may be productive of real, and great mischief. The bones are supposed to be sound, but displaced; these machines are designed to bring them back to their former situation, and thereby to restore to the spine its proper rectitude; if therefore they have any power, that power must be exercised on the parts in connexion with the curve; which parts, when the disease is at all advanced, are in- capable of bearing such a degree of violence without being much hurt thereby: this, if it frere merely theo- retical, being a conclusion drawn from the obvious and demonstrable state of the distempered parts, could not be deemed unreasonable; but, unfortunately for the af- flicted, it is confirmed by practice. They who have had patience and fortitude to bear the use of them to feuch a degree as to affect the parts concerned, have always found increase of pain and fever, and an exasperation of all their bad symptoms, and I have kuoM7n more than one instance in which the attempt has proved fatal. "The use of some or other of these pieces of machinery is so general, and the vulgar prejudice iu their favour so great, that notwithstanding I have been long con- vinced of their perfect inutility, yet if I had no other ob- jection to them, I would not attempt to rob the afflicted of what they seem to derive such comfortable expecta- tion from; but as I am satisfied of their mischievous ef- fects, not only in the case of the present subject, but in many others; 1 cannot help bearing my testimony against the indiscriminate and very improper use which is daily made of them. " They are used with design to prevent growing chil- dren from becoming crooked or misshapen, and this they are supposed to do by supporting the back-bone, and by forcing the shoulders unnaturally backward; the former they cannot do, and in all cases where the spine 232 ELEMENTS OF SURGERY. is weak, and thereby inclined to deviate from a right figure, the latter action of these instruments must con- tribute to, rather than prevent such deviation; as will appear to whoever will with any attention examine the matter: if, instead of adding to the embarrassments of children's dress by such iron restraints, parents would throw off all of every kind, and thereby give nature an opportunity of exerting her own powers; and if in all cases of manifest debility recourse was had to friction, bark, and cold bathing, with a due attention to air, diet, exercise, and rest, the children of the opulent would, perhaps, stand a chance of being as stout, as straight, and as well shapen as those of the laborious poor. "When a child appears to be what the common people call naturally weakly, whatever complaints it may have are supposed to be caused by its weak state, and it is generally believed that time and common care will re- move them ; but when a curvature has made its appear- ance, all these marks of ill health, such as laborious re- spiration, hard cough, quick pulse, hectical heat and flushing, pain and tightness of the stomach, &c. are more attentively regarded, and set to the account of the de- formity consequent to the curve, more especially if the curvature be of the dorsal vertebrae, in which case the deformity is always greatest: but whoever will carefully attend to all the circumstances of this disorder, will be convinced, that most, if not all the complaints of chil- dren, labouring under this infirmity, precede the curva- ture, and that a morbid state of the spine, and of the parts connected with it, is the original and primary cause of both. "I have in the former edition informed the reader, that my particular attention to this disease was first excited by an instance of its being cured by a seemingly acci- dental abscess; that this first gave me reason to suspect. that we had mistaken an effect for a cause, and, that ELEMENTS OF SURGERY. 233 upon mature deliberation upon the matter, I was still more inclined to think so for the following reasons. 1. " That I did not remember ever to have seen this useless state of the limbs from a mere mal-formation of the spine, however crooked such mal-formation might have made it. 2. " That none of those deviations from right shape, which growing girls are so liable to, however great the deformity might be, was ever attended with this effect. 3. " That the kind of deformity, which was attended with this affection, of the limbs, although it was different as to its degree, and its extent in different people, yet it was uniform in one circumstance, which was, that the curvature always was from within outwards. 4. " That since I had been particularly attentive to the disorder, I thought that I had observed, that neither the extent, nor degree of the curve, had in general pro- duced any material difference in the symptoms, but that the smallest was when perfectly formed, attended with the same consequences as the largest. 5. " That although it had sometimes happened, that a blow, or a strain, had preceded the appearance of the curve, yet it much more frequently happened, that no such cause was assignable. 6. " That I had observed exactly the same symptoms in infants, and in young children, who had neither exert- ed themselves, nor were supposed to have received any injury from others ; and that the case was still the same in those adults, who had no such cause to look to. 7. " That although it might be expected, that a dislo- cation of any of the vertebrae, would be attended with symptoms of the paralytic kind, yet they would be very unlike to those which affected the limbs in the present case." "The suspicions which these circumstances had excit- ed in my mind, were confirmed by what I had a few op- Vol. n. h h 334 ELEMENTS OF SURGERY. portunities of observing, in the dead bodies of some who had died afflicted with this disorder, and altogether sa- tisfied me, that there must be something predisposing in the parts concerned ; and that when we attribute the use- less state of the limbs merely to the curvature, we mis- take, as I have just said, an effect for a cause. " At the same time I gave an account of a conversation, which passed between me and the late Dr. Cameron, of Worcester, who told me, that having remarked in Hip- pocrates, an account of a paralysis of the lower limbs, cured by an abscess in the back, he had, in a case of use- less limbs attended with a curvature of the spine, en- deavoured to imitate this act of nature by exciting a pu- rulent discharge, and that it had proved very beneficial; which Was confirmed to me by Mr. Jeffrys, of Worcester, who had made the same experiment with the same success. "From the time of my receiving this first information to the present, I have sought every opportunity of making the experiment; St. Bartholomew's hospital has seldom been without cases of this kind, and it is with infinite ^pleasure and satisfaction, that I find myself enabled to say, that in all cases where the complaint has been so circumstanced as to admit of even probable expectation, the attempt has been successful. "If the cure of this most dreadful distemper had depend- ed upon an application to the constitution in general, it might have required a variety of medicines, the adminis- tration of which must have demanded judgment in adapt- ing them to particular persons and constitutions ; and it must also, iu the nature of things, have happened that many individuals could not have been benefited at all. But fortunately for the afflicted, the means of relief are simple, uniform, and safely applicable to every indivi- dual, under almost every possible circumstance, not at tended by the smallest degree of hazard, and capable of ELEMENTS OF SURGERY. 235 being executed by any body who has the least portion of chirurgic knowledge : it consists merely in procuring a large discharge of matter, from underneath the raeni- brana adiposa on each side of the distempered bones forming the curvature, and in maintaining such discharge until the patient shall have recovered his health and limbs. They who are little conversant with matters of this sort, will suppose the means very inadequate to the proposed end ; but they who have been experimentally acquainted with the very wonderful effects of purulent drains, made from the immediate neighbourhood of dis- eases, will not be so much surprised at this particular one; and Mill immediately see how such kind of dis- charge, made, and continued from the distempered part, checks the further progress of the caries, gives nature an opportunity of exerting her own powers, of throwing off the diseased parts, and of producing by incarnation an union of the bones (now rendered sound) and thereby establishing a cure. " However, be all this as it may, the fact is undoubted, and the number of witnesses, as well as patients' produci- ble in confirmation of it is so considerable, that it is need- less to say any thing more on that head. " It is a matter of very little importance towards the cure, by what means the discharge be procured, provided it be large, that it come from a sufficient depth, and, that it be continued for a sufficient length of time.* " I have tried the different means of setons, issues by incision, and issues by caustic, and have found the last in general preferable, being least painful, most cleanly, most easily manageable, and capable of being longest continued. " The caustics should be applied on each side of the * " When I say this, I mean to signify that it is absolutely without limitation, and must depend on their beneficial effect." 236 ELEMENTS OF SURGERY. curvature, in such a manner as to leave tb« portion of skin covering the spinal processes of the protruding bones, entire and unhurt, and so large, that the sores upon the separation of the eschars, may easily hold each three or four peas in the case of the smallest curvature; but in large curves, at least as many more. " These issues should not only be kept open, but the discharge from them should be maintained by means of orange peas, cantharides in fine power, aerugo aeris, or any such application as may best serve the intended purpose, which should be that of a large, and long con- tinued drain. " Whatever length of time it may take to obtain a com- plete cure, by restoring the health as well as the limbs, the issues must be continued at least as long; and in my opinion, a considerable time longer, especially in the persons of infants and growing children; the necessity of which will appear more strongly, when it shall be considered that infants and young children of strumous habits, are the subjects who are most liable to this dis- temper, and that in all the time previous to menstruation in one sex, and puberty in the other, they are in general more served by artificial drains than any other persons whatever. "This, and this only, does or can alleviate the misery attending this distemper, and in proper time effect a cure. " By means of these discharges, the eroding caries is first checked, and then stopped ; in consequence of which an incarnation takes place, and the cartilages between the bodies of the vertebrae having been previously de- stroyed, the bones become united with each other and form a kind of anchylosis. " The time necessary for the accomplishment of this, must in the nature of things, be considerable in all oa- ELEMENTS OF SURGERY. 237 ses, but very different according to different circum- stances. " No degree of benefit or relief, nor any the smallest tendency towards a cure is to be expected, until the ca- ries be stopped, and the rotten bones have begun to in- carn ; the larger the quantity of bones concerned, and the greater degree of waste and havock committed by the caries, the greater must be the length of time re- quired for the correction of it, and for restoring to a sound state so large a quantity of distempered parts,—and vice versa.* "In the progress towards a cure, the same gradation or succession of circumstances may be observed, as was found to attend the formation of the disease, with this difference, that they which attend the latter, are much more rapid than those which accompany the former. "Afterthe discharge has been made some time, very uncertain what, the patient is found to be better in all general respect^, and if of age to distinguish, will ac- knowledge that he feels himself to tte in better health; he begins to recoyer his appetite, gets refreshing sleep, and has a more quiet and less hectical kind of pulse, but the relief which he feels above all others, is from having got rid of that distressing sensation of tightness about the stomach; in a little time more a degree of warmth, and a sensibility is felt in the thighs, which they had been strangers to for some time; and generally much about the same time, the power of retaining and discharging the urine and faeces begins to be in some de- gree exerted. " The first return of the power of motion in the limbs is rather disagreeable, the motions being involuntary and • '* Nothing can be more uncertain than the time required forthe cure of this distemper. 1 have seen it perfected in two or three months, and I have known it require two years; two thirds of which time passed before there was any visL ble amendment." A 238 ELEMENTS OF SURGEUV. of the spasmodic kind, principally in the night; and ge- nerally attended with a sense of pain in all the muscles concerned. "At this point of amendment, if it may be so called, it is no uncommon thing, especially in bad cases, for the patient to staud sonie time without making any farther progress; this iu adults occasions impatience, and in parents despair; but in the milder kind of case, the power of voluntary motion generally soon follows the in- voluntary. " The knees and ancles by degrees lose their stiffness, and the relaxation of the latter enables the patient to set his feet flat upon the ground, the certain mark that the power of walking will soon follow; but these joints hav- ing lost their rigidity, become exceedingly weak, and are not for some time capable of serving the purpose of progression. " The first voluntary motions are weak, not constantly performable, nor even every day, and liable to great va- riation, from a number of accidental circumstances, both external and internal, ^ " The first attempts to walk are feeble, irregular, and unsteady, and bear every mark of nervous, and muscular debility; the patien^stands in need of much help, and his steps, with the best support, will be, as I have just said, irregular and unsteady; but when they have ar- rived at this, I have never seen an instance in which they did not soon attain the full power of walking. " When the patient can just walk, either with crutches, or between two supporters, he generally finds much trou- ble and inconvenience, in not being able to resist, or to regulate, the more powerful action of the stronger mus- cles of the thigh over the weaker, by which his legs are frequently brought involuntarily across each other, and lie is suddenly thrown down. * ELEMENTS OF SURGERY. 239 "Adults find assistance in crutches, by laying hold of chairs, tables, &c. but the best and safest assistance for a child, is what is called a go-cart, of such height as to reach under the arms, and so made as to inclose the whole body : this takes all inconvenient weight off from the legs, and at the same time enables the child to move them as much as it may please. " Time and patience are very requisite; but they do in this case, as in many others, accomplish our wishes at last. " The deformity remaining after recovery is subject to great uncertainty, and considerable variety, as it depends on the degree of caries, and the number of bones affect- • ed : in general, it may be said, that where one vertebrae only is*affected, and the patient young, the curve will in length of time almost totally disappear ; but where two or three are affected, this cannot be expected; the thing aimed at is the consolidation and union of the bones, which had been carious, and are now become sound: this is the sine qud non of the cure, and this must in such cases render the curvature, and consequently the defor- mity, permanent: the issues Mill restore the use of the limbs, but not the lost figure of the^pne." (Pott.) Since the introduction of this method of treatment into general use many cures, have been effected of this for- merly incurable disease, and the practice of Mr. Pott has been approved and adopted by all modern surgeons. In some instances advantage is derived from machinery so constructed as to support the head, but this is not often required. The curvature of the spine resulting from rickets is generally distinguishable from that in which the vertebrae are carious. In rickets, the curvature is gradual and extends throughout the whole spine: it is also very irre- 240 ELEMENTS OF SURGERY. gular, and the spine is bent in several different direc- tions—in cases of caries a few of the vertebrae only are affected, and the curve is more abrupt and angular. In rickets too the other bones of the body are generally af- fected ;-the sternum projects;—the ribs are depressed;—the bones of the pelvis fall inwards ;-the clavicles are pro- minent ;-the os humeri bulges outwards;—the thighs are curved forM'ards and outwards;—the knees are bent in- wards ;-the tibia is unusually convex and prominent ;-and the feet turn outMTards. In short the whole skeleton in rickety subjects is deformed, and the whole appearance of the patient is feeble and sickly; whereas the disease of the spine which Has been described, is purely local, and appears to be unattended with any primary consti- tutional affection. Attempts have been made to cure the disease of the spine by simply confining the patient to bed. Of the suc- cess of this treatment I have no information, but it should certainly not supercede the employment of issues, from which so much benefit has been found to result. ELEMENTS OF SURGERY. 241 CHAPTER XXXI. Of Paronychia or Whitlow. Paronychia, Panaris, or Whitlow is a very painful and distressing inflammation seated at the end of a finger or thumb generally terminating in suppuration. It is usually divided into four species, which differ merely in the degree and situation of the inflammation. The first species is the least severe. It is seated near the root or side of the nail, and when it suppurates, mat- ter is formed immediately under the cuticle, and the in- flammation appears to extend no deeper than the true skin. When, however, in this case the matter forms under the nail, as it sometimes does, great pain results from its confinement. In the second species of whitlow the inflammation oc- curs under the true skin, and commonly near the extre- mity of the finger. The pain is very great, probably be*. eause the skin of the finger does not admit of ready dis- tention in the inflamed vessels, and when suppuration takes place the matter is confined, and the abscess does not soon open. The third species is that in which the inflammation is still more deeply seated, and affects the parts within the theca covering the flexor tendons. In this case the inflammation and suppuration frequently extend along the tendons to the wrist, and even to the elbow. In the fourth species the periosteum and sometimes the bone inflames. In this case the inflammation and sup- puration do not generally extend so far as in the third species. VOL. II. t i 242 ELEMENTS OF SURGERY. In the two last cases the pain is very excruciating, and there is no great tumefaction evident. Besides these four species of whitlow a fifth has been noticed affecting the bone exclusively, attended with ex- treme pain, continuing for weeks and months with inter- vals of ease, and occasional exacerbations. In one such case the finger is stated by Richter to have been re- moved, and the bone on examination was found entirely destroyed and chauged into a fatty substance. The causes of whitlow are not always known; vicis- situdes of temperature frequently occasion it. I have seen more cases of whitlow among washerwomen than in any other class of persons. Punctured wounds have sometimes produced paronychia. The most distressing cases of the disease are those in which the inflammation and suppuration proceed along the tendons, under the aponeurosis palmaris, and under the annular ligament of the wrist to the fore arm. Some- times gangrene results, and limbs have been amputated in consequence of whitlow, and death has in some cases followed this apparently trivial complaint. TREATMENT. The manner of treating paronychia varies somewhat according to the situation of the inflammation. In the first species it is necessary to evacuate the matter as soon as it forms, and in general it readily heals; the best ap- plication is the common epulotic cerate. If matter form under the nail it can be plainly seenr and must be eva- cuated, by scraping the nail very thin with glass or a sharp knife and then dividing it with a bistoury. When the inflammation is deeper seated and great pain results, the patient should be bled and purged. The application of leeches is also very effectual in abat- ing the inflammation. A blister should be applied over ELEMENTS OF SURGERY. 243 the part. In some cases advantage has been obtained from rubefacients, as hot water, &c. but the blister is to be preferred. As soon as matter forms, how- ever, it should be evacuated by a free incision, and whenever paronychia is attended with severe pain, and the skin is not very red and sensible, we may infer that the inflammation is situated in the tendon or periosteum, and therefoie an early and free incision in the direction of the tendon should be made down to the bone, which generally procures very speedy relief, evacuates matter if it be already formed, removes the tension of the parts if suppuration have not taken place, and substitutes a simple incision which will readily heal, for a most obsti- nate, painful, and dangerous malady. When matter travels along in the course of the ten- dons, free incisions should be made for its evacuation, and if carious bone be found it should be extracted as soon as it becomes sufficiently loose. It often happens that the tendons exfoliate or slough, a tedious process which prolongs the disease and pre- vents the soft parts from healing. In these cases if prac- ticable, the diseased tendon should be cut off, and with it a small portion of the sound tendon, for unless the in- cision be made in a sound part the cure will not be ex- pedited, since the absorbents will have still their work to perform. Fungus sometimes protrudes through the external opening, which should always in such cases be enlarged, to give free vent to confined pus, and to remove all stric- ture from the inflamed parts, 244 ELEMENTS OF SURGERY. CHAPTER XXXII Of Amputation of the Limbs. What the surgeon cannot cure he removes by his knife. If his art were perfect he would never amputate, but in the present state of medical science even this ter- rible operatiou is occasionally demanded. The modern improvements of surgery have lessened the number of cases M'hich call for amputation, and have greatly miti- gated its horrors, but it still leaves the patient a muti- lated victim, and it is an operation "terrible to bear and dreadful to behold." It is important for a surgeon to be well convinced of the propriety of amputation before he resolves upon it. He should never consider it as one of his remedies, but as an apology for their inefficacy, and notwithstanding this he should be ready to amputate when necessity de- mands it, and prompt to decide when that necessity exists. It is customary in systematic works to collect together a number of aphorisms to regulate the practitioner on the present occasion. I shall comply with the custom to a certain extent, premising that exceptions may be as nu- merous as the rules, and in many cases the best practice will consist in violating the best general directions, and a familiar acquaintance with every principle of surgery will be necessary in forming a judgment upon the end- less variety of cases which may involve the question of the propriety of amputation. I. Compound fractures have been supposed to ren der amputation necessary. We have already remarked ELEMENTS OF SURGERY. 245 (page 110, vol. 1.) that a broken bone affords no just reason for the operation. The concomitant injury and the circumstances under which the attempt to cure the patient will be made are the principal things to be taken into consideration. On the field of battle, or in the cock-pit amputation is warrantable and proper, in cases which would not justify it in the comfortable residence of an affluent citizen. To anticipate the particulars of each case is impossible. II. Compound dislocations are of a very serious nature, and are often complicated with other important injury to a limb. In hot weather such accidents not unusually terminate in tetanus—sometimes in gangrene— often in violent inflammatory fever—or in a profuse discharge of pus, and consequently great exhaustion and hectic fever. In these cases amputation is therefore a subject of serious deliberation. The dangers should be staled fairly and freely to the patient and his friends, and the surgeon should rather direct and inform, than con- trol their decision, always bearing in mind that many desperate cases get well under judicious and attentive treatment. III. Extensive wounds. Many wounds occur which render amputation indispensable. A limb is shot off' by a cannon ball—It is lacerated by a splinter and all its important bloodvessels torn open. Under such circum- stances immediate amputation substitutes a simple inci- sion for a ragged, lacerated, dangerous wound. In these cases no time should be lost. Ranby or Wiseman relates a case in which a sailor in an engagement had one of his arms shattered, went to the cock-pit, and after it was am- putated sprung upon deck, nothing daunted, and assisted with the other to traverse a gun. The operation is bet- ter borne immediately after the accident than at any other time. IV. Mortification. When a limb mortifies from want of blood, or from excessive inflammation, the. ab- 246 elements of surgery. sorbents if left to themselves Mill perform the amputation but in a slow and slovenly manner, and an irregular stump will be left. The surgeon should never ampu- tate whilst mortification is progressive, but if necessary afterwards he may perform the operation for the pur- pose of expediting the cure. V. Diseased joints;—cancerous and other in- curable ulcers, sometimes render amputation neces- sary. The great exhaustion of the patient, and his apparently approaching death, are the only good reasons fur amputating in such cases, since many diseases supposed incurable get well, and yet there are no in- stances where the benefit arising from amputation is so great and so immediate, as in cases such as we are now contemplating. I have known a pulse too frequent to be counted, become nearly natural in a few hours after the amputation of a scrofulous knee—the hectic was imme- diately relieved—the night sweats subsided—the strength rapidly returned, and in a few days, from the brink of the grave, the patient Mras snatched to a place of safety, and speedily restored to health. VI. Certain tumours rapidly increasing, or tending to end in incurable ulcers, as, the fungus nematodes— certain exostoses, or bony excrescences—caries of the bones of a joint and limb. These and other incurable affections of a like nature, warrant and demand the am- putation of a limb. Hemorrhage may generally be stopped without am- putation, and aneurisms no longer afford a pretext for the operation, though many limbs have been lost in con- sequence of a deficiency of knowledge as to the proper treatment of these cases. The tying-up of the artery supplying a limb, should be preferred to amputation. ELEMENTS OF SURGERY. 247 Mr. Boyer in his clinical lectures at the hospital La Charite, recommended amputation of the leg in cases of dislocated astragalus, even when unattended with a wound, but for this practice I think there is no excuse. Compound luxations do not afford a sufficient reason for amputation, and in the opinion of most surgeons, un- less they be attended with very extensive injury to sur- rounding parts, the operation ought not to be done. In a simple luxation therefore the practice of Mr. JBoyer should never be imitated. Mr. Larrey recommends amputation as a cure for te- tanus, in cases where this disease results from gun-shot wounds. In some cases I have known this practice tried, but always without success. For a number of very interesting observations on the present subject, the reader is referred to a masterly per- formance of Mr. Pott, entitled " Remarks on the neces- sity and propriety of the operation of amputation in cer- tain cases and under certain circumstances." 248 ELEMENTS OF SURGERY, CHAPTER XXXIII. Amputation of the Thigh. When the thigh is amputated in consequence of a dis- eased knee, the limb should be removed as low down as possible without cutting in diseased parts. Previously to this, and every painful operation, a dose of laudanum should be administered. The instruments necessary, are, a tourniquet—a com- press bandage—a large amputating knife—a scalpel— a retractor—a saw—bone nippers—sponges and warm water—a tenaculum—needles and ligatures—adhesive plasters—dry lint—lint spread with cerate—a pledgit of tow—and a muslin roller. It is best, in order to avoid embarrassment, to pro- vide two knives and two tourniquets, as accidents have sometimes rendered one of these instruments useless. The patient should be seated on a table covered with a folded blanket (a dining table with the leaves down is very convenient) he should be supported by pilloMrs, or by an assistant who takes him in his arms. The end of a roller folded to the thickness of a compress bandage is to be applied over the femoral artery at the upper and inner part of the thigh, and is to be kept in that situa- tion by one turn of the roller, over which the tourniquet is applied and buckled. The chief precautions in the application of the tourniquet are, to observe that the buckle is three or four inches distant from the screw, and that the two plates of the instrument are in contact. The reason of these directions will appear obvious to any ELEMENTS OF SURGERY. 249 person who examines the operation of the instrument; I have known the strap broken in consequence of the buckle coming in contact with the lower plate whilst the surgeon was screwing forcibly, and it has hap- pened that the whole effect of the tourniquet has been lost in consequence of the remoteness of the plates at the time of its application. The tourniquet being buckled on is to be screwed until the circulation is com- pletely stopped, which can be ascertained by examining the anterior tibial artery, where it passes over the top of the foot. When the thigh is amputated very high up, the artery may be compressed by the thumb of an assistant in the groin, and in case a tourniquet breaks, it is easy in this manner to arrest the hemorrhage till another is applied. The surgeon takes the position which he finds most convenient, on either side of the patient (and this he should do in all amputations since there is no important reason for preferring one side to the other, except his convenience at the time.) One assistant takes hold of the leg, the limb being grasped by another who draws the skin moderately up and thereby renders it tense. The surgeon with his large knife makes a straight inci- sion completely round the limb, extending in depth through the skin and fat, down to the fascia femoris. This skin and fat are then to be dissected loose from the fascia, and for this purpose the amputating knife is exchanged for a scalpel; when a sufficiency of integument is thus separated to Cover the end of the stump, it is to be reverted, and held back by an assistant. The surgeon again takes the amputating knife, and divides the muscles down to the bone, close to the reverted integuments. In this stage of the operation he should guide the edge of the knife by his eye, and be particularly cautious not to cut through the skin turned up, a piece of awkwardness utterly in- VOL. II. k k 250 ELEMENTS OF SURGERV. excusable. The retractor, apiece of slit linen or leather, is now applied to defend the muscles from the saw, and the assistants holding the limb above and below very steadily, the surgeon proceeds to saw through the bone. The cautions I \vish to offer on this stage of the opera- tion, are, not to scrape up with a knife the periosteum from the bone—a useless, painful, and tedious business, and one which will be apt to occasion exfoliation. 2. To use long strokes of the saw, which prevents the choking of the teeth, and expedites the operation. 3. Never to use a saw in which the teeth are not set wide, so as to make a groove wider than the thickness of the blade of the saw. Tf this be not attended to the saw hitches in the bone, its motions are irregular, and the bone often breaks off before it is cut through. The limb being thus removed, the surgeon proceeds to tie the femoral artery with a strong ligature: he will easily see it near the bone, and probably several other large vessels will be obvious each of which is to be drawn out by a tenacu- lum and tied in succession. The tourniquet is now to be loosened, and a jet of blood takes place from every considerable artery not yet secured; these are all to be taken up, and the stump cleansed with warm water and a clean sponge. The tourniquet and compress are now to be taken off. The bleeding having ceased, it is proper to wait a few minutes, and give the patient a little wine to excite the circulation, as a fainty state often stops the bleeding for a time before the arteries are secured. If no blood flows the skin is to be drawn over the end of the stump, wiped dry, and carefully approximated, and it is of no importance whether this be done in a line from side to side, or from before backwards.1' The liga- tures are to be brought out at each angle of the wound, and a small piece of lint interposed between the edges of the skin, in order to prevent the union of the skin be- ELEMENTS OF SURGERY. 251 lore the flap and muscles have united. A caution of much importance, as the neglect of it has occasioned in many cases an abscess to form from the confinement of blood and serum under the flap which have greatly re- tarded the cure. The occurrence of this accident is I believe a very principal reason why the French surgeons do not avail themselves of the adhesive inflammation in the present case. They believe it impossible for the skin and muscles to unite by the first intention, and they consequently cover the stump with lint. The fact is, much of the union will be accomplished by the first in- tention, if the plan I have suggested be adopted. Straps of adhesive plaster are now to be applied in order to se- cure the skin in its proper situation; over this a pledgit ^ of lint spread with simple cerate, and over this pledgit another of fine ton', which is to be secured by a roller. The malta cross—the elongates—the knitted cap—are all useless envelopes; the best of all is a roller properly applied. This roller is to be passed repeatedly round the lower part of the thigh, and after crossing the stump in opposite directions, is to be carried by circular turns up to the hip, and passed once or twice round the loins to prevent it from slipping down. The tourniquet is now loosely applied around the top of the thigh to be ready in case of bleeding, and the patient is laid on a mattress. The stump being placed on a pillow, a cradle is to be fixed over it as in cases of fracture to prevent the pres- sure of the bed clothes. The patient should be kept at rest—some pain and soreness of the thigh may be expected, but the stump should not be touched till the eighth day in cool weather, or the fourth or fifth day in summer, at which time it is to be dressed. In removing the dressings great caution must be used* The bandages should be well soaked in warm water, 252 ELEMENTS OF SURGERY. and poulticed for some hours, if necessary, to soften them. The dressings are to be reapplied as at first, and this should be repeated once in forty-eight hours, and after the third or fourth dressing every day. The liga- tures generally come away in a fortnight, and the stump in a successful case heals in three or four weeks. If there be any reason to suppose the femoral artery in a diseased state, and especially if it be found ossified, it will be proper to take it up with a needle, and the li- gature should include a portion of the surrounding sub- stance. It is of no great consequence to avoid inclosing a nerve in the knot, for I am convinced that this is often • done without occasioning spasms of the stump or any other inconvenience; nevertheless I do not recommend it to be done if it can be conveniently avoided. When the patient begins to use a wooden leg, great care should be taken to prevent ulceration of the stump. ELEMENTS OF SURGERY. 25.3 CHAPTER XXXIV. Amputation of the Leg. The method of amputating the leg which I shall re- commend, is one very easily performed, and equally suc- cessful with any other; avoiding therefore, as usual, a history of succesive improvements, I proceed to de- scribe it in the manner in which it has been for many years performed by Dr. Physick. The instruments and previous preparations are the same as have been recommended for amputation of the thigh, with the addition of a catlin, or double edged knife, and a retractor with three instead of two tails. The tourniquet need not be placed so high upon the thigh, but it is better to affix the compress under it at the spot where the femoral artery is tied in cases of popli- teal aneurism, and not as has sometimes been advised, low down near the knee, because the ham strings take off much of the pressure from the artery and render it necessary to screw it much tighter. The circulation being commanded, an assistant holds the foot and leg steady, another secures tbe knee, and the surgeon standing if convenient* on the inside of the knee, makes an incision with the amputating knife abont five inches below the patella, in front; extending consi- derably lower down behind, so as to be more distant from the knee behind than before. This incision is to be carried regularly round the limb, and deep enough to * I use this word, because, the direction of the light, the number of attend* ants, the size of the apartment, and many circumstnnces, may interfere with UjSb arrangement. 251 ELEMENTS OF SURGERY. divide the skin and adipose matter doAvn to the fascia cu Veringtbe muscles. With a scalpel the integuments arc to be dissected loose and turned back, the surgeon tak- ing care to reserve enough to cover the stump, and no more. A flap will in this manner be formed, consisting of the skin and cellular membrane,, which should meet just behind the tibia, of course about one inch of skin should be reserved in front. When this flap is turned back, with the amputating knife, or catlin (which Mr. C. Bell prefers) the surgeon proceeds to divide the mus- cles down to the bones, and inserting the catlin between the tibia and fibula, he divides the interosseous flesh and ligament. The retractor is next applied, one strip being interposed between the bones, and being drawn up by an assistant so as to protect the muscles, the surgeon saws through the bones in such a manner as to cut through the fibula by the time the tibia is about half divided : the object of this is to prevent. the lesser bone from breaking into splinters, when the support of the great- er is removed. Any spiculae which may project from either bone, can be removed with the nippers, and af- terwards the arteries are to be taken up. There are generally three which may readily be found : the anterior tibial between the bones, and a little anterior to the in- terosseous ligament; the posterior tibial lying a little to the inside of the former vessel near the tibia; and, the fibular artery, near to, and behind, the fibula. The tourniquet being loosened, other vessels will be observ- ed, and these must successively be taken up. The dressings are to be applied in the same manner as when the thigh is taken off, except, that in folding the skin over the tibia, care must be taken not to compress it by the plasters or dressings too firmly, as the sharp edge of the bone sometimes occasions ulceration. In many cases the disease for which a leg is removed, is situated on the foot, at the ankle, or so low in the leg ELEMENTS OF SURGERY 255 that the surgeon may choose at what part to amputate. In these cases if the patient be wealthy, and not very de- sirous of walking much after his cure, we may cut the leg low down, within a few inches of the ankle, and a cork supplement can be adapted to the stump; but in persons accustomed to labour, it will be best to operate near the knee, and have a wooden leg adapted to the flexed knee, so that the patient may bear his weight upon originally formed parts, which are not so liable to ulce- rate as the surface of a cicatrized stump. The operation last described is adapted to the re- moval of any part of the limb between the ankle and knee, and I belieye possesses all the real advantages of the common flap operation. If the ligatures do not remain long enough to retard the cure, the stump, in a healthy patient, generally heals in three or four weeks. It is a great desideratum to be able to remove ligatures when they cease to be neces- sary. 250 ELEMENTS OF SURGERY. CHAPTER XXXV. Amputation of the Arm. The amputation of the arm above the elbow, resembles so much that of the thigh, that it is unnecessary to de- scribe it. The amputation below the elbow resembles very much that of the leg, except that instead of the oblique inci- sion through the integuments, a circular or straight inci- sion is made. After amputating the arm, it is unnecessary to prevent by interposing a piece of lint, the union of the wounded skin, because the cut surfaces are so small that union by the first intention often takes place throughout the stump, the whole of which heals as soon as the ligatures come away. I have amputated a fore-arm, and in ten days found the stump entirely healed. When the arm is taken off near the wrist, some incon- venience results from the irregular contraction of the muscles, in consequence of which the tendons protrude very unequally from the stump; those which project arc easily however removed with the scissors. One of the most common cases demanding the amputation of the fore arm, is the bursting of a fowling piece, the left hand being placed near the breech of the gun, receives the load, and becomes so much shattered that it is impossi- ble to save it, and immediate amputation becomes re.* quisite. ELEMENTS OF SURGERY. 257 CHAPTER XXXVI Of amputation at the shoulder joint. This is a very serious operation, and may become ne- cessary from gun-shot wounds, from exostoses or bony tumours of rapid growth near the head of the humerus, from fungus hematodes and certain analagous cases. The operation of removing the arm at the shoulder joint, was first performed by the elder Morand and af- terwards by Le Dran, who describes very particularly the manner in which he operated. Various modes have since been adoptetl, which I shall not detail, but, hav- ing never had occasion to perform the operation on the living body, I shall describe the manner in which it is done by the most celebrated surgeons of the present day. The French surgeons amputate at the shoulder in the following manner. The patient is seated on a chair, his head leaning against the breast of an assistant; the operator placed at the external side of the limb, makes a first transverse incision down to the bone, at the inferior and anterior part of the deltoid muscle; a second incision is made longitudinally from the coracoid process to the internal angle of the first; and a third pos- teriorly, from the level of the articulation to the external extremity of the transverse incision; having thus cut the flap, he dissects it and turns it up, pressing the lower part of the arm against the trunk, to make the head of the humerus project, he then cuts the tendons of the teres minor, supra-spinatus, infra-spinatus, and biceps muscles; this done he rotates the arm backwards, cute vol. 11. i. 1 258 ELEMENTS OF SURGERY. the ligaments of the articulation, luxates the arm back- wards, compresses the flesh, by which the arm is yet held to the trunk, and lastly stops the hemorrhage from the brachial artery, and finishes the formation of the flap; the arm being separated from the trunk, he imme- diately proceeds to apply the ligatures, bring back the flap, and secure it by adhesive plaster, lint, compresses, &c. This operation will be less painful, and more quick- ly executed, if the external flap is formed by a skigle stroke, by using a double edged knife, with which the surgeon may di\ ide the deltoid at its base, and passing from top to bottom along the bone, until it comes within four fingers breadth of the articulation where the flap terminates. This mode of operating has been practised with great dexterity by professor Dupuytren, and is par- ticularly described in the first volume of the Dictionaire des Sciences Medicales," published at Paris in 1802. The celebrated and venerable Mr. Cline of London, has contrived an operation, much more simple than this, and one which I should certainly prefer to all others. My friend Dr. J. A. Smith of New-York who has seen Mr. Cline operate, thus describes to me his opera- tion. "The artery being previously secured by pres- sure on the first rib, an assistant takes hold of the arm, and pulls it from the body obliquely downwards, the sur- geon being provided with a narrow knife, takes up with his left hand as much of the deltoid muscle as he thinks will be sufficient to form a flap to cover the wound. The knife is then introduced in such a direction as to pass slant-wise between the acromion process and the head of the humerus; around the head of that bone the in- strument makes a semicircular sweep within the glenoid cavity, dividing at one stroke all the muscles which connect the arms with the scapula and body. The whole operation is little more than a simple incision, and is per- formed with a facility perfectly astonishing to those who ELEMENTS OF SURGERY. 259 see it for the first time, and if the surgeon have formed his flap of the proper size, it covers the wound with great accuracy." I have no doubt that the operation has often been per- formed without necessity. I have once amputated an arm torn off by a cannon shot, as high up as the axilla, I preserved a flap by retaining the integuments in such parts as appeared sound, and sawed through the bone in the usual manner, in this case the axillary artery was the only one which required a ligature. This case would in the opinion of many have warranted amputation at the joint, but it would have added much to the danger, pain, and confinement of my patient. That the operation becomes in some cases absolutely necessary I well know, and in such cases it should be performed in the manner recommended by Mr. Cline. With respect to the dressings, all that can be said is, that after the arteries are tied up, the flap is to be neatly applied over the joint, and kept in its proper position by adhesive plasters and a roller. 260 ELEMENTS OF SURGERY. CHAPTER XXXVII. Amputation at the Hip-joint. The dangers attending this tremendous operation have almost occasioned it to be laid aside. Mr. Pott declar- ed, after having seen it done, that he should never per- form it on the living body. A French surgeon by the name of Barbet, received a prize from the Academy of Surger\, for an essay on the present subject iu 1759. He considered it a neces- sary operation in three distinct cases. 1st, When the soft parts around the joint have mortified. 2dly, When a cannon ball has shattered the limb, in such a manner as to leave but a small portion of flesh to unite it with the trunk; and 3dly, In cases where the femoral artery has been wounded near Poupart's ligament. The two first cases are happily rare, and yet they cer- tainly sometimes sanction aud demand the operation. The third case is now treated in a very different manner, by tying the artery above the wound. Certain other dis- eases near the articulation may perhaps render the opera- tion necessary. Messrs. PariSet and Petit have written a short paper on this subject in the Dictionaire des Sciences Medica- les, in which they declare that the operation has been successfully performed by two French surgeons, La- croix and Perault. Dr. Larrey has performed this operation oftener than perhaps any other surgeon ever did; his patients have in most instances died, but I am informed that in three ca ELEMENTS OF SURGERY. 261 se« they recovered. It ought only to be performed when certain death is the alternative. It is evident that the circumstances demanding this operation must materially influence the mode of perform- ing it. The separation of the injured parts must be ef- fected in the simplest possible manner, and the blood- vessels carefully secured. Larrey in performing the ope- ration commences by tying the femoral artery as near as possible to the crural arch; he then forms a flap on the inside—cuts dowu to the articulation—divides the cap- sular and round ligaments—dislocates the bone—forms an external flap of the glutaei muscles adapted to meet the internal flap—after which the arteries are tied up, and the parts brought together and dressed in the usual manner. As some of the principal vessels wounded in this ope- ration are the branches of the internal iliac, it appears to me that in emaciated subjects it would be easy, for a time, to command the hemorrhage by compressing the aorta opposite the navel, and in most patients I believe this would diminish the loss of blood. 262 ELEMENTS OF SURGERY. CHAPTER XXXVHI. Amputation of the Fingers and Toes. The fingers and toes are generally removed at the joints. The operation is very simple when the structure of the joint is known. The skin should be moderately drawn back, and a circular incision made through it a little beyond the joint. A portion of skin is next de- tached with the scalpel sufficient to cover the stump. This little flap being reflected, the tendons and soft parts are to be cut down to the joint. The joint is now bent and the capsular ligament divided posteriorly, after which one of the lateral ligaments is to be cut through; the bones now easily separate and the scalpel can be passed between to complete the division of the connecting parts. After this is done the flap is brought forward, its edges neatly approximated, and secured by a strap of adhesive plaster, after which a narrow roller is to be bound round the stump. The bleeding generally ceases after the dressings are applied, but if not it is easy to take up the vessels. A new mode of amputating fingers is described by Mr. Charles Bell, but it is less simple and no better than the one I have mentioned. The removal of the metatarsal and metacarpal bones is an operation described by many writers, but one which is rarely necessary. I believe it will be found easier in most cases to cut down to the diseased bone, and remove with a trephine or saw resembling Mr. Hey's, the af- fected part. ELEMENTS OF SURGERY. 263 CHAPTER XXXIX. Of Hemorrhage after Amputation, It not unfrequently happens that a discharge of blood takes place from the stump after amputation. It is consequently of importance to leave a careful assistant with the patient, and a loose tourniquet applied on the limb. The most frequent cause of secondary hemorrhage is the omission to tie up some artery which did not bleed immediately after the operation, owing to the languor of circulation, and the coldness of the stump from exposure which occasions a temporary contraction of the vessels; the heat being restored and the circulation excited these vessels pour out blood. To obviate this inconvenience it is right to give the patient wine and water before the dressings are applied, and to wait a short time in order to ascertain whether the vessels will bleed. Another cause of bleeding after amputation is an im- proper degree of tightness in the circular bandage, which intercepts the return of blood through the cutaneous veins. Of course in cases of secondary hemorrhage a careful attention should be paid to the bandage surrounding the limb. Bleeding sometimes takes place from the medullary artery passing through a bone. I once saw a very trou- blesome hemorrhage of this sort, which was finally ar- rested by the introduction of a small cedar plug into the bony canal which afforded a passage to the vessel. Sometimes the bleedins* results from the slipping off a ligature which had been carelessly tied. This event 264 ELEMENTS OF SURGERY. should be guarded against by great care in securing every considerable vessel with a double knot. The bleeding sometimes also depends on a morbid condition of the system which is incompetent to those functions necessary for the restoration of the wound- ed parts. In this case the flap and stump will not reunite, and the arteries like the other parts will re- fuse to heal. This is only to be prevented by general remedies adapted to the constitution. In many cases the bleeding from a stump is so trifling as to give no serious alarm, but there are cases in which the loss of even a small quantity of blood is dangerons, and others in which so much is lost as to occasion great uneasiness. In these cases moderate pressure constant- ly continued by the hands of assistants may be tried, and in some instances this method prevents the unpleasant necessity of removing the dressings and exposing the stump. If it be not however successful the bleeding vessels must be carefully sought for, and secured by li- gatures. There is another kind of secondary hemorrage which results from ulceration of the larger arteries; this may occur at a remote period from the operation, sometimes a month has previously elapsed. It is, however, ex- tremely rare, and admits of no remedy but cutting down to the vessel and tying it up, or if this cannot be done, the trunk from which it proceeds should be tied. Mr. Hey has performed a singular operation with a view to arrest the secondary hemorrhage, and he says with success. I shall state his observations. "I have seen a few instances of the integuments becoming so con tracted after the operation as to compress the veins just above the extremity of the stump, and bring on after some hours copious hemorrhage. When it has appeared clear to me that the hemorrhage was venous I have made a division of the integuments on one side of the thigh ELEMENTS OF SURGERY". 265 sufficient to remove the stricture, and this method has immediately suppressed the hemorrhage." I have my- self never seen such a case' and therefore offer no opinion on the propriety of the practice. I shall subjoin from Mr. Hey a few more observations on the present sub- ject. " When we are under the necessity of amputating a limb that has suffered great contusion, though the opera- tion is performed upon a part apparently sound, the wound sometimes becomes sloughy, and ill-conditioned. No good granulations arise to cover the extremities of the arteries, but the ligatures cut through these vessels, or becoming loose, cease to make a sufficient pressure upon them, and hence repeated hemorrhages ensue. This is a dangerous state for a patient; for if the vessels arc taken up afresh with the needle, the hemorrhage will now and then retnrn in the course of two or three days. In such cases the application of dry sponge, cut trans- versely, as directed by Mr. White,* has been found sin- gularly useful, and has saved the life of the patient. But a constant pressure must be kept upon the pieces of sponge, by the fingers of a succession of assistants, till granulations begin to arise upon the stump, and the pros- pect of future hemorrhage disappear. This method is of the greatest importance after amputation on the thigh or leg, where the great vessels are deeply seated. In the arm, above the elbow, where the vessels are more superficial, the great artery may be taken up, with a por- tion of muscular flesh, above the surface of tbe stump, by making first an incision through the integuments. My colleague Mr. Logan has done this twice within the last year, with complete success, when repeated ligatures, applied in the usual way, had failed. * See Cases in Surgery, by Charles Wlute, F. R. S. Vol. ii. Mm 266 ELEMENTS OF SURGERY. "In the morbid sloughy state of the stump above men- tioned, the application of lint soaked in a liquid, com- posed of equal quantities of* lemon juice and rectified spirit of wine, has been found very advantageous, and has caused the stump to put on soon a healthy aspect." It is recommended to apply cold lotions in those cases in which the hemorrhage appears to proceed from one or more small vessels; cloths wet with a solution of sugar of lead may be placed upon the dressings and renewed from time to time as they become warm. The use of styptics and astringents can never be ap- plied with propriety to the surface of a stump. The agaric formerly employed, is never used at the present day. Mr. Petit contrived an instrument for the pur- pose of compressing the whole surface of a stump after amputation. To prove the importance of his inven- tion, he relates a case in wliich a thigh was amputated, and the femoral artery was found ossified, and could not be secured by a ligature; his complicated machinery was applied and arrested the hemorrhage; this contrivance, however, has sunk into deserved neglect, and no confi- dence should be placed in any similar machine. Upon the whole, the best mode of preventing trouble from hemorrhage after amputation, is to secure carefully every bleeding vessel by a ligature. ELEMENTS OF SURGERY. 267 CHAPTER XL. % Of Spasms of the Stump. It often happens that spasmodic motions in the mus- cles of the stump take place after amputation, which are attended with extreme pain. They sometimes continue for several days, and now and then affect the whole body; in some instances death has resulted. The present modes of operating are supposed to have diminished the frequency of these unpleasant conse- quences, but they still occasionally happen. The best mode of relieving the pain and of preventing injury to the stump, is to have it held by a succession of assis- tants, and to administer liberal doses of opium. In cases in which amputation is performed on persons addicted to habits of intemperance, the administration of opium is always proper to prevent the occurrence not only of spasm, but of delirium, and death; this remark however is equally applicable to all surgical operations under similar circumstances. Volatile alkali and other stimulating articles are also useful medicines in these in- stances. 268 ELEMENTS OF SURGERY. # CHAPTER XLI. Extirpation of Tumours. One of the most eloquent compositions contained in our medical libraries is the treatise upon tumours con- tained in Mr. John Bell's Principles of Surgery; having very freely censured this writer in a former chapter, I take great pleasure in applauding where I have so fair an opportunity. To his treatise therefore I refer my readers for a most elaborate and instructive history of our present subject. The limits allotted to this work prevent me from entering extensively into it, and I shall in general terms advise the early removal of all tumours which constantly increase in growth—which after being indolent become painful—or which are situated in parts where their enlargement or ulcera- tion would occasion an interruption to any of the func- tions of the body. Encysted tumours wliich in popular language are called wens, ought to be cut out, for although they have no tendency to end in cancer and do not often ulcerate, yet they encrease occasionally to an enormous size. They consist of an external bag or sac, containing either fat, in which case the tumour is called steatomatous, or a substance resembling honey termed meliceris, or a soft pappy substance called atheroma. Commonly these wens are not deeply seated and are moveable, in which case they arc very easily taken out. The operation consists in making an incision through the skin down to the tu- mour, and dissecting round it, carefully avoiding an opening into the sac. The method of dissecting out a ELEMENTS OF 6URGFRY. 269 cancerous breast, is applicable to most encysted tu- mours. The skin to be saved must be sufficient to cover the wound, but it is inconvenient to leave more and there- fore where the tumour is large, two incisions are to be made meeting like two segments of a circle, or the marks of a parenthesis (). Fleshy or sarcomatous tumours have been the sub- ject of a very valuable essay by Mr. Abernethy. He di- vides them into a number of classes which I shall not^ enumerate, because the knife is the safest and least pain- ful remedy for them all. The surgeon should prefer the early extirpation of tu- mours, but he is not to be deterred by their future growth from dissecting them out. A very large tumour was safely and successfully removed from a man's neck and face by Dr. Physick in the Pennsylvania Hospital. The weight of this tumour was seven pounds, its circumference twen- ty-three inches at its base, and twenty five and a half inches at its largest part. It involved the parotid duct which was divided in the operation. The patient soon re- covered, and was discharged cured. Previously to the operation he appeared like a man with two heads. 270 elements of surgery. CHAPTER XLII, Of Warts and Corns. Most persons are acquainted with the usual appear- ances of warts. They are generally situated in the hands and fingers; they are a sort of excrescence com- posed of fibres projecting from the cutis vera, or parts below. They do not acquire a large size, but sometimes become irritable and painful, and when scratched or bruised they bleed and occasionally ulcerate. The best method of treating them is by stimulating ap- plications : such as tincture of cantharides,-strong vine- gar-caustic volatile alkali,-the various escharotic salts, as corrosive sublimate,-blue vitriol; and if these fail, the wart should be destroyed by means of lunar caustic, or nitric, or sulphuric acid. Corns are as familiarly known as warts; the former fashion of tight shoes has crippled a great many belles and beaux of the last age. Corns are generally situated on the joints of the toes, and consist in a great induration of the skin, sometimes extending into the cellular substance below. At times they are indolent, but irritation in walking excites great pain, and changes of the weather in some persons, al- ways occasion extreme pain. To relieve the inconveniences of corns it is essential that the patient wear loose and soft shoes. When the corn is covered with a mass of thickened cuticle, the foot should be soaked in warm water, and this cuticle pared off. A very excellent mode of defending the corn from the pressure of the shoe, when the patient walks, is to elements of surgery. 271 spread several small pieces of leather with adhesive plaster; in the centre of these leather strips, a hole is to be cut rather larger than the corn. They are to be ap- plied successively over the toe or foot in such a manner that the corn shall be surrounded by the leather, and the shoe will then press upon the leather, the corn re- maining untouched. When situated on the sole of the foot, a felt or cork sole should be worn with a hole cut in it opposite to the corn. Mr. S. Cooper states that a corn may be infallibly cured by the following method. " The corn is to be rubbed twice a day with any emollient ointment, and in the interim it is to be covered with a softening plas- ter. Every morning and evening the foot is to be put for half an hour in warm water, and whilst there the corn is to be well rubbed with soap; afterwards all the white pulpy outside of the corn is to be scraped off, taking care not to give the least pain. The same treatment is to be continued without interruption until the corn is totally extirpated, which generally happens in eight or twelve days." 272 elements of surgery. CHAPTER XLIII. Of the Inverted Toe nail. A disease frequently occurs in the great toe, produc-- tive of more inconvenience and distress than the worst corns ;—an inversion of the nail of the great toe which grows in upon the flesh^ generally in consequence of wearing a tight shoe. This complaint is attended with severe pain and in- flammation, sometimes with ulceration, a fungus arises in many cases which is extremely sensible, and gives great pain wrhen touched, so that the patient is completely in- capacitated from walking. The nail in many cases be- comes completely imbedded in the flesh, and in others a thick skin forms over the greater part of it. Distress- ing spasms occasionally result. In general persons afflicted in this way, are in the ha- bit of cutting the nails short, and interposing lint between the flesh and its edge ; but this does not retard the pro- gress or remove the pain of the complaint. The use of caustic is also ineffectual, and although it removes the fungus, yet this is speedily reproduced. Desault published a memoir on this complaint, and his curative indication consisted in keeping the nail and flesh separated. He effected it by taking a plate of tin, an inch and a half long, and about a quarter of an inch wide, and introducing it between the tumefied flesh and the edge of the nail; he afterwards raised up the nail by depressing the flesh, which served as a point of support to the plate, and which was covered with a small com- press spread with cerate, to defend it; then he bent back ELEMENTS OF SURGERY. 273 the plate from within outward, in such a manner as to embrace exactly the prominence formed by the flesh, and secured it by a small bandage rolled around the toe. Af- ter this the foot was poulticed. This operation succeeded with Desault, but he states that it is exceedingly painful, and as the process must be repeated daily, the pain is repeated as often. I there- fore take the liberty to recommend a simpler, easier, and more effectual remedy,—the excision of the inverted edge of the nail. Before commencing the operation, the foot should be soaked in warm water to soften the nail; with a sharp strong bistoury the nail is tp be slit down near the edge completely to the root, this portion is then to be carefully, but quickly, detached from the soft parts, after which a poultice is to be applied. The whole success of the operation depends on removing radically every vestige of the nail at its root, after which the parts readi- ly heal, and a radical cure is effected. The relief pro- cured by this operation is hardly credible by those who have never witnessed it. It is well however for the sur- geon to be aware, that it is an operation as painful as al- most any he will be called on to perform, and therefore he should complete it as speedily as may be consistent with a certainty of removing the whole offending part. VOL. II. n n 274 ELEMENTS of surgery. CHAPTER XLIV. Of Paracentesis Abdominis. The operation of tapping the abdomen in cases of dropsy, is performed usually by introducing a trochar through the parietes of the abdomen, through the canula of which the water is allowed to escape. The place at which this puncture has. been made, until within a few years, was at the middle of a line drawn from the umbi licus to the superior auterior spinous process of the os ilium. The left side was chosen to avoid the liver. It has however happened in several iustances that the epi- gastric artery pursuing an unusual course has been punc- tured in this operation ; and, in other instances, the tro- char instead of perforating the liuea semilunaris, as was intended, has pierced through the thick muscular pa- rietes of the belly, and occasioned much pain and in- flammation. This mode of operating, therefore, has been universally deserted, and surgeons now insert the trochar through the linea alba, two or three inches be- low the navel, in a direct line towards the symphysis pubis. The opening may very conveniently be made with a common trochar, or with a flattened trochar, but Dr. Physick has in my opinion greatly improved the operation, by substituting for the trochar a lancet, which makes a clear incised wound, through which a flattened canula is inserted. The incision heals readi- ly without inflammation. The most convenient mode of performing the opera- tion is, to place the patient near the edge of the bed, and ELEMENTS OF SURGERY. 275 under him a piece of oil cloth to prevent the fluid from wetting the bed clothes. The lancet is then inserted through the parietes of the abdomen, about two inches below the navel, and as soon as it is removed the canula is introduced. To prevent the edges of the canula from irritating any of the abdominal viscera, a smaller one clo- sed at the extremity and terminating in a smooth polish- ed surface perforated with several holes, is to be intro- duced after the water has flowed a short time. If these canulae, however, be not at hand, a common female silver catheter and a lancet may be substituted, and with these instruments the operation has frequently been very well performed. In order to prevent the unpleasant effects which sometimes result from the sudden removal of the f water, it is necessary after a portion has flowed out, to compress the belly in various places, by means of the hands of assistants, or by passing a sheet round the ab- domen, the two ends of which are to be drawn by assist- ants, and after the operation is completed to apply a bandage moderately tight round the abdomen. The current of water sometimes suddenly stops before the whole of it is discharged, in consequence of a portion of intestine or omentum getting before the aperture of the canula, this is to be removed by introducing a probe or director. The fluid is sometimes too viscid to flow through the small apertures of a female catheter, in which case they must be enlarged, or a canula introduc- ed open at the extremity. The only dressing the wound requires is a dossil of lint, or a strip of adhesive plas- ter. It is generally necessary in cases of dropsy to repeat this operation frequently. In these cases the puncture should never be tv ice made in precisely the same spot, because it has happened that adhesion has formed, con- necting an intestine to the cicatrix, and the intestine has been wounded in a subsequent operation. 276 ELEMENTS OF SURGERY. Dropsy of the ovaria is a case sometimes demanding paracentesis. The tumour in this case commences on one side, and seems to rise out of the pelvis; gradually enlarging, it at length fills the greater part of the abdo- men, and in its latter stage cannot from its appearance be distinguished from ascites, which from the beginning is attended by an equal, uniform swelling of the abdo- men. The cyst of the ovary which contains the fluid in ova- rian dropsy commonly adheres in various places to the peritoneum so that there is no particular danger in tap- ping it. The operation is to be performed in. the same manner as in ascites, and generally in the same place; but if one part of the abdomen be more prominent than the rest in ovarian dropsy, the lancet should be inserted at that part. It only palliates the disease, and must in general be frequently repeated. Le Dran in some cases laid open the cyst of ovarian dropsies. His patients sur- vived and were cured of the dropsy, but a fleshy tumour formed, which gradually increased and destroyed the pa- tient, or else incurable fistulous ulcers remained. Attempts have been made to cure this complaint by injecting wine after evacuating the cyst, as in cases of hydrocele, but death has generally resulted, sometimes from the inflammation immediately subsequent, and at other times a more lingering termination has taken place. The seton has also been tried without success, and the best plan I believe is to evacuate the water occa- sionally in the manner which has been described. Paracentesis is sometimes but very rarely necessary for the evacuation of air iu cases of Tympanites. It may be performed in the same way as for the evacuation of water. ELEMENTS OF SURGERY. "W 4 CHAPTER XLV. Paracentesis Thoracis. The thorax is sometimes opened for the purpose of discharging water, air pus, or blood, which may have collected from accident or disease. The manner of performing this operation is essentially different from that of tapping the abdomen. The place at which to make the aperture is, between the sixth and seventh true ribs, equi-distant from the spine and sternum. An incision about two inches long is to be made through the integuments of this part with a common scalpel; the intercostal muscles are next to be carefully cut through by an incision smaller than the external one. The pleu- ra costalis is now exposed, and a small puncture may be made through it. Water, air, pus, or fluid blood, will readily escape through a small aperture, but if coagula be found the incision must be enlarged. In order to avoid the intercostal artery, it is safest to cut through the mus- cular flesh close to the upper edge of the lower rib. In order to evacuate the fluid, the patient after the puncture should place the wound in a depending posture, by lying on his side. After the evacuation of the contents of the pleura, the wound is to be closed, and dressed with ad- hesive plaster. ^78 ELEMENTS OF SURGERY. CHAPTER XLVL Of Bloodletting. For the cure of numerous morbid affections, blood must be evacuated. The means of drawing blood in use among medical men are several. General bleeding is performed by opening a vein, an operation called phlebotomy or venesection, and the punc- ture of an artery called arteriotomy. Topical or local bloodletting is performed by means of leeches; by opening the vessels of a part with a lancet or knife; and by cupping. Phlebotomy or venesection is the most frequent and one of the simplest of surgical operations. It is usually effected by opening a vein in the arm. A band or ligature is to be applied around the arm be- tween the vein to be opened and the heart; in conse- quence of this ligature the vein swells and becomes tur- gid; the bandage, however, should never be drawn so tight as to intercept the blood by the arteries, and it will be well, previously to applying the ligature, to feel for the pulsation of the artery in order to learn its precise situa- tion. A vein is now to be chosen sufficiently turgid and superficial, and sufficiently remote from the artery; this vein is to be opened by a lancet, or German fleam. If the lancet is to be used (and most surgeons recommend it) it should be exceedingly sharp, in which case the shape of it is not so important as many have supposed, since it is easy with a very sharp lancet to make an aperture of any requisite size in the vein. When the Ian- elements of surgery. 279 cet is introduced with the right hand, the thumb of the left hand is to be placed on the vein a little below where the puncture is to be made in order to fix the vein, but care should be taken not to alter the relative position of the skin and vein, because in regaining this position after the lancet is inserted, the aperture through the skin will no longer correspond with, or be opposite to that in the vein, in consequence of which a thrombus or ecchymosis will form—a very common accident in ve- nesection. The lancet is to be pushed into the vein, and when its point is within the cavity of the vessel it is to be carried forward a little, so as to enlarge the opening sufficiently. The arm is to be kept extended after the operation until the necessary quantity of blood is taken. If the blood should not flow as freely as is desfred, the patient should exert the muscles of the arm by grasping a stick, or moving the fingers. After the blood is drawn the arm is to be wiped, and the sides of the orifice neatly approximated in the man- ner directed by Mr. Hunter, which has been described in the chapter on wounds of veins, vol. 1. page 100. The external jugular vein is sometimes opened. The head should be laid on one side, and the vein is to be compressed by the surgeon's thumb near the clavicle, and the opening made in that part of the vein which lies over the sterno-cleido-mastoid muscle. The blood soon ceases after the pressure is removed, but a small strip of adhesive plaster is sometimes necessary. Veins in the legs and feet can sometimes be found in children when there are none visible in the arm. To promote their distention, and to encrease the bleeding from them it is useful to immerse the limb in warm wa- ter. The German fleam or spring lancet I prefer greatly to the common English lancet for phlebotomy; it is now in some parts of the United States almost exclusively used. 280 ELEMENTS OF SURGERY. I shall insert some remarks on this subject which I pub- lished in an edition of Cooper's surgical dictionary in 1810. " In a country situated like the United States, where every surgeon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring-lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instrument; and no one can calculate with certainty the depth to which it will enter: to sharpen a lancet, is regarded by the cutler as one of his nicest and most difficult jobs; it is one to which few surgeons are competent. " The safety of using the fleam is demonstrated by daily experience; there is no country in which venesec- tion is more frequently performed than in the United States, and perhaps none where fewer accidents from the operation have occurred, of these few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used." I have since however met with an exception to this statement. I have seen the brachial artery opened by a spring-lancet, but it was by an old barber, half blind, and very clumsy. "The manner of using the spring-lancet differs in nothing from the operation with the common lancet, ex- cepting that the surgeon must place the instrument in such a situation, over the vein, that when the spring is touched, the orifice into the vein will have a proper size and direction. Dexterity in this is very readily and speedily acquired. In point of facility in its use it has a great advantage over the lancet. " Among the advantages of the spring-lancet economy is not the least. A country practitioner who is constantly employing Hie English lancets, and who is particular in ELEMENTS OF SURGERY. 281 using none but the best, must necessarily consume half the emolument derived from the operation, in the pur- chase of his instruments. One spring-lancet, with an oc- casional new blade, will serve him all his life." ARTERIOTOMY. Arteriotomy is commonly performed by puncturing the trunk or branches of the temporal artery. The vessel in general lies so near the surface that a lancet may easily be inserted into it—after enough blood is evacuated the bleeding is readily arrested by applying a compress and bandage. When difficulty is experienced in stop- ping the bleeding, it has been found useful to divide the artery entirely; which facilitates, if Dr. Jones's experi- ments be not fallacious, the natural process by which the bleeding is stopped. CUPPING. Cupping consists in extracting blood by an exhaust- ed receiver from punctures made in the skin. It is performed by means of a scarificator, and a small bell glass, or tin cup, the mouth of which is more contracted than the bottom. The scarificator is an instrument containing from sixteen to twenty small lancets, which start out when a spring is touched, and make the necessary punctures of a proper depth; the depth being regulated by means of a screw. The small cutaneous vessels only are divided in this opera- tion, and it is necessary to promote the bleeding by ap- plying the cups, exhausted of air, or rather filled with air greatly rarified, over the punctures. This part of the operation is effected by moistening the skin with warm water, and by heating the air in the cup by the flame of a small lamp (which requires much dexterity and prac- vol. n. o o 282 ELEMENTS OF SURGERY. tice, but is certainly the best method) or by a piece of paper, or tow dipped in spirits of wine and inflamed, which is thrown into the cup immediately before its ap- plication. In this manner a powerful suction is made and the blood flows into the cup : when the cups are moderately full they may be emptied and reapplied. It is best to apply the cups before making the scarifi- cations, in order to render the vessels turgid, and they bleed more freely after this manoeuvre. leechtng. Within a few years leeches have been found in great abundance, and have been introduced extensively into practice in this city, and in other parts of the United States. Bleeding by leeches occasions less irritation than cupping, and is preferable in a great number of cases. The mode of using them which succeeds best in the hands of those whose business it is to apply them, consists in confining a number of the leeches in an in- verted glass or cup, over the part from which the blood is to be drawn, and this part is previously smeared with blood drawn from the operators finger by a lancet or pin, from time to time the glass is taken up to ascertain when the requisite number have adhered, and when this is ef- fected the glass is removed, and the leeches after filling themselves with blood successively drop off. The leech- ers in this town generally moisten their leeches with warm water to enliven them. ELEMENTS OF SURGERY. 283 CHAPTER XLVII. Of Ulcers. An ulcer is a solution of continuity in a soft part, dis- charging pus. Ulcers arise from various accidental injuries which are succeeded by inflammation and suppuration, as from wounds, bruises, burns, &c. They also occur in all cases where a part of the body has been destroyed by morti- fication, and they are the result of certain morbid ac- tions attended with local inflammation, as scrofula, sy- philis, &c. The nature of the ulcerative process has been already cursorily explained in the chapter on inflammation, and a very short account of the manner in which injured parts are restored, has been offered^in the commencement of the present work—it will not, however, be unpro- fitable to enlarge a little on the latter subject, because the cure of ulcers must be attempted under great disadvan- tages, by one who is but partially acquainted with those operations of nature which it is his business to facilitate. When a part of the body is wounded, blood is poured out, and this blood sometimes becomes the bond of union; at other times this effect does not happen, i>ut in- flammation arises, and coagulating lymph is secreted and poured out, and this forms the uniting medium. But the circumstances of an ulcer differ very materially from those of a wound. The absorbent vessels have removed in cases of ulcer a portion of the original flesh, and a vacuity more or less considerable is occasioned by this loss of substance. The whole nature of the part is ZM ELEMENTS OF SURGERY'. changed—it is no longer skin, or muscle, but a secret ing surface, constantly inflamed, and pouring out a fluid. A wound, however, may very readily be converted into an ulcer, and the change takes place in the follow- ing manner. In every wound there is a solution of con- tinuity in a soft part; blood is poured out and generally fills the cavity of the wound; the bleeding having ceased, this blood coagulates. Inflammation succeeds, and the part becomes red, tense, swollen, hot, and painful. The coagulated blood putrefies, and dissolves, emitting an offensive odour; the first discharge therefore from the wound is putrid blood; but soon after a secretion of se- rum takes place, and this mixes with the putrid blood and flows out together with it. The serous thin discharge gradually becomes changed in colour and consistence, approaching more and more in its appearance to pus, and generally in four or five days the inflammation hav- ing abated, pure pus is discharged. In order for the restoration of suppurating wounds something more is re- quisite than what takes place in those which are healed by the first intention. "For there is always a consider- ble gap, by the opposite parts retracting from each other. This gap is, of course, greater in wounds with loss of substance, than in others; but it occurs in all. In order to fill up this vacancy, a growth of new flesh is necessa- ry, and accordingly there sprouts up a new kind of sub- stance, which is named granulations, from all the in- flamed surfaces. " This substance is of a florid red colour, it arises with small irregular round points, something like little grains (hence the name) or rather resembling the head of a cauliflower. " The surfaces of the granulations are moist by their constantly secreting pus; and they are so tender that they bleed if touched a little roughly. This delicate pro- duction springs up in a very irregular manner from the ELEMENTS OF SURGERY. > 285 whole suppurating surfaces; in some parts it sprouts up exuberantly, sending forth pyramids and columns; while in others it goes on very slowly. " In general the principal growth is from the bottom and deeper parts of the wound, very little arising from the superficial. " When two granulations come in contact, they ad- here and grow together. In this manner they increase and unite, until the whole cavity of the wound is filled with them as high as the skin. "This new flesh is of the same nature and appearance, from whatever part of the body it springs; even that which arises from bones, differs in no respect from that which grows from the softest parts. When granulations are cut, they appear an uniform mass without fibres run- ning in any particular direction. They seem principally composed of blood-vessels; and as the blood circulating in them is nearly in contact with the air, it acquires the florid red colour, which good blood always receives when in that situation. There are a great many lym- phatics in granulations, which is proved by salivations having been induced by dressing sores with mercurial applications. Nerves likewise enter into their composi- tion, as is evident from their sensibility; and besides this congeries of vessels and nerves there is probably a con- necting substance uniting all these parts together. "Such is the nature of the new flesh which arises to fill up a suppurating cavity, and to unite the solution of continuity. But this substance does not begin to spring up for the first three or four days. Duriug that period the fever is high, there is a great deal of redness, hard- ness, and tension, in all the parts contiguous to the wound, and the pain and heat are considerable. " These symptoms gradually diminish. At length all pain and tension disappear, and the redness is confined to the surface of the sore, and less than a quarter of an 286 ELEMENTS OF SURGERY. inch around it. The discharge, likewise, also alters materially. It is at first of a thin consistence, of a se- rous colour and offensive smell; and by degrees it be- comes thick and viscid, of a yellowish or white colour, and nearly inodorous." (Moore.) The parts are now in the condition of a healthy or healing ulcer, and resemble those ulcers which arise from the separation of mortified flesh, and all such as are attended with no local or general morbid affection, and in which the parts have sufficient strength to effect the process of restoration. In a simple or healthy ulcer as the granulations arise the discharge is diminished in quantity, and becomes thicker in consistence; at length the deficiency of sub- stance is repaired, and there remains no longer a cavity, but the granulations are on a level with the surrounding skin, or elevated somewhat above it. The process of cicatrization or the formation of skin next commences. " The formation of the cicatrix begins from the edges of the old skin. The redness which existed during the inflamed state abating, the swelling subsiding, and the edges of the sore uniting with the rising granulations. The margin then acquires a bluish white or pearly co- lour, which gradually extends itself to the centre, till the whole sore is covered with new skin. It sometimes hap- pens in broad sores, that cicatrization takes place not only from the circumference, but likewise from one or two points in the centre; these appear like islands in the midst of a sea of granulations; they are of the same colour as the healing margin; and they become larger by extending in every direction. In consequence of ci- catrization going on from different central parts, it hap- pens not unfrequently during the progress of healing, that one broad sore is divided into two or three smaller ones; and when this happens, the cure must go on faster. There is always more or less of a cuticular co- ELEMENTS OF SURGERY. 287 vering upon the cicatrix, which being constantly mois- tened by the discharge from the granulations, is soft and pulpy, and occasions that whitish colour observable on the edges of healing sores. I have sometimes removed this cuticular substance, and have observed underneath the real new skin, which seems a very fine membrane of a red colour, the granulations shining through it. " When a suppurative sore is nearly healed, if it is not kept moist by some application, a scab is apt to form in the same manner as in those wounds which are healed by the first intention. This crust consists of pus dried by the evaporation of the watery parts; the new skin forms under it, and it soon after falls off. " From the surface of the cicatrix there is no secre- tion; there are only the perspirable vessels. While it is forming it is kept moist by the discharge from the un- covered granulations; but when completely formed, the cicatrix is as dry as any other skin. " It appears that the new skin at first cannot form a good cuticle and rete-mucosum, for there is always a succession of scales falling off for sometime; at last this ceases, and the new skin is covered with a good cuticle and rete-mucosum, like other parts. The cicatrix changes successively from a reddish colour to a brown; and lastly it becomes whiter, and of a more shining ap- pearance than the original skin. This is a curious cir- cumstance and merits some attention. "The cutis, as every anatomist knows, is not a smooth polished membrane, but is full of eminences, which are named papillae. These, in some parts of the body, run in waving rows, and form in others irregular lozenges and triangles. The rete-mucosum and cuticle wliich lie immediately over the cutis, are marked with furrows analogous to the eminences of the cutis. The cuticle is of a light colour and semi-transparent. The rete-muco- sum, is white, yellowish, brown, or black, in men of 288 ELEMENTS OF SURGERY. these various colours. And the cutis is extremely vascu- lar; the blood contained in these vessels shines through, and gives the florid fleshy tint to the body. " The colour of the skin, then depends partly upon the rete-mucosum, and partly upon the blood which cir- culates in the cutis. In white men the cuticle and rete- mucosum, which cover cicatrices, appear similar to that which covers other parts; but there is a great difference in the quantity of blood, which circulates in the old and new skin. For the new is far less vascular than the old; or, at least, the greater number of its vessels are of a much smaller diameter, and admit a lesser quantity of red globules of the blood. It happens in consequence of this that the cicatrices are of a whiter colour than the original skin. In negroes the reverse takes place, their scars being generally blacker than other parts, owing to a darker rete-mucosum forming in them upon scars, than upon the old skin. " Besides the difference of colour, a cicatrix has a glossy, shining look, which the skin does not possess : this is owing to the scar being a smooth polished mem- brane without hair, or any of those papillae, which arc upon the cutis; both the papillae and hair are parts which are formed in the first organization of the body, and are never afterwards produced. " As scars are less vascular than the old skin, it is probable that they have fewer nerves; for blood-vessels and nerves are generally in proportion to one another. But as nerves can hardly ever be traced to the surface of the body, we can only judge of their number there, by the degree of sensibility; and this is considerably weak- er in cicatrices than in old skin. This indeed might na- turally be expected, for scars have no papillae, which are supposed to be the principal seat of the sense of feel ing in the skin. ELEMENTS OF SURGERY. &89 " It is observed that scars are generally far less move- able than the original skin; the latter being commonly attached by a loose cellular membrane to the deep seated parts; whereas the scar forms itself immediately upon the granulations, and is so intimately connected, as to make the same substance with them. This is the reason, likewise, that although a scar is at first exactly level with the skin, yet after a certain period, it is often de- pressed. For during the healing of a sore, particularly if the discharge is great, the fat and neighbouring flesh are considerably wasted by absorption. But when the whole is healed, the internal parts recover their bulk, and the fat is regenerated. The skin being attached loosely, readily yields and accommodates itself to* this increase; whereas the cicatrix adhering closely, and be- ing as it were tacked down to the parts upon which it is formed, appears depressed. "It sometimes happens that a cicatrix instead of being depressed, rather projects above the skin owing to the exuberancy of the granulations upon which it is formed; and very often the scar has an irregular, unseemly appearance, from the granulations rising to unequal heights." With respect to the nature of the new-formed parts various opinions have existed. It is certain, however; that in some cases they resemble somewhat the origi- nal flesh, the deficiency in which they are intended to supply, and in other instances the parts newly formed difter very essentially from it. Mr. Moore observes that "in some eases the body is unable to produce any new substance to supply the place of that which was lost, and nothing more is attempted than simply to throw a cicatrix over the sore. In other cases a new substance is formed which fills up the va- cuity, but is incapable of performing the office of the old, vol. it, p p 290 ELEMENTS OF SURGERY. and lastly it sometimes happens that a new substance is produced similar to the old and fit for all its offices." The quantity of new parts formed is not always equal to the parts which have been lost, and in the healing of certain ulcers, a great difference is observed between the size of the original sore and that of the cicatrix, which re- mains after it has healed, owing to the power which the granulations have of contracting. This is most evident in ulcers seated in parts where the skin is loose; in such cases plaits or folds are often formed in the skin in con- sequence of the contraction of the granulations. The healing of a sore is much expedited by this process. This long account of the healing of ulcers I consider by no means unimportant, as it will preclude repetitions in the remaining pages. The simple or healing ulcer then it appears needs no surgical treatment, but requires only rest to enable the parts to restore themselves; cleanliness is however ne- cessary, because filth like all other irritating matters will occasion inflammation and thereby retard the cure. Notwithstanding the tendency of the healthy ulcer to cicatrize, it is a fact that trifling circumstances influence very materially the rapidity of the cure, and therefore Mr. Home very properly advises the dressings to be such as best agree with the granulations, and with the sur- rounding skin. In general dry lint is the best applica- tion, as it absorbs and retains the matter from the sore, and serves as a soft covering for the granulations; over this lint it is proper to apply a pledgit spread with sim- ple cerate, to prevent the evaporation and drying of the matter, and to facilitate consequently the removal of the dressings. In many instances moderate pressure promotes the healing of an ulcer, and in others it retards it: some ul- cers heal most readily when dressed with simple cerate, ELEMENTS OF SURGERY. 291 and others when allowed to scab and dry. Mr. Home does not ascribe these variations to disease, but to con- stitutional causes, for the ulcers heal as soon as the par- ticular things which disagree with them are discontinued. It is proper therefore to ascertain from patients having ulcers, what particular applications have formerly agreed best with their sores, because both in healthy and dis- eased ulcers it will be proper to avoid those dressings which have proved injurious. Various circumstances take place to interrupt the heal- ing of ulcers, and accordingly we find many of them very obstinate and difficult of cure. It would be an endless labour to describe all these circumstances. I shall there- fore detail the appearances and treatment of those ulcers most frequently met with. Ulcers are more frequently situated in the legs than in any other part, and are more obstinate from circum- stances which it is not necessary to explain. Mr. Home in his excellent treatise on the present subject, has de- scribed the various ulcers which are met with under six different divisions. 1. Ulcers in parts which have sufficient strength to carry on the actions necessary for their recovery. 2. Ulcers in parts that are too weak for that purpose. 3. Ulcers in parts whose actions are too violent to form healthy granulations whether this arises from the state of the parts or of the constitution. 4. Ulcers in parts whose actions are too indolent, whether this arises from the state of the parts or of the constitution. 5. Ulcers in parts which have acquired some specific action either from a diseased state of the parts or of the constitution. 6. Ulcers in parts wliich are prevented from healing by a varicose state of the superficial veins of the tipper part of the limb. 292 ELEMENTS OF SURGERY. Dr. Physick in order to describe the usual appear ances of old ulcers, classes them under the following heads, some of which are noticed and some omitted by Mr. Home, viz. 1. The inflamed ulcer. 2. The fungous ulcer. 3. Ulcers seated in oedematous limbs. 4. The sloughing ulcer. 5. The indolent ulcer. 6. Ulcers attended with carious bone. 7. Ulcers attended with varicose veins. 8. Ulcers attended by specific diseased actions. I shall adopt the latter arrangement in the following pages. The appearance of a healthy ulcer such as Mr. Home describes in his first division, has already been mentioned. The granulations in such an ulcer are small, firm, florid, and somewhat pointed at the top. They secrete pus of a light yellow or whitish colour, of a thick consistence, separating readily from the surface of the sore. When the granulations arrive at the level of the surrounding- skin, cicatrization takes place in the manner already de- scribed. But if from accidental irritation, or from constitutional affection, inflammation runs so high as to interrupt the process of healing, the condition of the ulcer is materially changed. ELEMENTS OF SURGERY. 293 CHAPTER XLV1II. Of Inflamed Ulcers. It might be supposed by persons unacquainted with the subject that no difficulty could exist in distinguishing from the appearance, an inflamed ulcer from any other, but the fact is otherwise, and although the circumstances of the cases considered in connection, sufficiently discri- minate the inflamed ulcer, yet except in strongly marked cases, the mere aspect of the sore is not sufficient to ena- ble the surgeon to decide whether an ulcer is inflamed. An inflamed^ ulcer in general puts on the following ap- pearances. The surrounding parts are red, swelled, and very sen- sible to the touch; the blood pressed out of them with a finger quickly returns, and the red colour with it; the margin of the sore is ragged, the skin terminating in a sharp elevated edge around it; the bottom of the ulcer is made up of concavities and no distinct appearance of granulations is seetf—-*t whitish spongy substance exist- ing in their room formed of coagulating lymph. The dis- charge from an inflamed ulcer is thin and serous, and by no means resembles healthy pus. The surface of the sore is acutely sensible, and often bleeds when touched or irritated. The pain attending an inflamed ulcer is in some cases very great; in general it is not constant, but comes on usually in the evening, and continues several hours, at- tended in some cases with spasms of the limb. The ulcers on the legs of sailors and intemperate per- sons generally exhibit, on their admission into a hospital, 294 ELEMENTS OF SURGERY. the symptoms and appearances just described, aud that such ulcers are inflamed there can be no doubt. When, however, these marks are not present, the his- tory of the case and the effects of medicines upon the sore enable us to decide, and it is in general a good rule to consider all doubtful cases as inflamed, because the remedies indicated will do no mischief in any case in which this point is doubtful, and their ill success in case of error will be speedily apparent without any serious or permanent injury. The treatment of an inflamed ulcer consists in the use of the common remedies for inflammation—Rest in a horizontal posture—a low diet—purging and occasional- ly bloodletting. The best local application is a soft bread and milk, or linseed poultice. When by these mea- sures the inflammation is lessened and the sore assumes the appearance of a healthy ulcer, it is to be treated as has been already directed. ELEMENTS OF SURGERY. 39*5 CHAPTER XLIX. The Fungous Ulcer. Instead of the healthy appearance of florid pointed granulations of a firm texture, the fungous ulcer is co- vered with large round granulations rising above the level of the surrounding parts; they are less compact in texture, and appear somewhat transparent; they have no disposition to cicatrize. In some cases the sensibility of the granulations is greater than in healthy sores, and bleeding takes place from every accidental irritation—at other times they are not very sensible and less vascular than healthy granulations. The treatment of fungous ulcers is to be commenced by pressure made with a bandage and roller, or by dress- ing in the manner recommended by Mr. Baynton for the cure of old ulcers, which will be described when the treatment of indolent ulcers is considered. If the pres- sure should not prove successful, escharotic applications are to be used; the red precipitate answrers in many cases very well, but should this fail lunar caustic is to be ap- plied, and the granulations around the edges of the sore are to be destroyed by this application, after which the ulcer may be dressed twice a day with simple cerate and a roller of muslin. Should the ulcer be of small size the whole surface may be touched with caustic at once. It is worthy of remark, however, that in some cases an ulcer will shoot up fungous granulations after the appli- cation of lunar caustic or red precipitate, and this dispo- sition will be effectually checked by an application of 296 ELEMENTS OF SURGERY. blue vitriol. The use of burnt alum is in many cases extremely serviceable in repressing fungous granulations. Various astringent lotions are also useful; a decoction of oak galls; solutions of white vitriol, and other metal- lic salts have been found^ beneficial. It is my cus- tom therefore always to vary the escharotic mediciues in such cases, and sometimes the ulcer heals under the use of one which in other cases has no effect. The great extent to which fungous granulations pro- ceed in some cases is truly surprising. Cancerous ul- cers sometimes shoot out a fungus, which grows so ra- pidly that its increase in volume is almost visible. It is exceedingly difficult in such cases to repress the fun- gus; the older surgeons employed wooden cups which were bound fast upon the ulcer, and by means of these they compressed the granulations. Stimulating applica- tions aggravate the complaint, and are therefore inad- missible; moderate pressure ought to be applied, and antiphlogistic measures should be employed to mitigate the pain and inflammation which attend. ELEMENTS OF SURGERY. 297 CHAPTER L. Of JJlcers in (Edematous Limbs. (Edema signifies an extravasation of water into the cells of the cellular texture, and is a local anasarca, dif- fering from general dropsy only in extent. It depends therefore frequently upon general or constitutional causes, but also very often upon local circumstances, and proceeds from fractures, sprains, and bruises. Inter- ruptions to the circulation of a part in some cases pro- duce this effect, and oedematous swellings result from the pressure of a tumour upon the principal vessels of a limb. In the latter months of pregnancy oedematous legs are very common. An cedematous limb is usually cold, swollen, and of a pale colour. It retains the mark or pit made by the pressure of a finger. An ulcer seated in such a limb is generally painful and somewhat inflamed. The granu- lations have not a healthy appearance, but are purple, and in spots appear gangrenous or sloughy. Great pain is sometimes felt, and the ulcer remains stationary or spreads in extent. Ulcers in cedematous limbs very frequently are attend- ed by so much fever that bloodletting is indicated, and repeated purges are often necessary. Tn many instances, however, the patient's strength is so much reduced that these remedies cannot be used, and in such cases Dr. Physick's plan of elevating the feet of the bedstead has a very happy effect in diminishing the bulk of the limb, and in abating the inflammation of the nicer. In addj- VOL. II. q q 298 ELEMENTS OF SURGERY. tion to this, gentle pressure is to be made by means of a roller of muslin or a laced stocking extending from the foot to the knee, and the ulcer is to be dressed with strips of adhesive plaster, its edges being approximated as much as possible. Under this treatment the ulcer generally heals, but the bandage or laced stocking should be worn for a con- siderable time, to prevent its recurrence. It is the custom with many practitioners to recom- mend exercise to patients with ulcers in oedematous legs ; this treatment I believe to be very injurious, and al- though cases are brought forward to attest its efficacy, it is extremely probable that these cures would have taken place without the exercise, and in a much shorter space of time; in proof of this I would remark that when an cedematous limb is in a depending posture during the day, it is found greatly swelled at night, and of course the cells of the cellular texture are distended, and the vessels of the ulcer and adjacent parts are stretched and irritated—a condition surely unfavourable for the heal- ing of the sore. ELEMENTS OP SURGERY. 299 CHAPTER LI. The Sloughing Ulcer. In consequence of deficiency in the strength of the constitution or part affected, the granulations of an ul- cer very frequently mortify, and sloughs fall off from va- rious parts of the ulcer, and sometimes from its whole surface; in some cases this sloughing takes place after the cuticle is formed, the new skin becoming purple, livid, and black. The sloughing of an ulcer sometimes depends on local causes, and it has happened that an ulcer on one leg of a patient has healed up whilst the sloughing was going on in a sore on the other leg. That general or con- stitutional causes often occasion ulcers to slough there is no doubt, for change in diet or air frequently produce sloughing in Ulcers which have been healing. In gene- ral pain and fever attend a sloughing ulcer. Analogous to this species of uleer is that in which the process of ulceration suddenly takes place, after a sore has been apparently healing. This is owing in Mr. Home's opinion, to the parts being too weak to carry on the actions necessary for their recovery: such ulcers Mr. Home remarks do not readily form skin and " in a still more weakened state of the parts the granulations after having gone on favourably for several days shall all at once give way and be absorbed into the constitu- tion, leaving the ulcer as broad and as deep as it was before, the granulations not being strong enough to pre- serve themselves from decay. 300 ELEMENTS OP cSTTHaEFTJ "Ulcers may from the beginning exhibit these ap pearances of want of strength in the newly formed parts, or they may at first go on for a few days in every re- spect like those in healthy parts, but become unable to do so beyond that period, and the granulations begin then to shew signs of weakness; for granulations of the most healthy kind if they are not skinned over in a cer- tain time, appear to lose their original strength and fall into a weak state." In the treatment of the sloughing ulcer and of such ulcers as have just been described, tonics are requisite. The state of the system generally indicates them. Bark, wine, porter, and a generous diet are to be directed, and opium must be given to relieve pain. The best local applications are those of a moderately stimulating kind. It has been usual to apply bark in powder to the sore, and lapis calaminaris, prepared chalk, plaster of paris, &c. A soft carrot poultice is to the patient pleasanter, and I believe in general answers bet- ter than any of these remedies. It is prepared by boiling scraped carrots in milk. Sometimes advantage is derived from washing the ulcer with diluted laudanum, or an in- fusion of oak galls. Mr. Home recommends spirit of wine and a decoction of poppies in equal proportions. He says "they must not be applied hot; they often soothe the sensations of the parts and lessen their actions. Where the granulations appear to be disposed to run into mortification, tins application is sometimes the means of preventing it." The sloughs having separated, the ulcer is to be treat* ed as a simple healthy ulcer, but the state of the system in this as in every other form of the disease, must be strictly attended to, and general remedies adapted to it must be administered. ELEMENTS OF SURGERY, 301 CHAPTER LII. Of Indolent Ulcers. Chronic ulcers generally become indolent, and from the frequent interruptions to the curative operations of nature, incapable of forming healthy granulations. In- dolent ulcers are generally characterized by appearances very unlike those of a healthy ulcer. " The edges of the surrounding skin are thick, prominent, smooth, and rounded. The granulations are smooth and glossy on the surface. The pus is imperfectly formed, but not thin and watery; it consists of pus and coagulating lymph mixed. The lymph is made up of flakes, and is with difficulty separated from the surface of the granulations, so that when the ulcer is wiped clean the coagulating lymph adheres in several places giving a white appear- ance to these parts of the ulcer. The bottom of the ul- cer is commonly all of the same level or nearly so. The general aspect gives the idea of a portion of the skin and parts underneath having been for some time removed, and the exposed surface not having commenced any new action to fill up the cavity. "These appearances are only met with in the truly indolent ulcers, in which the symptoms are the most strongly marked;" in others of this species the appear- ances very much resemble those that belong to the in- flamed ulcer, and indeed we are sometimes only able to ascertain the difference by the effects of our remedies. It is to be recollected, however, that many indolent ulcers become at times inflamed, and when the temporary in- flammation subsides revert to their old condition. 302 ELEMENTS OF SURGERY. The treatment of indolent ulcers is a subject of ac- knowledged and great difficulty; it is also one of great importance, because by far the greater proportion of ul- cers on the legs are of this kind, and the continuance of any other ulcers almost invariably produces these. It is this form of ulcer which fills the wards of hospitals and poor-houses, and which incapacitates from duty large numbers of soldiers and sailors. In the treatment of indolent ulcers Mr. Home observes our object should be "not simply to produce a cure, but to render that cure as permanent as possible. This is only to be done by changing the disposition of the granu- lations, and rendering them strong enough to stand their ground after the ulcer is completely filled up." In cases where inflammation supervenes upon an indo- lent ulcer the usual remedies for inflammation are to be employed, and when the inflammatory symptoms have subsided, Dr. Physick's practice has been "to remove completely the callous edges and the whole surface of the ulcer, and thereby to change its nature entirely by reducing it to the condition of a sore from accident." The success of this practice has for many years been proved at the Pennsylvania Hospital, by the numerous and speedy cures of chronic ulcers of the legs. The modes of effecting the object are by means of the knife or caustic; in general the latter is preferable. The edges of the sore will commonly be found most readily removed by rubbing a piece of caustic vegetable alkali fifteen mi- nutes upon them, and care should be taken completely to accomplish this end. After the sloughs separate the granulations which arise will probably require very re- peated applications of caustic, and the lunar caustic is then to be employed. It should be applied daily to the sore, but not in sufficient quantity to produce much sloughing. When cuticle begins to form, the caustic must be spa- ELEMENTS OF SURGERY. 303 ringly used, but still it must be used, and applied chiefly to the middle of the ulcer. In order to stimulate the granulations of indolent ul- cers an almost endless variety of applications have been recommended; all the escharotic medicines—red pre- cipitate—corrosive sublimate—green, blue, and white vitriol—nitric, muriatic, and sulphuric acid—caustic, and**mild potash—carbonate of soda—alkohol, and nu- merous tinctures—gastric liquor—rhubarb—powdered galls—peruvian bark, and a thousand other stimulating articles, all of which have in some cases proved benefi- cial, and in indolent ulcers a change of practice should be adopted whenever the sore becomes stationary, or worse. I have applied with great advantage, powdered can- tharides to certain indolent ulcers of the leg. The cases iu which they have proved most beneficial are those in which there is a cluster of small ulcers, which have re- fused to yield to the common treatment. One remark I wish to make in this place with respect to local applica- tions to indolent ulcers, which is, to vary them when- ever they cease to produce a good effect. 1 shall next detail Mr. Baynton's method of treating chronic ulcers, which has been adopted by almost every modern surgeon, and which ought to be used in conjunc- tion with the remedies which have been recommended. I would premise, however, that Mr. Baynton accom- plished his cures without pain or confinement, advantages obtained by few other surgeons, and the practice of al- lowing patients with ulcers to walk about is so generally injurious and so very rarely beneficial, that a prohibition of exercise ought in my opinion almost universally to be made. " The parts should be first cleared of the hair, some- times found in considerable quantities upon the legs, by means of a razor, that none of the discharges, by beins 304 ELEMENTS OF SURGERY. retained, may become acrid, and inflame the skin, and that the dressings may be removed with ease at each time of their renewal, which in some cases, where the discharges are very profuse, and the ulcers very irrita- ble, may, perhaps, be necessary twice in the twenty-four hours, but which T have, in every instance, been only under the necessity of performing once in that space of time. "The plaster should be prepared by slowly melting, in an iron ladle, a sufficient quantity of litharge plaster, or diachylon, which, if too brittle, when cold, to adhere, may be rendered adhesive by melting half a drachm of resin with every ounce of the plaster: when melted it should be stirred till it begins to cool, and then spread thinly upon slips of smooth porous calico, of a conve- nient length and breadth, by sweeping it quickly from the end, held by the left hand of the person who spreads it, to the other, held firmly by another person, w ith the common elastic spatula used by apothecaries; the un- even edges must be taken off, and the pieces cut into slips, about two inches in breadth, and of a length that will, after being passed round the limb, leave an end of about four or five inches. The middle of the piece so prepared, is to be applied to the sound part of the limb, opposite to the inferior part of the ulcer, so that the lower edge of the plaster may be placed about an inch below the lower edge of the sore, and the ends drawn over the ulcer with as much gradual extension as the patient can wrell bear; other slips are to be secured in the same way, each above and in contact with the other, until the whole surface of the sore and the limb are completely covered, at least one inch below and two or three above the disr eased part. " The whole of the leg should then be equally de- fended with pieces of soft calico, three or four times dou- bled, and a bandage of the same, about three inches in ELEMENTS OF SURGERY. 305 breadth, and four or five yards in length, or rather as much as will be sufficient to support the limb from the toes to the knee, should be applied as smoothly as can be possibly performed by the surgeon, and with as much firmness as can be borne by the patient, being first pass- ed round the leg, at the ankle joint, then as many times round the foot as will cover and support every part of it, except the toes, and afterwards up the limb till it reaches the knee, observing that each turn of the bandage shpuld have its lower edge so placed as to be about an inch above the lower edge of the fold next below. " If the parts be much inflamed, or the discharge very profuse, they should be well moistened, and kept cool with cold spring-water poured upon them as often as the heat may indicate to be necessary, or, perhaps, at least, once every hour. The patient may take what ex- ercise he pleases, and it will be always found, that an alleviation of his pain and the promotion of his cure, will follow as its consequence, though, under other modes of treating the disease, it aggravates the pain and prevents the cure. "These means, when it can be made convenient, should be applied soon after rising in the morning, as the legs of persons affected with this disease are then found more free from tumefaction, and the advantages will be greater than when they are applied to limbs in a swollen state. But at whatever time the applications be made, or in whatever condition the parts be found, I be- lieve it will always happen, that cures may be obtained by these means alone, except in one species of the dis- ease, which seldom occurs. The first application will sometimes occasion pain, which however, subsides in a short time, and is felt less sensibly at each succeeding dressing. The force with which the ends are drawn over the limb, must then be gradually increased, and when the parts are restored to their natural state of ease VOL. II. r r 306 ELEMENTS OF SURGERY. and sensibility, which will soon happen, as much may be applied as the calico will bear, or the surgeons can exert; especially if the limb be in that enlarged and in- compressible state which has been denominated the scor- butic, or if the edges of the wound be widely separated from each other." (Baynton.) Mr. Baynton's direction to cover the ulcer completely with strips of adhesive plaster is I think very injudicious, because the matter will be thus confined, and a kind of abscess formed, the anterior parietes of which are the plasters. Instead of this, it is better to make use of strips of plaster an inch in width, in large ulcers, and narrow- er in those which are small, placed at a distance of half an inch, one from the other, so that a free exit may re- main for the pus secreted. In this manner indolent ul- cers heal in general more readily than under any mode of treatment I have ever witnessed. His remarks on ex- ercise I believe are altogether erroneous. ELEMENTS OF SURGERY. 307 CHAPTER LUI. The Carious Ulcer. Ulcers situated in the vicinity of carious or dead bone are prevented from healing until the exfoliation and se- paration of the bone are accomplished, and this in many cases is a very tedious process. The manner in which exfoliation takes place has been already explained; the surgeon must necessarily wait until the bone becomes loose, after which he should with- out delay extract it. Many chronic ulcers which succeed the venereal disease are prevented from healing by the presence of dead bone; these ulcers are not to be considered as ve- nereal or treated as such, because after the separation of the bone is effected, they readily heal. Carious ulcers are often fistulous, consisting of a canal with an indurated margin, discharging foetid sanies. Where a large carious ulcer exists, thefoetor is often very great. To hasten the exfoliation of carious bone is by no means an easy matter; the French surgeons employ with this view the old and painful remedy, the actual cautery, and if any of the means in use can succeed, this is the one. I have thought it useless to recount the nu- merous ridiculous remedies sometimes employed with this view, as I believe them perfectly inert. When the carious Hone can be removed by an operation this ought to be performed, in order to expedite the cure. Portions of the tibia can very often be cut away by means of Hey's 308 ELEMENTS OF SURGERY. saw, and the crown of a trephine. Gouges and chisels are also in some cases necessary. It is in general a very bad practice to inject corroding liquors into sinuses leading to carious boue, because they act much more powerfully on the soft parts in which the sinus is situated than on the bone, and therefore excite much unnecessary inflammation. To attempt the healing of such sinuses before the bone is removed is always improper; on the contrary, the size of the external aperture should be enlarged with sponge tent if it become very much contracted. The subject of caries, however, will be resumed in another chapter. The difference of time required for the separation of caries in different bones is very great, and if a unifor- mity in the exfoliation of certain bones should be found to exist, a very valuable table might be formed exhibit- ing these periods; I have known a caries of the os calcis in which at the end of several years the separation was not completed; a few months suffices in general for the separation of the tibia in cases where the foot and ankle mortify. ELEMENTS OF SURGERY. 309 CHAPTER LIV. Ulcers attended with Varicose Veins. These are a species of indolent ulcer, and resemble in appearance those which have been described. The most usual situation of ulcers in cases where the veins are va- ricose, is said by Mr. Home, to be on the inside of the leg just above the ankle. They have their origin from accidental causes, but when once they occur they are difficult of cure and almost always break out again. Mr. Home adds that they occur most commonly in tall per- sons. The branches of the saphena vein and indeed all the superficial veins of the leg are found in a varicose state, greatly distended, and the saphena itself is extremely large. " This species of ulcer is seldom very deep; when it spreads it is generally along the surface; its shape is com- monly oval pointing vertically. The edges of the surround- ing skin are commonly neither thick nor irregular, but are imperceptibly lost in the ulcer. The pain which it gives is seldom from the surface, for pressure does not increase it, but there is an aching uneasy sensation in that part of the leg. This pain is deeper seated than the surface of the ulcer, and very often extends up the leg in the di- rection of the veins, and is increased to a very great de- gree if the limb is long kept in an erect posture. " It is this species of ulcer which, from its great back- wardness to heal, has given the idea of its being a natu- ral drain from the constitution, which it was improper 310 ELEMENTS OF SURGERY. to dry up; and the strong argument advanced in favour of this opinion has been, that whenever it was healed, it broke out again, and the patient was full as easy while the ulcer was open, as when it was closed, if not more. This may at first appear extraordinary, but can be rea- dily explained; since the pain, in such cases, arises more from the distended state of the veins, than from the ulcer; and the patient will naturally be led to use more exercise when the ulcer is healed, which will keep the veins in a more uneasy state. " This is the species of ulcer in which tight bandaging to the leg is particularly applicable, and rolling the whole limb from the toes to the knee, is found to be at- tended with the greatest advantage. It is to be under- stood that the tight bandaging is not immediately appli- cable to the ulcer itself, as it will appear that it is im- material in what way the management of the ulcer is con- ducted, and it is probable that the success of tight ban- daging in ulcers attended with varicose veins, has led to the use of compression in other species of ulcers, where- in it has proved hurtful; not being suited to the state of the limb, which often is unable to bear any thing tight upon it. " Soldiers who have the slightest disposition to a vari- cose state of the veins, whether there is an ulcer on the leg or not, should have their gaiters so made as to an- swer the purpose of a tight bandage, which may be rea- dily done by having them very accurately fitted to the leg; for this purpose those made of woolen cloth will an- swer best, as its elasticity allows it to yield to the mo- tion of the muscles, and always preserves an uniform compression. "A laced stocking is a most useful application, and if it could be worn without inconvenience, probably no other mode of treatment would be necessary; but it too often happens that the patient is unable to bear the neces- ELEMENTS OF SURGERY. 311 sary degree of compression for any length of time, and therefore after using it for some weeks, is obliged to leave it off. " In considering the mode by which the varicose veins prevent an ulcer from healing it appeared to be most rea- dily accounted for in the following manner. That in consequence of the size of the vena saphena, and its num- berless convolutions, the return of the blood from the smaller branches is so impeded, as to retard the circula- tion in the smaller arteries, and to interfere with their action in forming healthy granulations. This observa- tion is, in some measure, confirmed by the following cir- cumstance. In cases of ulcers attended with weakness, on the lower part of the leg, the granulations while the patient lies in an horizontal position, appear florid and healthy; but if he is made to stand up, and continues in that posture only for a few minutes, they become of a deep dark-red colour, and frequently bleed. This change can only arise from the increased resistance which the blood encounters in its return through the veins of the limb, when the body is erect. "An enlargement of the veins produces also another effect. The coats of the^vessels and the valves become thickened, which renders valves less pliant, they do not occupy the whole area, and therefore are no longer of any use; and from this defect the whole length of the column of blood in the vena saphena is in the erect po- sition, pressing upon the contents of the smaller veins, so as to dilate them still more and more, and keep the limb always in a weak state. " Under these circumstances, it appears to be an ob- ject of no small importance to take off a part of the pres- sure of this column of blood, which would probably al- low the parts lower down to be in a more easy state, and better able to recover themselves; it might also prevent 312 ELEMENTS OF SURGERY. the veins from being still more dilated, and so far stop the progress of the disease in these vessels. " The only mode of doing this that suggested itself, was that of making an artificial valve, by passing a liga- ture round the vena saphena, as it passes over the knee joint, and obliterating the vein at that part. The reason for applying the ligature upon this particular portion of the vein is, that just at that part the branches from the different parts of the leg unite and form a common trunk, and as it is the preternatural enlargement of some, or all these branches, which constitutes the principal part of the disease, the most effectual mode of taking off the weight of the column of blood contained in the common trunk will be by obliterating it, as near as possible to the ter- mination of those branches into it." (Home.) Mr. Home accordingly performed the operation of ty- ing up the saphena with a view to heal ulcers on the leg, in a variety of instances with complete success, and is the author of the practice; for although Mr. Hunter had previously tied up some veins in the leg, and also several very old surgeons, yet it was with very different views, and without any reference to this object. Dr. Physick has practiced Mr. Home's operation in a num- ber of cases, with various success; in some instances the ulcers have healed very rapidly, in others no benefit has apparently resulted. I have myself several times per- formed it, and always with advantage. In the hands of other surgeons it has proved in many cases beneficial, but in some instances the operation lias been followed by death from tetanus, in others by inflammation of the internal coat of the vein—accidents which in America I believe have never succeeded this operation, and therefore in those cases where ulcers of the leg are evi- dently kept from healing by a varicose state of the limb, ELEMENTS OF SURGERY. 313 I have no hesitation in recommending Mr. Home's ope- ration. " The operation for taking up the vena saphena is extremely simple, may be performed in a very short time, and is attended with less pain, if we may judge from the account of those on whom it has been performed, than it would be natural to expect. My attention has been di- rected in every case in which it has been performed, to render it as little painful as possible, and the mode which appears to me the least so is the following: " As the veins are only turgid in the erect posture, the operation should be performed while the patient is standing; and if placed on a table, upon which there is a chair, the back of the chair will serve him to rest upon, and he will have the knee joint at a very convenient height for the surgeon. The leg to be operated upon, must stand with the inner ankle facing the light, which will expose very advantageously the enlarged vena sa- phena, passing over the side of the knee joint. While the patient is in this posture, if a fold of the skin which is very loose at this part, is pinched up transversely, and kept in that position by the finger and thumb of the sur- geon on one side, and of an assistant on the other; this fold may be divided by a pointed scalpel pushed through it with the back of the knife towards the limb, to pre- vent the vein being wounded; much in the same way that the skin is divided in making an issue. This will expose the vein sufficiently, but there is commonly a thin membranous fascia, confining it in its situation : and when that is met with, the vein had better be laterally disengaged by the point of the knife. This is most ex- peditiously done by laying hold of the fascia with a pair of dissecting forceps, and dividing it; for it is difficult to cut upon parts which give little resistance, and there is a risk of woundiug the vein. After this, a silver crook- ed needle, with the point rounded off*, will readily force Vol. ii. s s 314 ELEMENTS OE SLRGERV. its way through the cellular membrane connected with the vein, without any danger of wounding the vessel, and carry a ligature round it. This part, or indeed what may be considered the whole of the operation, being finished, the patient had better be put to bed, so as to allow the vein to be in its easiest state before the ligature is tied, and then a knot is to be made upon the vein; this gives some pain, but it is by no means severe. The edges of the wound in the skin are now to be brought together by sticking plaster, except where the ligature passes out, and a compress and bandage applied, so' as to keep up a moderate degrep of pressure upon the vein, both above and below the part included iu the ligature. The in- flammation, in general, is very trifling; it does, however, in particular cases, extend for some way in the course of the veins under the skin; but even where this has hap- pened in the greatest extent, it has been attended with no bad consequences. The ligature comes away about the ninth or not later than the twelfth day, after which the parts commonly heal up. As it answers no good purpose for the ligature to remain so long, and only pro- tracts the cure, I have been in the habit of removing it on the fifth day, which saves the patient five or six days of confinement. The mode of removing the ligature is very simple; the vein is so near the skin, that the knot is readily brought into view, and the ring of the ligature, which at the time of the operation was filled up by the vein, is now become loose, its contents having been con- siderably diminished by absorption, so that the point of a pair of scissors can be readily passed through it, by which it may with ease be divided, and the whole of the ligature brought away. " Cases occur in which there is a smaller vein run- ning parallel to the vena saphena. This, when the vena saphena has been taken up, afterwards becomes enlarg- ed, and continues the disease; when that is the case, ELEMENTS OF SURGERY. Si J this vein also must be taken up. These circumstances ought to be attended to in the first examination of the disease, as sometimes the two veins are so close together, that they may both be included in one ligature. " This enlargement of the vena saphena is sometimes combined with an enlargement of the branches of the vena saphena minor or posterior, that passes up behind, between the two hamstrings; when this is the case, the disease is in an uncommon degree of violence, and in such instances would be less likely to be attended with success unless both venal trunks were taken up. " In two or three cases, there has been an enlargement of the branches of the vena saphena minor, without the vena saphena itself being at all affected; the principal convolutions of the enlarged veins were on the calf of the leg, and on the outside of the foot, just below the outer ankle. In these instances there was no ulcer, and there- fore no very forcible reason could be urged to induce the patients to undergo an operation, nor was there the same chance of success, the use of a laced stocking was there- fore recommended; and in case that should not answer, it was explained to them, that they had it in their power afterwards to have recourse to taking up the venal trunk. " The enlargement of the vena saphena minor, is rather mentioned as an uncommon occurrence, than as a case to be relieved by surgical treatment; that when it is met with, it may be distinguished from the vena saphena, the subject under consideration. " In one case where there was an ulcer and only the branches of the vena saphena minor enlarged, the ulcer was situated more posteriorly than it is usually met with, and the branches upon the calf of the leg were iu an ex- tremely varicose state, forming large projections, the trunk itself was very large, while the vena saphena was nearly of its natural size. The patient was a young wo- man of a very delicate constitution, but in good health: 316 ELEMENTS OF SURGERY. she was twenty-five years of age, and suffered so much pain in the ulcer, and in the course of the enlarged branches, as to be unable to walk or stand for any length of time, unless the limb was supported by a bandage. " As instances occur, in which, though the immediate branches of the vena saphena arc affected, the disease extends no farther; and as the same thing happens, though less frequently, to the branches of the vena sa- phena minor; and in other cases, the disease is found to take place in both, it becomes necessary to explain in what manner complicated cases may be distinguished. - " The branches of the veins, passing up from the foot to form these two venal trunks, anastomose very fre- quently and freely with each other; it is therefore im- possible to say precisely to which of them the collateral branches belong. " When the vena saphena becomes enlarged, many of the common branches, and some of those belonging to the posterior trunk, will consequently be affected; and vice versa, w hen the vena saphena minor is enlarged. This, however, is not to be considered as implicating both veins in the disease, for the branches of one of them are only affected in a secondary way by their connection with the other. Whatever number of the venal branches of the lower part of the limb is enlarged, if this enlarge- ment in those of the upper part of the leg only extends in the course of one of the venal trunks, the disease should be referred to that trunk, which ever it is, as it is evident that the other, from its remaining of the natu- ral size, can have no part in the disease." (Home.) ELEMENTS OF SURGERY. SI- CHAPTER LV. Ulcers attended with specific diseased actions. These are exceedingly numerous, and under the pre- sent division may be included all ulcers from a local or constitutional action of a morbid nature ;—all scrofulous, venereal, and cancerous ulcers, and probably many others. A dissertation on these complaints is not at pre- sent necessary, but as a general rule it will be proper where the constitution is affected, to apply those reme- dies which may be indicated by the nature of the disease, and when the morbid action is local, if possible, the dis- eased parts should be totally removed by the knife or caustic, and a simple ulcer will then be left which can be readily healed. I shall conclude by selecting from Mr. Home's valu- able work on ulcers, some observations on the present subject. I. OF THOSE ULCERS WHICH YIELD TO MERCURY. " It is not meant as has been already stated to consi- der those ulcers that are connected with the venereal disease, but such only as are produced by other diseases of the general system, or of the parts which yield to the effects of this medicine. " It wras natural when the beneficial effects of mercury in the venereal disease were first discovered to suppose that every complaint wliich yielded to mercury must be venereal. It was, however, to be expected that observa- tions accurately made would soon ascertain that this ac- 318 ELEMENTS OF SURGERY. tive medicine is capable of producing salutary effects in many other diseases. Yet a long time elapsed before this was generally allowed. " Even now when it is universally admitted that mer- cury employed through the medium of the system is the most efficacious medicine in inflammation of the liver, and in diseases of many other of the viscera, surgeons very unwillingly give it credit for the cure of ulcers that are not venereal, but are inclined to suppose every ulcer that yields to such treatment, arises from that disease. " This is by no means true; for many ulcers uncon- nected with the venereal disease which received no be- nefit from other medicines shall heal under a mercurial course, or yield to mercurial applications. In some cases the ulcer has remained stationary during the use of the mercury, but as soon as it was left off has put on a more kindly appearance, the mercurial course having produced so great a change in the constitution as to destroy the disposition which had kept the ulcer from healing. " Such ulcers are in general in their appearance al- lied to the indolent kind, but have some diseased dispo- ;(ion peculiar to themselves. Mercurial frictions are in »uese cases to be preferred, as it is a material object to impair the constitution as little as possible, by leaving the stomach undisturbed and in a condition to take nou- rishment. " There are ulcers on the instep and foot with a very thickened edge, and a diseased state of the surrounding skin, approaching in their appearance to what is called elephantiasis; these are frequently met with in servants of opulent families, where they had led an indolent life and fed upon a luxurious diet. In cases of this kind, fumigations with the hydrargyrus sulphuratus ruber has healed the ulcers, and resolved in a great degree the swelling of the surrounding parts. ELEMENTS OF SURGERY. 319 " The mercurial ointment made either by calomel and hogs-lard, or the unguentum hydrargyri mitius mixed with camphor answers in some cases better than any other application. " Camphor in general renders the mercury more ac- tive than when employed alone, and the mouth has been frequently known to be effected by an application of this kind to a small surface, when the mercurial ointment, applied to a much larger extent, has produced no such effect. " The hydrargyrus muriatus, diluted with water, (to which a small portion of spirit has been added) in the proportion of a grain to an ounce, is a very useful appli- cation to many ulcers with a diseased aspect, more par- ticularly those that are superficial, with a thickened edge, and appear to be principally confined to the skin." II. OF ULCERS WHICH YIELD TO THE USE OF THE DIFFER- ENT PREPARATIONS OF THE CONIUM MACULATUM, OR HEMLOCK. " The inspissated juice of the conium maculatum, in- ternally employed, is by some practitioners supposed to be entirely inert; while by others it is believed to have considerable powers over many diseases. From these opinions, so diametrically opposite, and both taken from actual observation, it would seem that its effects are very precarious. I confess myself by no means warm in its favour; for though it is sometimes of service in local complaints, it has so often failed, that much reliance cannot be placed upon it as an internal medicine, in dis- eases connected with surgery. " As an external application, the conium maculatum is a much more certain medicine, and I do not hesitate to declare myself convinced, that there are cases of diseased 320 ELEMENTS OF SURGERY. ulcers on the legs which are cured by it more readily than by other means. " The ulcers which are most generally benefitted by it, from their appearance, would be classed with the irri- table ; but there is in the surrounding parts a degree of thickening, which must be attributed to some specific diseased action. These ulcers are met with in the neigh- bourhood of the ankle joint, and the joint itself is en- larged. They sometimes occur upon the ligaments of the joint of the knee, but less frequently. From their situa- tion and the enlargement of the joint, they may be sup- posed to be scrofulous; but from their sensibility they must be considered as an uncommon variety, if they really belong to that disease. In such diseased ulcers the conium maculatum takes off the pain, reduces the swelling of the joint, and seems to counteract the dis- eased disposition, whatever may be its nature. " In many ulcers that are truly scrofulous, the exter- nal applications of the conium maculatum are productive of the greatest advantage, particularly in those attended with irritability. " The conium maculatum admits of being employed in three different forms, but only two of them are in ge- neral use. " The decoction is used as a fomentation, which is a very advantageous form, in those cases that are attended with pain; since the warmth assists in soothing and alle- viating the symptoms. " It is used in the form of poultice, which has an ad- vantage, as it admits of being much longer continued to the ulcer. The decoction of which the poultice is made, should be much stronger than is commonly directed. Eight bundles, or four handfuls, of the dried -herb, and a greater quantity of fresh leaves in proportion, should be boiled in a quart of water, to a pint. A poultice made ELEMENTS OF SURGERY, 321 with a weak decoction has frequently been used without the smallest benefit; but when the strength of the de- coction was increased, the ulcer shewed evident signs of amendment. Where the weight of the poultice is oppres- sive to the limb, the decoction may be applied upon lint to the ulcer. " The inspissated juice of the conium maculatum ad- mits readily of being formed into an ointment; but al- though several trials have been made with it, the results were not in its favour as an external application." OF ULCERS WHICH YIELD TO THE APPLICATION OF SALT WATER. " Salt water is an exceedingly good application in many scrofulous ulcers, some of them being more readily cured by it, than by other applications. The form of poultice is most commonly employed; but in many cases of ulcers on the legs, keeping the part immersed in tepid salt water, for fifteen minutes, twice a day, appears to be preferable to any other mode. Several small ulcers have got well under this treatment in a fortnight which had resisted the effects of internal medicines, and many different external applications, for six months; nor did the ulcers return afterwards in the course of several years. The same mode has been used with large ulcers, and frequently with success. In scrofulous ulcers on the legs and feet, the salt water poultice sometimes brings out pimples on the skin, so that the application cannot be continued. When this is the case, adding equal parts of decoction of poppies takes off this unpleasant effect; and after the skin has been for some time accustomed to the salt water in a diluted state, it will bear the salt wa- ter by itself. VOL. 11. Tt 322 ELEMENTS OF SURGERY. " In such cases the foot or leg at the times the pout tice is to he changed will receive benefit by being im- mersed for ten minutes in tepid salt water. " In some superficial ulcers attended with a thicken- ing of the skin, that have been in that state for months, the application of tepid salt water has produced a cure. "When there is an unusual coldness in the limb, without any tendency to mortification, the tepid salt wa- ter may be used with great advantage; it brings a glow upon the skin, and rouses up the actions of the parts, so as to give an ulcer, which had for some time been in an inactive state, a disposition to heal. These cases occur in tall thin men who are unhealthy, and advanced in life. They are also met with in young women, who are very weak and unhealthy; the whole system in such cases is apparently defective, not having sufficient ener- gy to do more than carry on the functions of life, and being therefore unable to support the effects of disease. " Where the leg has a tendency to become anasarcous, the application of tepid salt water is sometimes found entirely to remove that disposition." OF ULCERS WHICH YIELD TO THE USE OF THL ARGENTUM NITRATUM. " There is a species of ulcer wliich does not appear to go deeper than the cutis, but spreads in all directions, producing ulceration on the surface of the skin, and fre- quently extends in depth its whole thickness, or nearly so. This diseased disposition, whatever it is, does not remain in the parts that have ulcerated, but only on the edge of the skin, where the ulcer is increasing, for the surface first affected heals, while the skin beyond it is in a state of ulceration. " This description applies nearly equally well to the ulcers produced by three separate diseases, to all of which ELEMENTS OF SURGERY. 323 the soldier is peculiarly liable. One is a leprous erup- tion, most commonly met with among the impressed men brought from Ireland. Another is the consequence of buboes, which from their long continuance after the ve- nereal virus has been destroyed, dispose the skin to take on this disease. The third is a disease of warm cli- mates, commonly called the ring-worm. All of these as far as my experience enables me to form an opinion, yield more readily to the solution of the argentum nitra- tum applied to them in different proportions, than to any other local treatment. " The disease met with among the Irish recruits is evidently of the leprous kind, as it is communicated by infection ; and in those instances that have come under my care, was received by lying in bed with persons af- fected by it. Under these circumstances, a vulgar pre- judice of its only affecting parts similar to those that had the disease, is very readily explained, for such similar parts in bed are the most likely to come into contact with each other. " It affects in general the breast, back, and legs; it shows itself by a swelling like a large boil, with a pale red margin, extending for some way all round; a reddish black scale forms on the top, the boil becomes extremely painful and itches; the scales fall off exposing a foul ul- cer, which discharges a fetid limpid fluid, and excoriates the surrounding skin, producing ulceration wherever it comes in contact: in this way it spreads over the greater part of the limb, and in some instances over a consider- able portion of the body; the parts first affected healing, while the disease is extending to those beyond. These ulcers remain open, three, four or even six months, and then heal up leaving a cicatrix similar to that which re- mains after the small pox; these cicatrices often break out again in the spring in the same way that the disease first began, by forming a boil, which becomes an ulcer 324 ELEMENTS OF SURGERV. and spreads as it did before. In the very hot weather the pain and quantity of the discharge are the greatest; so that in the month of June the disease is the most vi- rulent and in the autumn subsides. " The symptoms are aggravated by the use of spi- rituous liquors, by feeding on salt provisions, and catch- ing cold; under any of these circumstances the ulcers are more inflamed and the pain more violent. " A number of cases of this kind came under my care in the year 1778 at the naval hospital at Plymouth, be- ing brought from Ireland, among the men impressed for the use of the navy. Mild applications did not answer; more stimulating medicines gave relief; and the solution of the argentum nitratum appeared upon the whole to be the best adapted to this disease. The disease in the skin produced by the effects of very irritable buboes, in constitutions broken down by mercury, is very similar in its progress to that which has been described; it is, however, more violent, the ulcera- tion going deeper than the skin, which makes it more painful; it spreads in some cases down the greater part of the thigh, and upwards almost around the body. The new skin which forms is readily disposed to ulceration, and the parts break out again very commonly in the spring. The discharge is of a thin acrid kind; and as it excoriates the surrounding skin, there is little doubt but it would affect the skin of another person. " In several cases of this kind, a variety of applica- tions have been tried, but none of them agreed with the skin so well as the argentum nitratum; all preparations of mercury did harm; no unctuous application answer- ed, so that it was always necessary to return to the ar- gentum nitratum; and by steadily persevering in its use, even in the worst of them, a cure was nearly effected, after a continuance of the disease for nine months pre- vious to its being applied. ELEMENTS OF SURGERY. 325 " The ring-worm is considered as a disease of warm climates; and in the stage where an ulcer is formed, it certainly is confined to hot countries; it is, however, met with in a less degree in the warm season in England. It is supposed to be infectious, and always to be caught in that way; that it is so generally, there can be no doubt, but it also arises very commonly without any in- fection : this however, probably happens where the skin is very readily affected by the disease. That infection is not necessary for the production of the ring-worm, is proved by the following instances where it arose sponta- neously. " In the summer 1779, while at Plymouth, I Was con- sulted by an officer in the 75th regiment, at the desire of Mr. Venven, who was then surgeon of it, for a com- plaint on the skin of the upper part of the thigh, which appeared an uncommon disease, and did not yield to any applications that were made to it. I felt myself equally at a loss in what view to c/msider it; mercury was used in different forms, but Without any good effect and in the autumn it very gradually went off. " About a year after seeing this case, I embarked for the West Indies, and as soon as the ship had got within the tropics, found myself more oppressed and irritated by the heat than most of the Europeans on board, and to my astonishment found a similar complaint had taken place to that under which the officer had laboured at Plymouth. To allay the extreme pain and itching it produced, cold water was frequently applied to the part which kept it very cool; under this treatment it went off, but not for several weeks. Upon my arrival in the West Indies, the disease returned, and was ascertained to be * the ring-worm, so common in that country, w Inch it was impossible for me or the officer of the 75th regiment at Plymouth to have rceeived by infection. 326 ELEMENTS OF SURGERY. " The ring-worm begins with an efflorescence on the skin, a little raised above the natural level, which spreads from a centre; when the disease increases in violence, the margin of the circle is raised into a welt, and the surface contained in it appears scurfy; the welt becomes covered with a scab which falls off, exposing an ulcerated ring, commonly not more than a quarter of an inch broad; the ulceration spreads outwardly, and heals towards the centre, so that in general the breadth of the ulceration is nearly the same, although the circle is becoming larger and larger. It seldom becomes of any depth, being entirely confined to the cutis; but in the worst cases it appears to extend through its whole thick- ness. In this stage it must be classed among the dis- eased ulcers, and among those of a very distressing kind, as the painful symptoms are very violent. The discharge is not pus, but a thin watery fluid, of a very acrid nature, which by its virulent properties, most probably extends the disease along the skin. "In the East Indies the application in use to it, in this stage, is vinegar saturated with borax. The na- tives employ the juice of some plants, which is sold as a seeret medicine; it is made by a Hindoo doctor at Vi- zagapatam, and sold at the different presidencies in In- dia. This medicine is of a very acrid nature, giving the patient excruciating pain, but removes the disease in a very short time. " The solution of the argentum nitratum answers in the milder cases, and there is little doubt of its being equally successful in those that are more severe." OF ULCERS THAT YIELD TO THE USE OF ARSENIC. " Arsenic has been applied externally in eases of can- cer, by a number of empyrics, as a caustic; but from the violence of its effects, regular practitioners have in ge- ELEMENTS OF SURGERY. 327 neral been afraid to employ it in cases of surgery. It is, however, a medicine that may be used with safety, both internally and externally, in many diseased ulcers, with the greatest advantage. " Those ulcers in which I have been led to employ it, are named from the virulence of their disposition, noli me tangere; and are very nearly allied to cancer: dif- fering from it in not contaminating the neighbouring parts by absorption, but only spreading by immediate con- tact. " Ulcers of this kind differ exceedingly from one ano- ther in their degree of virulence; but they are all so far of the same nature, that arsenic in general agrees with them, and puts a stop to their progress, while they are aggravated by milder dressings. " I have been in the habit, for many years, of using ar- senic externally to such ulcers, and its effects encouraged me to continue this practice; but did not authorize giving it internally with this view, lest the quantity necessary to be of any service might prove hurtful to the coats of the stomach. T was, however, induced to try it some years ago in SSt^George's hospital, in the following case, in which nothing could be well applied to the part it- self. " A woman, sixty-five years of age, came into Sk George's hospital on the 15th of June, 1796, with an ulcer on the side of the tongue, of three months continu- ance. It was foul, and was spreading backwards to the root of the tongue, was extremely painful, and the ulcer had an offensive smell. It was out of the reach of ex- ternal application. Finding no advantage from the use of the extract of the conium maculatum, which was given in large doses, it was thought right to try the solution of white arsenic in boiling water. She took at bed time five drops for a dose; this made her very sick: next night three drops were given, which did not disturb her 328 ELEMENTS OF SURGERY. stomach; this dose was continued for four successive nights, and as the stomach was very quiet, the number of drops was again increased to five, which were now found to agree very well. The ulcer was evidently better, and at the end of three weeks from the time the arsenic was given, was much diminished in size. The dose was in- creased to six drops, and in a fortnight more the ulcer was completely healed. The arsenic in this case could not act locally, as the ulcer was not situated upon a part of the tongue to which it could apply itself in the act of swallowing, and if it had, the time of application must have been too short to produce much effect. "The success attending this case induced me to try the internal use of arsenic for an ulcer upon the side of the nose of a young woman, which had much the appearance of the noli me tangere. Nothing was externally applied, the whole treatment consisted in the internal use of arse- nic, and in the course of a few weeks the nose was nearly healed. " These not being cases of ulcers on the legs, may be considered as foreign to the present subject; but they are here introduced with a view to justify the internal use of arsenic in those ulcers on the leg, which receive benefit from its external application; since they show, in the most unequivocal manner, that such practice is in itself not only safe, but capable of being attended with great advantage. " To ulcers of an untoward appearance on the legs, ar- senic may be used both internally and externally, with success. " The cases to which this treatment is peculiarly appli- cable, are those of the fungated ulcer. They are met with in the calf of the leg, and on the sole of the foot, shooting out a fungus from the surface, which is entirely different from common granulations: the new formed sub- stance is radiated from its structure, the bottom of the ELEMENTS OF SURGERY. 828 ulcer being the central point, and the external surface •(which is always increasing) the circumference. This fungus is very tender in its substance, and bleeds if the slightest violence is committed on it. This disease in its origin sometimes appears like a scrofulous affection of the metatarsal bones of the foot; but the enlargement of the parts exceeds what commonly is met with in scrofula, ulceration takes place upon the skin, and a fungus shoots out, showing, for the first time, the nature of the disease. Whether such cases are originally scrofulous, and after- wards assume the new diseased disposition, it is diffi- cult to determine; but their remaining for a year before the fungus shows itself, renders it highly probable. The same disease takes place in the testicle. " There appear to be two kinds of this disease; one which is poisonous, and capable of contaminating the lymphatic glands in the course of absorption ; the other not. There is no mode by which these two species can be distinguished in their earlier stages ; and the first kind is not to be removed by this or any other application, at present known : it is therefore only in the second kind that the arsenic is capable of effecting a cure. This me- dicine should however, be used in all cases not ascertain- ed to be poisonous. " The solution of arsenic, which I have always used, is made by boiling white arsenic in water for several hours in a sand heat, and taking this saturated solution for use. When given internally the dose is from three drops to ten, when externally applied, a drachm is diluted with lb. ij of wrater; and the solution is gradually made stronger, as the parts become accustomed to it, till it is of double strength. This solution is either applied on lint, or made into a poultice. VOL. II. • u 330 ELEMENTS OF SURGERY. " In ulcers connected with diseased bone, wliich pre vents them from healing, the luxuriant granulations rise up round the orifice leading to the bone, and require be- ing destroyed by some escharotic; the solution of arse- nic answers this purpose better than any of those in com- mon use." (Home.) In the treatment of ulcers attended with specific action, as in all others the state of the systhn must be always kept in view. If an inflammatory disposition be mani- fested, the remedies for inflammation must be adminis- tered ; if, on the contrary, great debility prevail, an in- vigorating diet and tonics are to be directed. The in fluence of the general health upon all ulcers is very great; an epidemic will sometimes occasion every ulcer in a large hospital to " wear its livery," and until this morbid diathesis is removed, the ulcers cannot be cured. The surgeon should therefore never lose sight of the state of the system. ELEMENTS OF SURGERY. 331 CHAPTER LVL Of Caries. Having treated of ulcers in the soft parts we proceed to speak of caries, which consists in ulceration of a bone, and is analogous to the same process in soft parts, the action of the absorbents being essential in both cases. Every bone in the body is occasionally affected with caries; the spongy bones, however, more frequently than the rest; the bones of the tarsus and carpus, the sternum, and the vertebrae arc most liable to caries, and when it attacks the long bones, their spongy extremities are ge- nerally affected. The bones in early age are more lia- ble to caries than in advanced life. The substance of a bone affected with caries becomes soft, so that a probe may readily be forced into it. Fun- gous flesh forms around it, which is exceedingly vas- cular and bleeds whenever it is touched. A serous discharge takes place, of a black colour and offensive smell. Caries differs from Necrosis as ulcer differs from gangrene. In caries there is action, and the absor- bents remove the diseased bone; in necrosis the bone is dead, and the absorbents of the neighbouring living bone detach it, as a slough or eschar is detached in the soft parts. Caries is produced by a great variety of causes; it seldom, however, results from external violence, because a blow on a bone, if sufficiently forcible, occasions ne- crosis ; but caries sometimes results from blows, and ac- cording to Boyer it is produced by an extravasation of blood into the cells of the bone, and the inability of the 332 ELEMENTS OF SURGERY. absorbents to remove the effused blood which occasions ulceration or caries. " Abscesses are said to occasion sometimes a caries of the bones, over which they take place; and we are told, that the existence of the morbid state of the bone may be ascertained by introducing a probe to the bottom of the abscess. ".Conformably to this theory, it has been laid down as a rule, that abscesses situated over bones should be opened at an early period, in order to prevent any disor- der of the bone or periosteum from the stagnation of the purulent matter. But if abscesses formed over certain bones, as, for instance, over the anterior face of the ti- bia, or mastoid process of the temporal bone, be fre- quently accompanied with caries, the latter is the cause, and not a consequence of the abscess. Pus, which is a bland, unctuous, and inodorous fluid, never attacks the soft parts with which it is in contact, until its qualities are changed by exposure to the air. When an abscess forms in the anterior parietes of the abdomen, the peri- toneum naturally a thin membrane, instead of being cor- roded, becomes thick and strong enough to resist the ef- fusion of the pus into the cavity of the abdomen. The periosteum becomes thickened in similar circumstances, when the abscess is a consequence of an external injury. We may conclude, then, that caries is seldom produced by an external cause ; and that most frequently a blow or external injury, when followed by that disease, has- acted only as an exciting cause, a disposition to it hav- ing pre-existed. There is every reason to believe that it may be ascribed in almost all cases to a disease of the system, such as scrofula, lues, scurvy, or even cancer. " Scurvy diminishes the energy of the contractile fibre, and diffuses a principle of dissolution in the solids and fluids. The blood rendered more fluid by it than natural, oozes through the pores of its small vessels: ELEMENTS OF SURGERY. 333 spots or ecchymoses manifest themselves, first in the parts in which circulation is most languid, as on the hands and feet: the muscles become soft and painful; the gums swell, and separate from the alveolar process: the periosteum may become tumefied in like manner, and lose its connexion with the bone affected with caries. " Scrofula attacks the spongy part of bones and the lymphatic system. A caries from this cause is very fre- quent in the tarsus, carpus, elbow, and knee; but it is always preceded by a white swelling. " The venereal disease is sometimes a cause of caries, though its action on the osseous system more generally produces necrosis or exostosis. However, when it at- tacks the bones of the nose, it produces a caries of them, by which they are consumed, and the face sadly disfi- gured. The bones of the palate are sometimes destroy- ed in the same manner, and by the same cause. " In cancers of the mammae, the sides of the sternum are often found carious; which proves that cancerous ul- cers may, as well as the preceding diseases, occasion a caries of the bones in their neighbourhood. " Nothing can be easier than to ascertain the exis- tence of a superficial caries; and when the affected bone is deep-seated, it may be discovered by introducing a probe; for if the bone be carious, the probe may be easi- ly forced into its substance. But bones which we can- not readily come at may be carious, in which case the diagnosis is somewhat more difficult; however, if a fistu- la, from which a fetid blackish matter flows, be directed towards a bone, and if the surrounding soft parts be at the same time turgid and indurated, there is every reason to apprehend a caries. The black colour of the dis- charge is, however, equivocal; because, as remarked by Ambrose Pare, it may be occasioned by a bit of agaric or other foreign body introduced into the wound. It will be prudent, therefore, in dubious cases, to trust chiefly it) the history of the disease. 334 ELEMENTS OF SURGERY. " If a person affected with a certain constitutional dis case, feel deep-seated and acute*pains in any of hi* bones; and if the pained part swell and become the seat of an abscess, from which a purulent matter of a bad quality flows, there is every reason to believe that the bone aflected with pain is carious. Inert abscesses are attended with nearly the same symptoms, with this dif- ference, that they are not preceded by pain. Caries oc- casioned by syphilis affects most commonly the tibia, os frontis, ossa nasi, ossa palati, and sternum. Whenever, therefore, any of these bones become carious, whilst the person labours under syphilis, there is just ground for concluding that the caries is a symptom of the venereal affection. " A caries of the vertebrae is known by peculiar symp- toms, among which a paralysis of the inferior extremi- ties, and the formation of abscesses in the groin, verge of the anus, or lumbar region, are the most remarkable. " The prognosis is more unfavourable in cases of ca- ries of spongy bones, than in those of a similar affection of compact ones, thus there is not so much to be appre- hended when the bones of the cranium or the scapulas are affected, as when the extremities of long bones are similarly diseased. Caries of the bones of the carpus and tarsus is also very dangerous. The evil, on account of these bones being in such close contact, extends from one to the other; and when one of them becomes carious, it is very difficult to stop the progress of the disease with^ out amputating the limb. " " This operation is often the only resource in our power against caries of short bones, or of the extremi- ties of long ones; and we are even deprived of this when the bone affected with it is deep-seated: thus caries of the head of the femur, or of the cotyloid cavity, cannot be remedied by this operation. The same may be said of caries of the spine, also named gibbosity, in which, ELEMENTS OF SURGERY. 335 as well as in the preceding case, our treatment must be merely palliative.* " Caries from an external cause is less dangerous as well as less frequent than that from an internal; and that resulting from an internal disposition is much more dangerous when it proceeds from a scrofulous or cance- rous diathesis, than from a venereal or scorbutic; for some efficacious remedies against the latter are known; but cancer and scrofula resist all the remedies with which we are as yet acquainted. It is also more dange- rous to old than to young persons, not that its progress is not more rapid in the latter, as already mentioned, but because nature is more capable of limiting its ravages in youth than in old age. Finally, the prognosis is further in- fluenced by the extent of the disease, the patient's strength, and state of the neighbouring soft parts." (Boyer) TREATMENT. In the treatment of caries much depends on the source or cause of the disease. If any peculiar morbid affec- tion of the system exist, this must be previously reme- died. If the venereal disease have produced the affec- tion, mercury must be administered. The caries, how- ever, which results from the venereal disease, is by no means to be considered as indicative of the presence of venereal action, because, after the bone has become carious, it is possible for the venereal action to be com- pletely removed by the use of mercury without an imme- diate separation of the bone. It is to be remarked here, however, that although caries sometimes results from the venereal disease, yet, it oftener happens, that por- tions of bone are completely killed, and exfoliate in con- siderable masses after the venereal disease is cured. It • Not always: there is reason to believe it sometimes care pletely taken out. In time, however, it becomes loose enough to be removed. Sometimes, the middle portion of the sequestrum pre- sents itself externally, while its sides are every where wedged in the substance of the new bone. The natural end of sueh a case would be very tedious of accomplish- ment, and the interference of art is essentially service- able in accelerating the separation of the dead bone, thus circumstanced. After the sequestrum has been either absorbed or thrown off, in one of the above ways, the cavity of the new bone becomes filled up with granula- tions, which are, at length, converted into bony matter. Thus the new bone differs from the original one, in be- ing solid instead of hollow. " When the sequestrum is thrown off slowly, the in- flammation is moderate; but, when it separates quickly, while the new bone is in a soft state, the detachment is always preceded by severe inflammatory symptoms, and Vol. ii. v y 346 ELEMENTS OF SURGERY. followed by a temporary loss of the natural firmness of the limb. This premature separation of the sequestrum often occurs in necrosis of the lower jaw, and the chin consequently falls down on the neck. Iu certain cases, the sequestrum separates at each end from the living portions of the old bone, before the new osseous shell has acquired firmness, so that the limb feels as if it were broken in two places. " When the dead bone is removed by absorption, the process is tedious, and attended with a profuse discharge of matter, which gradually ceases, and at last stops al- together. In young subjects, this work is more quickly perfected, than in old ones. There are some chronic cases of necrosis, in which the sequestrum remains un- absolved, for an indefinite length of time, producing no violent irritation, yet, always enough to teaze the 'pa- tient, and disturb his health. " In necrosis of the long bones, there are always round apertures in the new osseous shell, corresponding with the external fistulous openings, so long as the se- questrum remains enclosed in it. "The tibia, femur, lower jaw, clavicle, humerus, fibula, radius, and ulna, are most frequently affected with necrosis. Excepting the lower jaw and scapula, the process of regeneration has only been noticed, in the cylindrical bones. From twelve to eighteen years of age is the time of life most subject to necrosis. The necro- sis of the lower jaw, however, seldom occurs before the age of thirty. In some persons, two bones are affected at once owing to constitutional causes. " The process of cure is said to take place with more celerity in the lower jaw, than any other bone, and may be completed in three months. Mr. Russell has never kimwn a necrosis of the tibia get well in less than a year; but, in general, nearly two years elapse first; some- ELEMENTS OF SURGERY. 347 times, the cure is protracted to a much greater length of time. " When the constitution is predisposed to necrosis, any cause, capable of exciting inflammation, may occa- sion an attack of it. Often, however, the disease is pure- ly sporadical, and not referrible to outward causes. Cases, which occur from external injury, are generally those of the lower jaw, which are frequently imputable to blows, the application of acrid substances to carious teeth, effects of mercury, &c. " Necrosis of the lower jaw and clavicle never proves fatal: that of the lower extremities, which is the worst case, does so very seldom, and only, from the violence of the first inflammatory symptoms, which rapidly bring on a hectic fever, which proves incurable without re- moving its local cause by a timely amputation. When the violence of the first stage, however, has abated, the irritation ceases, and the hectic symptoms, if there are any, are generally moderate. Nor is this state of tran- quillity disturbed, till the sequestrum, in making its way outward, again produces irritation. At this second pe- riod of urgency, extensive inflammation may originate, ulcerations spread all over the surface of the limb, as- sume an unhealthy appearance, violent fever succeed, and the patient either perish, or sink into a state, in which he must consent to amputation, as the only means of sav- ing nis life. This is the last crisis of imminent danger ; but, in general it is less perilous, than when the in- flammation comes on in an incipient stage of necro- ds." TREATMENT. It may not be improper to remark in the first place that much may be done in preventing necrosis, and if the surgeon be called during the inflammatory stage of 348 ELEMENTS OF SURGERY. the disease which precedes the death of the bone, the antiphlogistic measures are to be vigorously employed. Bleeding general and local, purging, and blisters will be found of great use, and there is reason to believe these remedies frequently successful in arresting the progress of the disease. When the bone is actually dead it has already been stated that the actions of the adjacent parts are in gene- ral competent to the cure, but in many cases art is re- quired. The means necessary to be pursued vary with the cases which occur; when the dead portion is part of a broad flat bone, nothing is required but to wait for exfo- liation, which in general is accomplished without surgi- cal assistance. An inflammatory circle may be seen sur- rounding the dead portion, and after a time, a distinct fissure is formed and grows gradually wider, separating in every part of its circumference the dead from the liv- ing bone; if only a superficial part of the bone have lost its life (either in a flat or a round bone) then the separa- tion proceeds underneath this plate, and it is gradually detached and loosened. It is useful in this stage of the process daily to move the loosened part as soon as it ad- mits of motion, but there is no necessity for taking away a part of it by means of a trephine, or by scraping it thin- ner, because the same natural process is required for re- moving a small as a large, a thin as a thick portion of bone, and precisely the same period of time will be re- quired for separating the one as the other, supposing their surfaces to be equal. Exfoliations from the skull afford frequent illustrations of these remarks. When any of the cylindrical bones are affected with necrosis through their whole extent, and the sequestrum is included in the new bone, it generally occasions so little inconvenience that it may be deemed bad surgery to interfere with the operations of nature. ELEMENTS OF SURGERY. 349 When the adjacent parts inflame, leeches and blisters should be applied, and the blisters should be dressed with savin ointment as recommended by Crowther. In some cases it becomes necessary to remove by a surgical operation the sequestrum. This is often a very painful, difficult, and hazardous operation. Supposing the affection seated in the thigh bone, nothing but neces- sity should induce the surgeon to lay bare and extract the dead bone before it becomes loose and approaches the surface.* In the tibia the operation is easier per- formed and oftener required. The circumstances which should induce the surgeon to perform the operation are, when great irritation is ex- perienced from the dead bone,—when it can be easily re- moved in consequence of its superficial or exposed si- tuation,—when the new bone incloses or overlaps it in such a way that a long period will probably be required for its removal, and when the articulating extremities of the bone are sound, for if these be diseased, amputation should be preferred to the extraction of the dead bone. OPERATION. This operation varies so much in different cases that general rules only can be given for performing it. The first stage of it consists in laying bare the affect- ed bone, and this should be done by cutting through the soft parts where they are thinnest, and where there is least danger of meeting with large bloodvessels, or other important parts. It is best to remove completely a portion of the integuments covering the bone by means of two curved incisions meeting at their extremities; a simple incision does not sufficiently expose the bone. Af- ter laying bare the new bone, a perforation is to be made through it with a trephine, and by means of this the se- • The necessity alluded to is the extreme exhaustion and hectic state of the patient. 350 ELEMENTS OF SURGERY. questrum contained in it can be readily examined, and if small, can now be extracted. If this, however, cannot be done, the remainder of the operation consists in en- larging the opening by means of Hey's saw, or of chisels and gouges, until the dead bone can be removed. In general, it is best to perforate the lower part of the new bone, because a smaller aperture at an extremity will be sufficient, than at the middle of the bone. Perhaps the operation may in some cases be facilitated by breaking with strong forceps the sequestrum, when it is found too large to be conveniently extracted. After the dead bone is removed, the wound is to be dressed with dry lint, and treated as a common wound. Mr. Boyer is of opinion that very few cases occur which warrant the operation ; the British surgeons, on the contrary, often perform it. There can be no doubt that in many cases, great advantage must accrue from it, and whenever it is practicable, under the circumstances which have been mentioned, it ought to be performed. To ascertain in the clearest manner the propriety of an operation, Mr. Russell's mode of examining the parts may be adopted; it consists in laying bare small portions of the bone in the vicinity of the fistulous openings, and if possible, introducing a probe into its cavity; but if this cannot be done, a small hole may easily be drilled by means of a perforator, and through this the examina- tion may be made. If a large loose sequestrum be found, the operation of extracting it can be subsequently per- formed in the manner above directed. ELEMENTS OF SURGERY. 351 CHAPTER LVHI. Of Setons and Issues. A seton is a wound kept in a suppurating state by means of a foreign matter which prevents its healing. The usual manner of making a seton is to pass a large flat needle nearly half an inch broad, through a folded portion of the skin. The needle is double-edged, and is armed with a skein of silk or thread dipped in sweet oil. The principal cautions necessary in forming a seton are in pinching up the fold of skin to avoid any other substance, and to be careful not to puncture any deeper seated part; and in the next place, to make the aper- tures through the skin sufficiently distant to prevent the thread from ulcerating through it. If no seton needle be at hand, the same end may be answered by puncturing a fold of skin with a common lancet, and then by means of an eyed probe, a skein of silk or thread can be passed through the wound. Setons may safely be made almost in any situation on the surface of the body. It is convenient to have one opening more dependent than the other, in order to fa- cilitate the discharge of pus. The skein of silk or thread should remain for a few days untouched until it becomes loosened by means of suppuration, after which that part of it which is nearest the wound is to be smeared with oil or ointment, and gently drawn into the suppurating canal. This process is to be repeated once or twice every twenty four hours, and when the thread is nearly all used, a fresh skein is to be attached to it. 352 ELEMENTS OF SURGERY. Great attention should be paid to cleanliness, espe- cially in warm weather, and the silk or thread should be prevented from imbibing the pus which is discharged. It is easy when the matter does not flow in sufficient quantity to stimulate the wound by mixing cantharides with the oil or ointment smeared upon the thread. Issues are small ulcers artificially established for the purpose of procuring a discharge of pus. They form an important remedy in several diseases, and it is therefore of consequence to understand the best and easiest me- thods of making them. The situation in which the issue is to be formed is ge- nerally pointed out by the disease, but it is best to avoid placing them over a bone which is thinly covered, or over a considerable tendon, nerve, or bloodvessel, for very obvious reasons; the belly of a muscle is also an un- favourable spot upon which to form an issue, because the motion of the part will occasion pain and inconve- nience. Among the most convenient situations for issues are the back part of the neck—the spaces along-side of the spinous processes of the vertebra—the arm at or near the insertion of the deltoid muscle—a hollow on each side of the knee above the flexor tendons of the leg. Various methods of forming issues have been con- trived. Among the simplest is the application of a small blister, which is to be dressed from time to time with epispastic ointment. This, however, is a plan which occasions a good deal of trouble to prevent the sore from healing, and the discharge is not in general sufficiently copious. Incisions are sometimes made through the skin, and into these incisions beans and peas are inserted to pre- vent the wound from cicatrizing. elements of surgery. 353 -I he use of caustic is however the best and most usual method of forming issues. The manner in which I have been taught, and accustomed to apply it is as follows. A piece of leather is to be spread with adhesive plaster, and a hole is to be cut through this leather of the size and form of the intended issue. Another piece of leather is to be spread with the same plaster, in order to confine the caustic. The plaster first mentioned is to be warm- ed and applied to the skin in such a way that the hole cut through it may be on the part where the issue is to be made; this hole is to be filled up with paste caustic and covered by adhesive plaster, to prevent it from fall- ing off. The paste caustic is made by mixing two parts of fresh burnt quick lime and one of common caustic (pure vegetable alkali) together, in powder, and forming them into a paste with a little soap, and a few drops of water. The caustic is to be left on until it destroys the skin, which will generally be found black and gangre- nous in an hour and a half or two hours, but if not, it must be reapplied and allowed to remain still longer. A poultice is afterwards to be applied, and in the course of a few days the eschar will separate from the sound parts. Dr. Wistar has contrived a method of forming issues which I think the most simple and least painful I have ever tried; it consists in blistering with Spanish flies the surface of the skin, and rubbing for about ten minutes the blistered surface with common caustic. In this short space of time an issue is formed of the necessary depth. In order to make the issues of the proper shape, it is best to apply the Spanish flies to the skin in the same manner as the paste caustic is usually placed, in a hole cut out of a piece of leather spread with adhesive plas- ter. VOL. II. Z 7 354 ELEMENTS OF SURGERY. In order to keep an issue from healing it is necessary to press upon its surface beans, peas, or other foreign bodies, and occasionally to apply savin cerate, or Span- ish flies. I have often used a small block of hard wood with lozenges cut upon it; the points of these lozenges bound upon the issue are more convenient of applica- tion than the beans or peas. To prevent the wood from imbibing moisture it may be coated with a solution of sealing wax in spirit of wine. Fungous granulations frequently arise from issues, and grow to a very considerable height; when this hap- pens, the application of lunar caustic should be made and repeated as often as may become necessary, and the future growth of these granulations may be prevented by dressing the issue occasionally with escharotics, as burnt alum, or red precipitate. Issues should be washed twice in twenty-four hours with warm water; if cleanliness be neglected they be- come extremely offensive. *# I',ujr J.te Vol L' Club Foot. ./.S.lwr dit 4 .»'r«4" ELEMENTS OF SURGERY. 355 CHAPTER LIX. Of Malformations. To enumerate all the deformities found in new born infants would require many chapters. The records of medicine, especially those written in more credulous ages, are replete with monstrosities in every form. The writings of Ambrose Pare exhibit a motley group of these prodigies. On the present occasion it will only be necessary to speak of those deformities which are of frequent occur* rence or which can be remedied by art. OF CLUB FOOT, It is a matter of some surprise to all intelligent men that the treatment of distorted limbs has excited so little the attention of surgeons. In consequence of this neglect, the management of such cases generally falls into the hands of empirics, or nurses, and if this class of persons are warrantable for their interference in any com- plaints it is in these, because the cure consists in me- chanical contrivances which cannot affect life, and which are often highly serviceable. It is evident at the first view of such a subject, that distortions of the feet must vary greatly in their na- ture and degree, and consequently require very different treatment. The most Usual form of the complaint, how ever, consists in a turning inward and upward of the sole of the foot, in the manner represented in the oppo- site out lines: when a person with such a foot begins to 356 ELEMENTS OF SURGERY. walk, he walks on the outer edge of the foot, and the de- formity gradually increasing, the upper part of the foot becomes the lower, and he walks upon the top or instep instead of the sole. The relative position of the bones of the tarsus to those of the leg is altered in club foot, and constitutes one derangement of the parts. The bones of the tarsus are themselves unnaturally formed, and this constitutes a second deformity. The action of the muscles upon parts changed from their natural form will tend very materially to augment the deformity, and consequently the longer they are suffered to act, the greater this de- formity will be. The causes of club foot are not very easily ascertain- ed ; what effect pressure on the foetus in utero may have I am not prepared to decide. The indication of cure in club foot is to effect by ar- tificial means a change from the unnatural to a more na- tural posture of the foot, and this is to be attempted by splints and bandages accommodated to the particular nature of each case. It is of great importance to commence the treatment of club foot as soon as possible after birth. The bones are not at this time completely formed, and are suscep- tible of any change in shape which circumstances may direct. The muscles have not yet acted sufficiently to augment the original derangement. We are not, how- ever, to be deterred from endeavours to relieve the com- plaint even when years have elapsed before surgical aid is requested, for great benefit has been derived in many cases from the use of the necessary machinery even after the age of puberty. To effect a change in the shape of the foot, permanent pressure must be applied in such a manner as to sepa- rate those parts where bony matter is deficient, and to force together those in which it is redundant; this will ELEMENTS OF SURGERY. 357 be in fact to bring the foot as nearly as possible to its natural form. Mr. Sheldrake an ingenious instrument maker of Lon- don who has acquired much celebrity by his skill in the treatment of club foot, has very correctly stated the man- ner in which pressure acts in restoring the natural form. " If so much pressure is applied as to bring the sepa- rated parts of those bones into contact, and is invariably supported, it will stop the growth of that gelatinous sub- stance, which is first formed in those parts where the bones come in contact with each other; in those parts which do not come in contact, it will continue to grow till they meet; the progress of ossification will be con- tinued, in the natural way, till the patient arrives at ma- turity; and with no more mal-formation than existed at the time the pressure was first applied. " If more pressure is applied and uniformly kept up, the cartilages will be compressed in those parts in which they come in contact; and if only the natural action of the foot is permitted, will assume a permanent form, as nearly approaching to the natural one, as the pre-exist- ing deformity will admit. This compression of the car- tilages will, by condensing their substance, prevent the arteries from shooting so freely into it, in an improper di- rection, as they would have done but for this impedi- ment, and thus stop the progress of ossification in an im- proper direction, while that process will go on in the na- tural way, in every other part, till the patient has ar- rived at maturity, and every part is completely formed. " If the same pressure is uniformly continued, or a greater degree of pressure be constantly applied, the ac- tion of the arteries, which deposit the earthy particles nearest the surface of the bones, will likewise be im- peded, while the action of the absorbents, which, in the course of circulation, are employed in taking up earthy particles, will be continued in full vigour, if it i« not in- 358 ELEMENTS OF SURGERY. creased; and by perseverance in this process it is cef < tainly possible, that an unequal action, i. e. a diminished action of the secreting vessels, and an increased action of the absorbing vessels, may be kept up, and so modi- fied, as to alter the form of these bones, long after they are ossified; and, of course, so much of the deformity of such feet as depends on mal-formation of the bones, may be radically cured, long after that period of life at which they have generally been thought incurable." When the deformity consists in a curvature at the an- kle joint, and another in the foot, which is the case in a majority of instances, a great deficiency of bone appears in the inside of the foot, as much as if one of the cunei- form bones were completely absent, and a proportionate surplus of bone exists on the outside. In such cases Dr. Physick has succeeded in removing every vestige of deformity by a contrivance which is represented in the annexed plate. From the uniform success which resulted from the ap- plication of this apparatus I have used it, and known it used in a great number of instances, and I recommend it in preference to every other machine; modified accord- ing to circumstances, I believe it applicable to every case of club foot which is met with in practice. I lament that I have not been able to procure a trea* tise on club foot which has recently been published by Professor Scarpa, as I have no doubt his industry and zeal must have thrown light on this, as on the other sub- jects of which he has treated. Plate xxv Paqe 359 lol 2 ELEMENTS OF SURGERY. 359 v ^.EXPLANATION OF THE PLATE,. a. b. A shoe made of sheet tin covered with leather. a. a. The sole. b. A projecting plate of tin soldered to the sole, by which lateral pressure is made on the inner edge of the foot at b, and on the outer edge of the heel at c. d. A strap passing over the top of the foot and secured to the buckle e on the opposite side. The object of this strap is to compress the upper part of the foot, and to bring the sole gradually in contact with the sole of the shoe. Tt should always be drawn tight enough to prevent the foot from turning. /. A steel splint passing up the leg to counteract the ten- dency of the ankle joint to turn inwards; the joint g, allows some degree of extension and flexion to the foot. }i. ft. A plate of thin brass, iron, or tin, passing round the leg. This plate as well as the steel splint are covered with soft buckskin, which laces in front, but which to prevent confusion is omitted in the drawing. * The instrument here represented is adapted to the left foot of a new born infant. A larger one must be used for an older child. 360 ELEMENTS OF SURGERY. CHAPTER LX Of Spina Bifida. This consists in an imperfect state of one or more of the vertebrae, and a swelling containing a fluid at the spot where the imperfection exists. The tumour is generally found at one of the lumbar vertebrae; sometimes on the os sacrum; and occasionally at one of the cervical or dorsal vertebrae. A tumour ana- lagous to this occurs on the heads of children, and is called by the same name. The swelling in every case appears to result from imperfect ossification, or a con- genital deficiency of some part of the cranium or spine. Children affected with spina bifida seldom live long. Warner relates an instance in which the patient lived to the age of twenty, but in general they survive a very few years. The fluid contained in the tumour is commonly a lim- pid colourless serum, but sometimes it has been found turbid and tinged with blood. In examining spina bifida, a fluctuation can always be felt, and in general the defi- ciency of bone can be discovered by the finger; this de- ficiency is usually between two of the spinous processes, though sometimes one spinous process is entirely want- ing; a membrane, supposed to be a continuation of the dura mater, invests the fluid, and forms a kind of cyst around it, adhering closely to the external integuments. Paralysis of the lower limbs sometimes attends the complaint, but not uniformly. No remedy has hitherto been discovered for this com- plaint; and it has not, so far as I have learned, in a siu- gle instance been cured. The tumour has been opened by caustic and by incision, always with a fatal result. ELEMENTS OF SURGERY. 361 Mr. Abernethy has proposed to compress the tumour gradually from its commencement, with a view to effect the absorption of the fluid, and to prevent the distension of the unsupported dura mater. He also suggests the propriety, if this should fail, of puncturing the tumour with a finely cutting instrument, the wound to be imme- diately after closed with sticking plaster, and healed: the reaccumtilation of the fluid he proposes to prevent by local pressure. In one case Mr. Abernethy punc- tured a spina bifida every fourth day for six weeks, dur- ing which time the child's health continued unaffected, and the wounds healed. The plaster, however, was rubbed off from one of the punctures, and the part ul- cerated ; the opening could nof be healed, and death ensued: the discharge being previously changed from serum to a purulent fluid. Mr. Benjamin Bell proposed to tye a ligature firmly upon the tumour, a practice in no respect adapted to the case, and Richter's proposal of issues is as little likely to be serviceable; so that a remedy for spina bifida is still to be considered a desideratum. Spina bifida is occasionally accompanied by hydroce- phalus. A rupture of the tumour in such a case has oc- ^ casioned a diminution of the size of the patient's head, and discharged the fluid contained in it. I have evacu- ated the water of a hydrocephalus through a flattened trochar in a child several times, with the effect relieving the symptoms, but death resulted. Upon dissection I found that my operation had been a very safe one, for the whole brain was compressed in such a way as to form a lining for the dura mater scarce half an inch thick, its blood-vessels were very-small, and the punctures had healed up. Whether Mr. Abernethy's operation on the spina bifida would be more successful I very much doubt, it is however warrantable,—" anceps remedium potius quam nullum." vol. n. 3 A 362 ELEMENTS OF SURGERY. CHAPTER LX1. Of Imperforate Anus. Mr. Benjamin Bell has published in his system of surgery a very good account of this subject; from that work I shall offer the following extract. " Although an imperforated anus is not a frequent oc- currence, yet as it is occasionally met with, and as it is of much importance to have such deficiencies soon dis- covered, every midwife ought to examine with attention the state of all the natural passages as soon as possible after delivery. " In some cases of this nature, the end of the rectum is found to be somewhat prominent at the usual situation of the anus, and to be only covered with skin and a small quantity of cellular membrane: but in others, no vestige of the rectum can be perceived; and the skin retains its natural appearance, without being any where elevated be- twixt the scrotum and the point of the coccyx. " In some of these, the rectum has been found to ter- minate within an inch of the ordinary seat of the anus; in others it has reached no farther than the top of the sa- crum. In some it has been known to terminate in the bladder; and in others, in the vagina. " When the assistance of an operator is required in such cases, as death is in all probability to be the conse- quence if a proper vent be not obtained for the faeces, no time should be lost in deliberation.—If the end of the gut is found to be covered with skin merely, and if a protuberance is formed by the faeces pushing it forward, all that a surgeon has to do, is with a scalpel or lancet ELEMENTS OF SURGERY. 363 to make an opening sufficient for evacuating them; but when no direction of this kind is met with, the case comes to be much more complicated, and more difficulty and danger are accordingly to be expected. " In such cases where the gut is found to lie deep, on the child being properly secured, an incision of an inch in length should be made directly on the spot where the anus ought to be; and this should be continued by gra- dual and repeated strokes of the scalpel, in the direction the rectum is usually known to take; not in a direct course through the axis of the pelvis, for in that direc- tion the vagina or bladder, or perhaps both, might be brought to suffer; but backwards along the coccyx, where there is no risk of wounding any part of importance. The best director, in every case of this kind, is the finger of the operator. The fore-finger of one hand being push- ed in towards the coccyx, the surgeon with the scalpel in the other, should dissect gradually in this direction, either till he meets with faeces, or till the scalpel has reached at least the full length of his finger; and if, af- ter all, the faeces are not evacuated, as death must un- doubtedly ensue if something farther be not attempted, a long trochar should be pushed forward upon the finger, in such a direction as the operator thinks will most pro- bably meet with the gut. " In this manner many lives have been saved which would otherwise have been lost. I myself have had two such cases; in both of which the gut lay deep, and in both I was fortunate enough to form an anus, which for a good many years has continued to answer the pur- pose sufficiently. But in each of these a great deal of difficulty was experienced in preserving the passage suf- ficiently wide and open; for as soon as the dossils of lint and other tents made use of for preserving the passage were withdrawn, such a contraction occurred as for a considerable time rendered the evacuation of the f»ces 364 ELEMENTS OF SURGERY. extremely difficult. Sponge tent, gentian root, and other substances which swell by moisture, were at different times employed; but these were uniformly found to pro- duce so much pain and irritation as rendered their con- tinuance altogether inadmissible: applications of this kind are frequently, indeed, recommended in such cases; but any person wrho has ever used them in parts so ex- quisitely sensible as the rectum always is, will readily acknowledge the impropriety of the advice. " Dossils of soft lint moistened in oil, and rolls of bou- gie plaster of a proper size, were found to irritate less than any other application; and for the purpose of dilat- ing the passage, when, at different times during the cure. it was found to have become too strait, the method we have already had occasion to mention, of compressing blood-vessels in the rectum by introducing a sheep's gut, shut at one end, into it, and forcing water into it by the other, was also found to answer here. But, upon the whole, although this part of the cure may appear to those who have not met with such cases, to be a simple and easy matter, it is found to be much otherwise in practice. Indeed, no case 1 was ever concerned in afforded so much trouble and perplexity as was experienced from each of those I have meutioued; for although in both, the openings were at first made sufficiently large, yet nothing but a continued attention for the space of eight or ten months prevented the necessity of a frequent repe- tition of the operation. When the skin alone is to be cut, it is a very simple matter indeed ; for in this case nothing in general is necessary but the introduction of a dossil of soft lint for a few days into the opening made by the scalpel. But when the rectum lies very deep, I am inclined to think, from the event of these cases al- luded to, that although, ultimately, a complete cure may commonly be obtained after a free discharge of faeces is ELEMENTS OF SURGERY. 365 procured, that much nicety and attention on the part of the operator will always be required for a considerable time after the operation; and in general we may suppose, that the difficulty will be in proportion to the depth of the cut. " Even where the gut is found to terminate in the blad- der or in the vagina, the operation we have recommend- ed should be undoubtedly practised : for, in the former case, as all the faeces must be emptied into the bladder, much risk must occur of such accumulations being form- ed as may put a total stop to the discharge by the ure- thra; and in the latter, where the rectum terminates in the vagina, much inconvenience and distress must be in- curred ; which, if the operation succeeds, may possibly be prevented. .There cannot indeed be any certainty of the operation in question proving altogether effectual in obviating the inconveniences produced by the gut termi- nating in the bladder or vagina, as there must still be a probability of part of the faeces continuing to pass off by these outlets; but as a free passage procured in this manner, affords at least a tolerable chance of relief, no doubt ought to be entertained of putting it in prac- tice. " When it unfortunately happens that no passage is obtained for the faeces by any of the means we have pointed out, might not we attempt an opening above the pubes, or perhaps on the right side so as to reach the caput coli, with a view of making an artificial anus in one or other of these places? It is true, the chance of success from such a measure would not be great; and, even allowin0* the attempt to succeed in the most com- plete manner, the discharge of faeces from such openings would always prove troublesome and uncomfortable: but the melancholy idea of leaving a child in such a si- tuation, to die in much pain, must prove so highly dis- 366 ELEMENTS OF SURGERY. tressing, both to the friends and the operator, as would at any time rather incline one to have recourse even to the doubtful and desperate remedy we have men- tioned." (B. Bell.) A very interesting case of imperforate anus is related by my friend Dr. J. A. Smith of New York, in the se- cond volume of the New York Medical and Philosphical Journal; in that case the rectum communicated with the urethra, through which canal its contents were eva- cuated. An unsuccessful operation was performed for the relief of the patient, the wound healed, but within a month the child expired, and no dissection being per- mitted, the mode and place of communication between the rectum and urethra or bladder remained unknown. Mr. Bell's proposal to cut into the caput coli, or to make an opening above the pubes, is one which has never been put in practice, and probably never will be by any prudent practitioner. ELEMENTS OF SURGERY. ^67 CHAPTER LXII. Of Imperforate Vagina. It is by no means unusual to find in new born girls, that the vagina is imperforate. Sometimes the passage is closed by an obstruction higher up than the meatus urinarius, and in that case the bladder evacuates itself as usual, and the imperfection remains for a time undis- covered ; sometimes even until after marriage when a surgical operation is found indispensable. In general the vagina in such cases is closed by a membrane, which is nothing more than the hymen, but is unusually dense and strong; if an aperture exist in it through which the menses can floiv, surgical aid will not often be required, but if it be entirely closed a great deal of suffering is experienced by the patient when the cata- menia commence, and death has even resulted before the nature of the complaint has been made known. When the vagina is closed by a membrane, the ope- ration by which it is to be relieved is extremely simple. A straight incision, or if the membrane be very dense, a crucial incision should be made through it, and the wound kept from uniting by the introduction of a sponge tent, or roll of linen. Cases are recorded in which pro- digious quantities of black putrid blood have been dis- charged by such an operation, and the lives of many pa- tients have been saved by this simple process. A more difficult operation l^Sfmes necessary when in- stead of a mere membrane to lie^M'ided, the surgeon finds an obliteration of the vagina, 6t a concretion of its 368 ELEMENTS OF SURGERY. sides. In this case he must proceed by slow and cau- tious dissection, guarding with extreme care the bladder on the one side and the rectum on the other. De Haen relates a case in wiiich the bladder was actually opened and death resulted. The vagina often becomes obliterated .by adhesions, in consequence of inflammation from disease or violence. I have known this to happen from an injury received in parturition, and I have had a patient under my care in whom it resulted from a disease of the uterus. In such cases if they occur in early life, and the menses collect, an aperture must be made for their evacuation. Dr. Physick has once been called upon to dissect a passage to the uterus, in a case where the vagina was entirely closed up to a considerable distance within the os externum. After a cautious dissection through a very considerable thickness of parts the operation was accom- plished, and the vagina was kept open and dilated by the use of tents. • *#w ELEMENTS OF SURGERY. 369 CHAPTER LXIII. Of the Caesarian Operation. The extraction of a foetus from the uterus by means of an incision through the parietes of the abdomen has long been known by the name of the Caesarian section. The operation is said to be necessary, first, when the foetus is alive and the mother has died in labour, or du- ring the two last months of pregnancy; secondly, when the foetus is dead, but cannot be expelled in the usual manner, in consequence of deformity in the mother, or of the inordinate size of the child; and thirdly, when both mother and child are living, and the causes last men- tioned prevent delivery. As the discussion of the causes which may demand the operation would involve a varie- ty of considerations not properly belonging to a surgical treatise, I shall refer to the writers on midwifery for an account of them, and on this question shall simply state that there are some cases in which no doubt can exist as to the propriety of extracting a foetus by an external in- cision, the use of the crotchet, however, has greatly lessened the necessity of the operation, and I wish by no means to be understood as recommending it except in cases where in the opinion of a skilful accoucheur the death of the mother is the only alternative, or where after the death of the mother there may be reason to suppose the child alive. In cases of extra-uterine conception it is sometimes ne- cessary when the foetus is situated in one of the ovaries, or fallopian tubes, or within the cavity of the peritoneum, Vol. h. -3 b 370 ELEMENTS OF SURGERY. it is impossible for it to be delivered in the usual manner. In these cases I believe the best practice is to wait until the formation of an abscess takes place, an event which may reasonably be expected. The putrid foetus will then be evacuated either through the rectum, or through the external parietes; many instances have occurred in which these terminations have taken place and the mother has happily survived. I received some time since from my friend Dr. \raughan of Virginia, the bones of a foetus evacuated through the rectum, the mother hav- ing completely recovered. Should suppuration, however, take place, and the ab- scess break externally without a sufficient opening for evacuating the foetus the aperture may be enlarged by the knife, to facilitate this process. Such a case occur- red recently in New York. Dr. J. A. Smith has de- tailed it in the first volume of the Medical and Philo- sophical Journal. In this case, Dr. Smith remarks, " there were two small orifices through which the matter made its way, one somewhat above, the other directly at, the umbilicus. Upon introducing a probe into the latter, bone could be felt at no great depth. As the patient was rapidly sink- ing under hectic fever and diarrhoea, it was decided that a speedy performance of an operation was the only means of saving her life. Having first introduced a probe into the sac, I made an incision at the inner edge of the right rectus abdominis muscle, from an inch aud a half above to the same distance below the umbilicus. At three strokes of the knife I got into the sac, aud intro- ducing my finger dilated upwards and downwards as far as could be done with safety, for had I gone beyond the adhesion of the sac to the parietes of the abdomen and thus exposed the cavity of the peritoneum, the patient must have died. I then proceeded to extract the bones with my dressing forceps conducted by my finger, which ELEMENTS OF SURGERY. 371 mi first was easily done, but after removing two or three it became more and more difficult, and at last I found it absolutely impracticable to get aWay any more, at least without doing a violence to the woman which she could not possibly survive. This disappointment arose from a circumstance which it was impossible to foresee, for from the length of time which had elapsed from the death of the foetus and other circumstances, we had every rea- son to suppose that all the soft parts of it were destroyed by putrefaction, but as this unfortunately had not happen- ed I was obliged to desist. This I did the more wil- lingly as I was convinced if the patient did not die of symptomatic fever that the putrefactive process would go on much more rapidly, and that the bones might be taken away as they became detached. The event justi- fied my expectation. The wound was filled with lint, and the patient put to bed." She lost an inconsiderable quantity of blood during the operation, and subsequently recovered, the whole foetus being removed from the wound within a few days. An instance is recorded of a living foetus cut out at the groin. But these are not genuine cases of the Caesa- rian operation. As the operation of opening the uterus through the ab- domen may become necessary from invincible obstacles to the extraction of the foetus, either in a living or dead state, I shall describe in this place the manner of per- forming it; it should certainly be done before both mother and child have perished from the violence of the paius, flooding, convulsions, &c. The operation being determined upon iu a case of uterine conception, the patient is to be placed upon a table of the usual height and laid upon her back, her head moderately elevated, aud her thighs somewhat raised in order to relax the muscles of the abdomen; an incision is then to be made six inches long through the 372 ELEMENTS OF SURGERY. skin and cellular substance. In my opinion this incision should be in the course of the linea alba, because no mus- cular fibres will be here divided, and there will be less probability of wounding an intestine: (an exception, however, to this direction will be presently mentioned.) After the linea alba is exposed, an opening should be made through it just below the umbilicus. A probe pointed curved bistoury is now to be introduced, and with it the incision through the tendon and periosteum is to be enlarged to the size of the external incision, great care being taken not to wound any of the intestines. The uterus is next to be opened by an incision of the same length as the first, and through this the foetus is to be extracted, and afterwards the placenta and mem- branes. A case is described by Mr. Artiste in the Ed- inburgh Surgical Journal in which the operation per- formed in this manner was completely successful, and both mother and child were preserved. The cases in which the external incision may be pro- perly made on one side of the abdomen, are those in which a part of the child can be distinctly and promi- nently felt, and at that part an incision being made pre- vents the danger of wounding any intestine. Mr. Wood describes a case in the sixth volume of the Medical Journal, in wliich the nates of the child projected late- rally and the incision was made nearly in a transverse direction on the left side of the abdomen, beginning at the umbilicus. Instead of dividing the placenta Mr. Wood introduced his hand betwixt it and the uterus, and extracted the foetus with ease; a hemorrhage was caused by this, which however soon ceased, and not more than seven or eight ounces of blood were lost. After the uterus was emptied the omentum aud intestines protruded from the wound but were reduced readily, and the wound was dressed by sutures and adhesive plaster. The wo- man, however, died on the fourth day afterwards. ELEMENTS OF SURGERY. 37^ Mr. Simon in the Memoirs of the Academy of Surgery relates sixty-four successful cases of the Caesarian opera- tion, more than half of which were performed on thirteen women, some of whom had undergone the operation once or twice, and others five or six times; one woman had suf- fered it seven times and always with success. Mr. Tenon counts up sixty-six cases which have occurred at the Hotel Dieu in Paris, and other writers have collected a considerable number. Baudelocque (by no means par- tial to the operation) reports that of one hundred and eleven csesarian operations, performed since the middle of the last century, forty-seven or forty -eight have been successful.* Mr. Capuron the latest French writer on midwifery observes that the Caesarian operation far from offering a melancholy catalogue of victims, affords a re- source always safe for the infant, and very often for the mother,f so that the operation although unquestionably hazardous, ought to be performed in all cases where the delivery is impracticable by other means, and any hope exists of saving the mother or infant by it. In cases of extra-uterine conception the operation as already remarked, had in general better be delayed until suppuration takes place. * In England the Casarian section has generally proved fatal. | Cours theorique et pratique d'acouchemens, par J. Capuron. A Paris, 1811. 374 ELEMENTS OF SURGERY. CHAPTER LXIV On the division of the symphysis pubis. Another operation, the consideration of which properly belongs to midwifery, is described in several systems of surgery, the division of the symphysis pubis for the pur- pose of enlarging the diameter of the pelvis, in cases of difficult labours. Mr. Sigault, a French accoucheur, con- trived this operation as a substitute for the Caesarian sec- tion, than wliich it is certainly less dangerous and severe; it was adopted by a majority of the French physicians, who proclaimed it one of the most important improve- ments of the healing art. The British generally reject- ed it, and subsequent investigations have proved their judgment in great measure correct. When the operation is to be performed, Mr. B. Bell directs the patient to be placed on her back, upon a ta- ble of convenient height; " the pelvis should be eleva- ted with two or three pillows, put beneath it, and the legs and arms should be secured by assistants. When in this situation, the bladder should be emptied by the introduction of a catheter, which should be retained in the urethra by one of the assistants till the division of the bones is completed. "After shaving the pubis, the operator, standing on one side of the patient, should, with a longitudinal incision, divide the skin and cellular substance covering the pubes at their symphysis : The cut should commence at the upper edge of these bones, and be continued nearly, but not entirely, along their whole breadth : On the bones being laid bare, the cartilages by which they are joined must be slowly and cautiously divided ; and as it is by ELEMENTS OF SURGERY. 375 no means hard, it is easily done. Both the teguments and cartilage may be divided with a firm round-edged scalpel of the common form, which is the only instrument except the catheter that is necessary in this operation. The intention of the catheter is, to point out the course of the urethra to the operator ; for it lies so contiguous to the pubes at their symphysis as to be in great danger of being cut, if this precaution be not attended to; even the bladder itself might be injured, were the division of the cartilage not conducted with caution : but with due attention to these points, and avoiding the total division of the soft parts at the under edge of the bones, all risk of hurting either the bladder or urethra may be pre- vented. " On the division of the cartilage being completed, the bones recede considerably from each other. To prevent any consequences that might ensue from their separating forcibly and suddenly, the assistants who have the charge of the thighs should be desired to support them, parti- cularly towards the end of the operation ; and if a suffi- cient opening is not gained in this manner, the thighs may afterwards be slowly and gradually separated. " The child is now to be delivered in the usual way by the vagina, and this being affected, and the placenta removed, the bones should be immediately put together, and retained as exactly as possible in their situation, by the proper application of a cotton or flannel roller round the pelvis and thighs; at the same time that the patient should be desired to remain as much as possible in one posture. The sore does not require any particular atten- tion ; in general it heals easily with light and mild dress- ings ; and for the most part the union of the bones is completed in the course of the fifth or sixth week. The patient however should not be allowed to walk, or to put the body into any posture that might eft'ect an altera 376 ELEMENTS OF SURGERY. tion in the situation of the bones, till nine or ten weeks have elapsed." Mr. Baudelocque declares, that he was unable in any experiments upon the dead subject, to increase the dia- meter of the pelvis by dividing the symphysis pubis, more than from three to six lines, (at most half an inch;) on the other hand, some advocates of the operation state, that the pelvis is enlarged by it more than two inches. Mr. Capuron complains that the division of the symphy- sis pubis has been performed in many cases in which the patient might have been delivered without recourse to it, and upon women who had previously borne seve- ral children; an abuse which cannot be too strongly cen- sured. Mr. Demangeon has lately published a small essay upon this subject, in which he decidedly prefers it to the Caesarian section, when one or other of these ope- rations must be performed.* I shall not venture an opi- nion on the question, but conclude by a caution never to perform either of these operations whilst there is the least remaining prospect of delivery without them. * De Ossium Pubis Synchondrotomia. Parisils. 1811. ELEMENTS OF SURGERY. 377 CHAPTER LXV. Of Prolapsus Uteri. The uterus losing its natural situation in the pelvis, sometimes descends into the vagina, where it may be felt forming a pyriform tumour projecting into this passage; the os tincae is situated in the centre of the tumour, and the finger can readily be passed round it, rendering the nature of the case sufficiently evident. A greater de- gree of protrusion often takes place, and the uterus is found situated exteriorly to the vulva, dragging down the vagina, which consequently doubles on itself, and draws downward the part of the bladder connected with it. The prolapsus when complete forms a tumour, of an oblong and nearly cylindrical form, terminating in a narrow circular extremity, in which the os tincse is situ- ated; through this aperture the menses are discharged at the usual periods. When prolapsus uteri exists in the degree first de- scribed, the uterus being situated within the vagina, the inconveniences experienced from it are, sensations of great weight and uneasiness in the pelvis, sometimes affecting the bladder and kidneys; these sensations not amounting to severe pain, are however very distressing, and are greatly augmented by exercise. Rest in a hori- zontal posture generally relieves them. In a more advanced stage, and greater degree, the prolapsus uteri occasions very severe sufferings. The symptoms are aggravated, and often very painful. The external situation of the uterus in a complete prolapsus, exposes it to irritation from various sources; the urine flowr- vol. n. 3 c ^78 ELEMENTS OF SURGERY. ing over it, and the friction occasioned by exercise, often produce great pain and distress. TREATMENT. When the complaint exists only in a slight degree, the uterus may very readily be pushed back with a fin- ger to its proper situation, and often indeed resumes it when the patient lies in a horizontal posture. The re- duction however is by no means so easy when the uterus is completely protruded outside of the vulva. The ab- dominal viscera having in some measure accommodated themselves to the change in those of the pelvis, do not very readily recede to their natural situation, and con- sequently preclude the ready return of the uterus: to overcome this obstacle, it is necessary to confine the pa- tient to a low diet, and to a horizontal posture, for a few- days, and to administer a cathartic. The warm bath may be used if any difficulty of reduction should remain. By the use of these remedies, and the assistance of the surgeons fingers, the uterus may be generally replaced. It is unnecessary to wait until all inflammation ceases, because as long as it remains in its unnatural situation, exposed to the external irritations which have been men- tioned, it will continue somewhat inflamed; at the same time it would be highly improper to make any effort at reduction, until the remedies just directed have had the effect of considerably reducing the inflammatory appear- ance of the uterus. In order to retain the uterus in its natural situation, an instrument, called a pessary, is to be introduced into the vagina. The pessaries formerly employed, were no- thing more than masses of wool, of lint, or other soft materials, adapted to the shape of the vagina; these are, however, at present laid aside, and a variety of sub- stitutes have been invented. A pessary ought to be formed of materials sufficiently ELEMENTS OF SURGERY. 3?9 firm to support the uterus, and so light as not to descend after it is placed in the vagina. It should be of a solid texture, incapable of imbibing the moisture of the parts, because nothing is more offensive than retained animal secretions. The form of a pessary is an object of im- portance. Dr. Denman directs them to be made globular; Dr. Clarke prefers a flat oval form, with a perforation in the centre. Both these gentlemen direct the pessary to be made of box-wood, and Denman's is made hollow, that it may be light, The French surgeons form their pessaries of the same materials as those which enter into the composition of the flexible catheter, their form is a ring, and the French pessaries are very light, and to a certain degree resist moisture; but none of these instru- ments are perfect, they all become exceedingly foetid after remaining a very short time in the vagina. Dr. Physick has had pessaries constructed of silver, very thickly gilt. He prefers the globular form in most cases, and in order to have the instrument light, it is made hol- low ; two very thin hemispheres of silver are soldered together, highly polished on the outside, and then coat- ed with gold. The silversmiths very easily fabricate such an instrument, and it possesses several advantages. The gold is not affected by the secretions of the vagina, and is the most cleanly substance of which the pessary can be made; the objections to forming the instrument entirely of gold, are, that it is softer than silver, and consequently must be made thicker; which, in addition to its greater specific gravity, would render the pessary too heavy; it is also more expensive. The use of as-. tringent injections has been found advantageous in cases of prolapsus uteri. Prolapsus uteri occurs sometimes during pregnancy,— on this subject I refer to the writers on midwifery,—as also for an account of the Inversion and Retro-ver* sion of the uterus. 380 ELEMENTS of SURGEHY. CHAPTER LXVI. Of Bandages. Bandages are strips of linen, muslin, or flannel, used for confining dressings upon wounds and ulcers, and for a variety of surgical purposes. The proper application of bandages can only be ac- quired by habit, and the best directions on the subject will be of no use without practice. In the education of a surgeon in Europe great attention is generally and de- servedly paid to instructing him in the dressing of wounds, ulcers, fractures &c. and I lament that oppor- tunities of acquiring dexterity in this important branch of surgery are so little sought after by medical students in this country. Bandages arc formed in general of muslin. This sub- stance answers better than linen or flannel. It is suffi- ciently strong to confine dressings, and if necessary, to compress the parts on which it is applied. It is suffi- ciently flexible to accommodate itself to the shape of every part of the body, and the roughness of its surface prevents it from slipping, properties which are combined in no substance to so great a degree as in muslin—flan- nel in some cases answers very well, but it retains in ge- neral too much heat. The muslin used for bandages is the coarser kind, and it should be washed before it is used. The selvage or stiff margin at the edge of the piece should be torn off before the bandage is made. In general it is best to have bandages free from seams. In case a long roller is wanted, it should be torn from a piece of muslin of the requisite length. ELEMENTS OF SURGERY. 381 The mode of applying a bandage must depend en- tirely on the purpose for which it is designed; where it is intended to confine the plasters on a sore, it should be tight enough to effect this object, without any risk of an interruption to the circulation of the blood. Inflamma- tion and gangrene have often resulted from negligence in this particular. In the preceding chapters the chief bandages which have been referred to are the roller, and the bandage of strips, the invention of which is ascribed to Scultetus. The simplicity of modern surgery has rejected a vast va- riety of bandages formerly employed, and with the two just named, the surgeon is enabled to effect most of those purposes for which bandages are necessary. The eighteen tailed bandage is a modification of that of Scultetus which I think ought never to be employed, because the strips being connected, when one part becomes soiled it is requisite to remove the whole, whereas in case one or more strips be soiled in the bandage of Scultetus it is easy to replace the soiled part. The inconvenience of changing the eighteen tailed bandage is in some cases very great, as in compound fractures, because to replace it the fractured limb must be completely raised up, whereas if the strips be separate they can be changed without exposing the patient to this painful resource, by pinning the clean strip to the end of each one which is to be removed, and drawing it gently under the limb;— by attentions like this, a skilful surgeon is often enabled to spare his patient a great deal of suffering, and there- fore it ought not to be considered as a subject of trifling importance. The principal instances in which the ban- dage of strips is proper have been already noticed, but I would now recommend it iu all cases in which frequent examinations of the state of a part may be advantageous, and in which the dressings are to be often changed ; it unquestionably in such cases is extremely convenient. 38% ELEMENTS OF SURGERY. The roller is a long bandage rolled up for its conve- nient application. The part rolled up is called its head, and surgeons with more ingenuity than science have com- plicated this simple bandage by rolling it with a double head, and even with four heads. The simple bandage called a single headed roller may be applied with great ease to any purpose which can be accomplished by these more complicated methods. The circular, spiral, unit- ing, retaining, and expellent bandages are names applied to the roller in consequence of the manner in which it is applied and of the purposes it is intended to answer. The art of applying a roller neatly to every part of the body is readily acquired by practice. I shall describe the mode of bandaging a leg, and when the student has sufficiently practiced these directions he will have no difficulty in applying a common roller to every other part of the body. The application of a roller to the leg is to be com- menced bv a few turns round the foot. The surgeon is then to carry the head of the roller over the instep, so as to unroll part of the bandage, and apply it just above the heel. It is next to be brought over the inner ankle, thence over the instep, and under the sole of the foot. From this place it is brought again round the foot to the outer part of the leg. After which it is to be carried round the leg by circular turns, ascending gradually in a spiral manner so that each turn of the bandage shall cover about one third of the turn immediately below it. The shape of the leg renders this business difficult enough to expose the unskilfulness of a surgeon not ac, customed to the operation, because when the bandage reaches the calf of the leg it becomes necessary to dou- ble back the roller to prevent it from becoming uneven, or ascending too high, so as to leave part of the skin uncovered—a manoeuvre requiring some address. This ELEMENTS OF SURGERY. 383 fold or reversing of the roller is to be repeated as often as the shape of the limb may render it necessary, and the roller is gradually carried up to the knee. The head may be bandaged by means of a roller car- ried round it in different directions, or by neatly tying a handkerchief about it. The T bandage which has been more than once re- ferred to, is generally used for covering the trunk of the body and parts in the vicinity of the organs of genera- tion. It consists of two bandages united together at right angles. Mr. John Bell remarks that this is the peculiar bandage of the body. " If the breast or belly be wounded we make the circular (the part which sur- rounds the abdomen) very broad which serves as the proper bandage of the body, and we split the tail part, and passing one leg over each side of the neck we pin it to the circular, so that it forms a suspensary for the main bandage which prevents it from slipping down. But if we have a wound or disease on operation near the groin or private parts, the tail part becomes then the most important part of the bandage; then the circular is smaller and goes round the pelvis while the tail part is made very broad. When the disease is in the private parts, perineum, or anus, we often split the tail accord- ing to circumstances, but when the disease is in one groin we generally leave the tail part entire and broad." For many judicious remarks on bandages the reader is referred to Bell's Principles of Surgery. 384 ELEMENTS OF SURGERY. CHAPTER LXVI1. Of Opening Dead Bodies. In a new country new diseases, and old diseases under new aspects, may be expected to arise. This affords an incentive to the study of morbid anatomy, in addition to the numerous advantages which medical science has al- ready derived from that source. An instinctive horror of dissecting the dead appears to pervade the whole human family, and in civilized coun- tries this aversion is so great as to afford a powerful obsta- cle to the improvement of the healing art. Enlightened reason, however, is making a rapid improvement in this respect, and the importance of dissections begins to be acknowledged amongst all ranks of society. In Europe the surgeon is frequently requested to examine dead bo- dies, and in America permission to do so is not often de- nied. It is therefore highly necessary that he should be well acquainted with the methods of conducting his ex- aminations in the most satisfactory manner. Morbid action it has been remarked by Dr. Baillie, is a very different thing from morbid structure; dissection which detects the latter, throws no light upon the for- mer, and hence the surgeon derives a caution not to hazard an opinion as to changes of structure, before death, unless there be very palpable evidence of the fact. I have examined a body in which there was almost every diag- nostic symptom of an organic affection of the heart, and all these symptoms probably arose from dyspepsia, as there was nothing unusual in any of the viscera. ELEMENTS OF SURGERY. 385 Another introductory remark I beg leave to offer which »s, that to ascertain the effects of disease on the animal structure, it is essential that its healthy coudition be well understood. No person therefore but an anatomist, one who is acquainted with the natural appearances of the various parts of the body, can be competent to such in- vestigations. To illustrate this, it may not be improper to mention one or two very common mistakes to which the unpracticed dissector is liable. He confounds coa- gula in various places with polypi. A coagulum in the heart or larger vessels is in his view a polypus. He mistakes natural, for diseased productions; the plexus choroides I have known to be magnified into a morbid ad- hesion; the glands of Pacchioni are sometimes con- sidered as scirrhous indurations, &c. But perhaps a more frequent mistake than any other has arisen from want of attention to the position of the body. The blood never fails to settle and stagnate in depending parts, and hence in general the back of the patient becomes purple and black, resembling those petechiae which are symp- tomatic of malignant fever. A young gentleman once supposed he had discovered a symptom of yellow fever which had escaped the notice of all the writers on the subject, a gangrene of the scrotum! Ilis discovery like many other discoveries depended on his ignorance of common appearances. . The scrotum being a depending part, is often black from stagnated blood. The surgeon is occasionally called on by the officers of government to ascertain by dissection the cause of death. In these cases, and in every instance in which his opinion can affect the life of a suspected criminal, too mu&n caution cannot be urged upon him. Very distressing accidents having sometimes arisen from wounds or punctures of the fingers in dissections, the surgeon should be careful to avoid such injuries. vol. 11. 3n 386 ELEMENTS OF SURGERY. The instruments necessary in the examination of dead bodies are scalpels, a saw, and strong elevator or chisel, needles, ligatures, and sponges. Care should be taken to avoid soiling the shroud and coverings of the sub- ject, and the utmost decency should mark the whole operation, every unnecessary exposure being carefully avoided. It is proper to make the external incision in such si- tuations as not to disfigure the corpse—of course in parts concealed from view. OF OPENING THE HEAD. When the head is to be opened for anatomical inspec- tion, it is to be elevated on a block placed behind the neck, and firmly held in that position by an assistant. An incision should be made through the scalp, from one ear to the other, and the scalp dissected and revert- ed forward and backward so as to expose the cranium; the temporal muscle is to be divided where it covers the temporal bone in such a manner that it may not interfere with the action of the saw. The cranium is next to be divided with a common amputating saw as nearly as possible in a straight line, beginning just above the fron- tal sinuses, and continued horizontally around the cra- nium ; the dura mater should be avoided as carefully as possible, but it is scarcely practicable to prevent its be- ing injured in some places. With the elevator, or what is better a strong chisel, the cranium is to be separated and the external surface of the dura mater examined. This membrane is to be next divided iu a line corresponding with that by w*tiich the bone had been sawed; at the falciform process it will adhere, but the brain will become exposed by lift- ing up the lateral portions of the dura mater, and the pia mater can then be examined; the substance of the brain ELEMENTS OF SURGERY. 387 and its ventricles are best exposed by horizontal sec- tions, and if necessary, the falx can afterwards be cut loose, and the whole contents of the cranium inspected. The blood being removed with a sponge the brain is to be replaced, the cranium laid over it, the scalp drawn into its natural situation, and by means of an armed needle it is to'be there retained by the common glover's suture. OF OPENING THE THORAX AND AUDOMEN. When the great cavities are to be examined an incision is to be made through the integuments from the top of the sternum to the navel, and from thence continued to the anterior superior spinous process of each os ilium, or rather below them.* The integuments and muscles are then to be dissected from the thorax until the car- tilages of the ribs are exposed, and these are to be di- vided near the ribs by a strong knife; the diaphragm is to be separated beneath, the lower part of the sternum is to be elevated, the mediastinum cut from it, and an inci- sion is now to be made across the upper end of the ster- num in order to divide the strong ligamentous matter which gives it strength; when this is done it can easily be broken through and turned upwards in such a man- ner as to expose the contents of the thorax. If, however, the upper part of the thorax is to be care- fully examined, it will be found more convenient to sepa- rate the cordiform portion of the sternum from the clavi- cles, and in this manner to expose the whole cavity of the thorax. In opening the abdomen some caution is ne- cessary in dividing the peritoneum, because when the in- testines are distended with flatus they are very apt to he opened unnecessarily by a hasty or careless incision; when the peritoneum is punctured at one place, two fin- * The crucial incision usually made, occasions more exposure than is neccs- savy and therefore should be laid aside. 38S ELEMENTS OF SURGERY. gers should be introduced into the aperture, and the in- cision completed by cutting outward between these two fingers. The cavities being in this manner laid open, their re- spective viscera will be subjected to inspection, and this being completed, ligatures are to be tied round any of the viscera or larger vessels which may have been di- vided, and the parts replaced in their natural situation, are to be kept so by the glover's suture. When it is in- tended to remove the morbid parts in order to preserve them, great caution is necessary in the dissection, and it is best to take along with the affected parts some portion of the surrounding substance which can be subsequently dissected off with neatness and caution. In examining the throat and fauces an incision should be made from the chin to the sternum; and the pharynx, larynx, tongue, and parts adjacent, are to be brought out and inspected at this incision, after which they are easily replaced, and the skin being neatly closed with the common suture, the body will not be disfigured by the examination. In the dissection of other parts the best general rule which can be given, is to make incisions sufficiently ex tensive to answer the end, and to make them as much as possible in places not exposed to view. I shall conclude this subject by remarking that no anatomical investigation should be commenced until the death of the subject is absolutely certain. The signs of death are foreign from my present subject, but coldness and putrefaction are among those which should be pre- sent before any human corpse is subjected to dissec- tion. FINIS. W. Brown, Printer, Cfcurch Alley. 1213 V.JL