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SECONB EDITIOW WITH ADMTJIOH'S/
ji?
VOL.. II.
         for want of timely care
Millions have died of medicable wounds.
ARMSTRONG.
I
PENNSYLVANIA iiOSPITAL.


P HIL AD 1£U»HI A

Published by K.& R.Parker & Bemauiiu \\aryer.
^ o r n> ''
f 
 
2En>ismsM
OF
   SURGERY:


                    FOR,


       THE USE OF STUDENTS;


               WITH PLATES.


                     BY


       JOHN SYNG DORSEY, M. D.
                     »*»
PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA,
   ONE OF THE SURGEONS TO THE PENNSYLVANIA HOSPITAL,
       AND TO THE PHILADELPHIA ALMS HOUSE, &C.

             IN TWO VOLUMES.
SECOND EDITION, WITH ADDITIONS.
VOL. II.
......................for want of timely care
Millions have died of medicable wounds,
                       Armstrong
               PHILADELPHIA *.

PUBLISHED BY EDWARD & RICHARD PARKER, No. 178, AND
    BENJAMIN WARNER, No 171, MARKET STREET.  *
1818. 
DISTRICT OF PENNSYLVANIA, to wit :
    Be it  rememhered, That on the twenty-first day of September, in the
forty-third year of the independence  of the United  States of America, A. D.
1818, Edward & Richard Parker, and Benjamin Warner, of the said District,
have deposited in this office the title of a book, the right whereof they claim
as proprietors, in'the Words following, to wit:

  "Elements of Surgery: for the use of Students; with Plates. By John Syng
    " Dorsey, M. D. Professor of Anatomy in the University of Pennsylvania,
    " one of the Surgeons  to the Pennsylvania Hospital, and  to the Philadel-
    " phia Alms House, &c. In two volumes.  Second Edition, with additions."
  In conformity to the act of the congress of the United States entitled,«« An
Act for the Encouragement of Learning, by securing the copies of Maps, Charts,
and Books, to the authors and proprietors of such copies during the times
therein mentioned." And also to the act, entitled, " An Act supplementary to
an Act, entitled, " An Act for the Encouragement of Learning, by securing the
copies  of Maps, Charts, and Books, to the authors and proprietors of such
copies  during the times therein mentioned," and extending the  benefits thereof
to the arts of designing, engraving, and etching historical and  other prints."
                                                D. CALDWELL,
                                  Clerk of the District of Pennsylvania, 
CONTENTS* OF VOL. H.
                    CHAPTER I.
Of Scirrhus and Cancer,
      Operation,      -
                    CHAPTER II.
Of fungus hematodes,   -
                    CHAPTER III.
Of hernia,
                    CHAPTER TV.
Symptoms of reducible hernia,  -
                    CHAPTER V.
Symptoms of strangulated hernia,
                    CHAPTER VI.
Treatment of reducible hernia,
                    CHAPTER VII.
Treatment of irreducible hernia,
                  CHAPTER VIII.
Treatment of strangulated hernia,
           1. Of the  taxis,
           2. Of blood-letting,
           3. Of the warm bath,
           4. The tobacco clyster,
           5. Cold applications,
           6. Opium,   -
           7. Cathartics,
     Vol. II.                A 
11                      CONTENTS.
                                                     Page
                     CHATTER IX.
Of inguinal hernia,   -      -       -      -       -      59
       Operation,     -             -      -             66
                     CHAPTER X.
Of mortified intestine,        - '*%           -       -      79
                     CHAPTER XI.
Artificial anus,     -       -       -                    90
                    CHAPTER XII.
Of femoral hernia,1                                       93
       Operation,   -       -       .      -       -    103
                   CHAPTER XIII.
Exomphalos, or umbilical hernia,    -       -       -    114
       Operation,   -       .      -       -       -    117
                   CHAPTER XIV.
Of ventral hernia,   -       -       _      _       -    123
                    CHAPTKR XV.
Of hernia congenita,         -       -      -       -    124
                   CHAPTER XVI.
Of hydrocele,        -       -      -      -       -    126
       Treatment,  -        -      -       -       -    130
       Of the palliative cure,       -      -       -      ib.
       Of the radical cure,   -       -      -  ■     -    132
                   CHAPTER XVII.
Of hematocele,     -       -       -      -       -    137
                   CHAPTER XVIII.
Of varicocele and circocelc,   -      -       -       -    138
                   CHAPTER XIX.
Of strictures in the  urethra,   -       -      -       -    140
       Treatment,  -       -       .      _       -    144
                    CHAPTER XX.
Of fistula in perineo,   -      -      -       -       -151 
                      CONTENTS.                     Jli
                                                   Page
                   CHAPTER XXI.
Of retention of urine,        -      -       -       -     155
                   CHAPTER XXII.
Of tapping the bladder,      -     •  -       -       -     166
      Of the puncture above the pubes,    -       -      ib.
      Of the puncture through the rectum,        -     168
                  CHAPTER XXIII.
Of stone in the bladder,      -       -       -       -     170
      Operation,   -      -       -       -       -     176
                   CHAPTER XXIV.
Of fistula in ano,    -      -      -      -      -    186
      Treatment,   -      -       -      -      -    187
                   CHAPTER XXV.
Of hemorrhoids,      -      -      -      -      -191
                   CHAPTER XXVI.
Of prolapsus ani,    -      -      -      -            194
                  CHAPTER XXVII.
Of aneurism,        -      -      -      -      -     197
      Treatment of true  aneurism,       -      -     201
      Popliteal aneurism,  -                          204
      Femoral and inguinal aneurism,    -      -     206
      Aneurism of the carotid artery,     -      -     212
      Aneurism of the axillary artery,    -      _    220
      Tying the arteria innominata,      -      -     225
      Tying the aorta,    ...      -    226
                  CHAPTER XXVIII.
Of false aneurisms,   -      -      -      -      -     251
                   CHAPTER XXIX.
Of mammary abscess,       -                          264
                   CHAPTER XXX.
Abscess of the hip joint,     -                          266
       Treatment,   -----     ^gg 
1Y
CONTENTS.
                                                 Page
                  CHAPTER  XXXI.
 Lumbar, or psoas abscess,    ...      -   270
       Treatment,   -----   271
                 CHAPTER XXXII.
 Of curved spine,     -      -       -      -      -   274
                 CHAPTER XXXIII.
 Of paronychia, or whitbiv,  -                        892
       Treatment,  -      -       -      -          293
                 CHAPTER XXXIV.
 Of amputation of the limbs,  -                        295
                 CHAPTER  XXXV.
 Amputation of the thigh,     -                        299
                 CHAPTER XXXVI.
 Amputation of the leg,      -                        304
                 CHAPTER XXXVII.
 Amputation of the arm,      -                        307
                CHAPTER XXXVIII.
 Of amputation at the shoulder joint,   -      -      -    308
                 CHAPTER XXXIX.
Amputation at the hip joint,  -       -      -      -    321
                   CHAPTER XL.
Amputation of the fingers and toes,   -      -      -   335
                  CHAPTER XLI.
 Of hemorrhage after amputation,     -  .    -      -    336
                 CHAPTER XLII.
Of spasms of the stump,     -                        340
                 CHAPTER XLIII.
Extirpation of tumours,     -       -      -      -    341
                 CHAPTER XLIV.
Of warts and corns, -      -       -      -          346 
                      CONTENTS.                     V
                                                   Page
                  CHAPTER XLV.
Of the inverted toe nail,      ....    348
                  CHAPTER XLVI.
Of paracentesis abdominis,   -      -      -      -    350
                  CHAPTER XLVII.
Paracentesis thoracis,        -      -      -           35S
                  CHAPTER XLVIII.
Of blood letting,     .       .      -                  355
      Plebotomy,   -----     ib.
      Arteriotomy,        -                         358
      Cupping,     -       -      -      -      -     ib.
      Leeching,    -----    359
                  CHAPTER XLIX.
Of ulcers,   ------    360
                    CHAPTER L.
Of inflamed ulcers,   -      -       -      -      -    370
                    CHAPTER LI.
TJie fungous ulcer,  -----    372
                   CHAPTER LII.
Of ulcers in cedamatous limbs,      -      -           374
                   CHAPTER  LIU.
The sloughing ulcer,        -      -      -      -    376
                   CHAPTER  LIV.
Of indolent ulcers,   -----    378
                   CHAPTER LV.
The carious ulcer,   -       -      -      -      -    384
                   CHAPTER  LVI.
Ulcers attended with varicose veins,  -      -      -    386 
?1
iSONTENTS.
                                                     Page
                   CHAPTER  LVII.
 Ulcers attended  with specific diseased actions, -       -     394
       1. Of those ulcers which yield to  mercury,        ib.
       2. Of ulcers  which yield to the different prepa-
         rations of the conium maculatum, or hemlock,    396
       3. Of ulcers  which yield to  the  application of
         salt water,        ....     398
       4. Of ulcers which yield to the use of the argen-
         tum nitratum,     -                           399
       5. Of ulcers that yield to the  use  of arsenic,      403
                   CHAPTER LVIII.
 Of caries,   ---__.    408
      Treatment,   -      -       -       -       -412

                    CHAPTER LIX.
Of necrosis,  -      -       -       _       _        -417
      Treatment,   -       -       -       -        -    425
                    CHAPTER LX.
Of setons and issues,       _       -       .        -    428

                    CHAPTER LXI,
Of malformations,   -      -       _       _        -    432
      Of hare-lip,   -      -       -       -       .     ib.

    -*              CHAPTER LXII.
Of club foot,        -----    436
                   CHAPTER LXIII.
Of spina bifida,      -      -       _       _        -    441

                   CHAPTER LXIV.
Of imperforate anus,        -       .       .        .445
                   CHAPTER LXV.
Of imperforate vagina,      -                          44S
                   CHAPTER LXVI.
Of the Cesarean operation,  .                          455 
                      CONTENTS.                    VU
                                                   Page
                  CHAPTER LXVII.
On the division of the symphysis pubis,       .       -    460
                 CHAPTER LXVIII.
Of prolapsus uteri,   -----    463
      Treatment,   -----    464
                  CHAPTER LXIX.
Of bandages,        -----    466
                   CHAPTER LXX.
Of opening dead bodies,      -                        470 
 
ELEMENTS
          OF


SURGERY-
                       CHAPTER I.

                   Of Scirrhus and Cancer.

     A PAINFUL, incurable ulcer, results from the suppu-
     ration of certain indurated tumpurs.   The tumours are
     denominated scirrhous ; the ulcer is called cancer. These
     definitions (if they deserve the name) are by no means
     satisfactory, but it  is  not easy to  describe in a  few
     words, those  tumours which will  certainly  produce
     cancer,  nor  those  ulcers which  are decidedly can-
     cerous, except in particular cases.   The truth of  this
     remark will not be doubted by any person  who will take
     the  trouble to consult the  different surgical  writings
     which contain histories of cancerous complaints. There
     is perhaps no subject on which accurate  discrimination
     is of more importance, and none in which it  is made
S    with more difficulty.
 \     Scirrhus and cancer occur in every part of the body,
 j   glandular parts  are however much more liable to the
*    disease than  others.
       A true scirrhus,  before it degenerates  into a cancer-
\    ous sore, is  hard and  unequal on  its surface, slightly
 \   sensible to the touch, not tending to suppuration, and en-
         Vol. JL             B 
 2              ELEMENTS OF SURGERY.

 larging very slowly in its commencement; " but at length
 assuming a more active form,  it is surrounded with
 superficial varicose  veins,  it becomes  more painful,
 and changes the texture of the adjacent cellular mem-
 brane  or cuticular covering, to which it frequently ad-
 heres : the skin will, in this advanced period, sometimes
 be discoloured, and puckered or retracted, especially in
 the female breast* perhaps  attended  with a degree of
 softness or fluctuation in some part of the tumour, with
 shooting pains in its  neighbourhood; and at  last break-
 ing into  a malignant sore, with fungous flesh, and re-
 troverted edges; it is named an open cancer."
  The progress of the disease is not  always equally ra-
 pid ; in some cases a scirrhous tumour remains for many
 years indolent, and  in other instances it ulcerates in a
 few weeks after it is  first noticed.
  It is always satisfactory to ascertain, if possible,  the
 nature of a tumour after it is removed. The appearance
 of a scirrhous tumour has been very well described by
 Mr.  Home.  " When a section  is made of such a tu-
 mour in an early stage, provided the structure can be
 seen to advantage, it puts on the following appearance :
 the centre is more compact, harder to the feel, and has a
 more uniform texture than the rest of the tumour; and is
 nearly of the consistence of cartilage.   This middle part
 does not exceed the size of a silver  penny: and from
this, in every direction, like rays, are seen ligamentous
 bands of a white colour, and very narrow;  looking, in
the  section like so many extremely irregular lines, pass-
 ing to the circumference of the tumour, which is blend-
 ed with the substance of the surrounding gland. In the
 interstices, between these bands, the substance is differ-
 ent  and becomes less compact towards the outer edse.
 On  a more minute examination, transverse ligamentous
 bands of a fainter appearance, form a kind of net-work, 
ELEMENTS OF SURGERY*.
3
in the mashe* of which the new-formed substance is in-
closed.   This structure accords with what Dr. Bailley
describes to  be the  case, in cancerous diseases of the
stomach and  uterus.
   " In a further advanced stage of the tumour, the whole
of the  diseased part has a more uniform structure; no
central point  can be  distinguished; the external edge i*
more defined, and distinct from the surrounding gland:
and the ligamentous bands, in different directions, are
very apparent, but do not follow any cpurse that can be
traced.
   " When the tumour has advanced to what may be called
cancerous suppuration, which, however, does not always
happen in the centre, before it has approached the skin,
and formed an external sore; it then  exhibits an appear-
ance totally different from what has been described. In
the centre is a small irregular cavity,  filled with a bloody
fluid, the edges of  which  are ulcerated,  jagged, and
spongy.   Beyond  these, there is a radiated appearance
of ligamentous bands, diverging towards the circumfer-
ence; but, the tumour near the circumference is more
compact, and is made up of distinct portions, each of
which  has a  centre, surrounded by ligamentous bands,
in concentric  circles.
   66 In  some  instances, the scirrhus  has no appearance
of suppuration, or ulceration in the centre, but consists
of a cyst, filled with a transparent fluid, and a fungous
excrescence,  projecting into  this cavity,  the  lining of
which is smooth and polished.  When a large hydatid
of this  kind  occurs, a number of very small ones have
been found, in different parts of the same tumour; and,
in other cases, there are many very small ones of the
size of a pin's head, without a large  one.  These hyda-
tids are certainly  by no means, sufficiently frequent in 
4              ELEMENTS OF SURGERY.
their occurrence to admit of their forming any part of
the character of a cancerous tumour."
  In some cases cysts exist of various forms and sizes,
and in different parts of the tumour ;  a late writer (Dr.
Adams) pronounces these to be living hydatids. When
tumours are extirpated exhibiting these appearances, we
may rest assured that they would never have been dis-
cussed and  in all probability would have advanced to
the state of true and  malignant cancer.
   We are not however always able to prediet what tu-
mours will become so, and what particular tumours may
remain unsuspected.   Mr. Home with great and com-
mendable candour remarks, that so much does the
same  disease differ  in its appearance in different pa-
tients, from the almost endless peculiarities of their con-
stitutions, by which every part of their bodies must be
more  or less influenced, that it is not possible in prac-
tice to distinguish, in all cases, between  cancerous and
scrofulous tumours,  after they have advanced  to a cer-
tain stage, and  he confesses that he  has in many in-
stances mistaken the one for the other, and has removed
by operation tumours, w hich at the time had the appear-
ance  of being cancerous, but which  upon examination
after their removal were found  of a scrofulous nature;
and,  on the other hand, he has neglected to remove tu-
mours, from circumstances making it probable that $iey
were  scrofulous, which afterwards  became cancerous
and destroyed the patient.
   Although surgeons generally have not confessed their
mistakes, yet the immense  disparity which appears in
the record of their  successes establishes the  fact that
Mr.  Home has not  been singular in  confounding can-
cerous  with other diseases.   Mr. Nooth, for example,
declares, that in one hundred  and two cases  in which
he extirpated scirrhus tumours, every patient remained 
ELEMENTS OF SURGERY.               5
free from a return of the complaint. Dr. Monro, on the
contrary states, that of sixty cancers which he had seen
extirpated, only four remained free of the disease for
two years, and these afterwards became cancerous.
   Mr. Hill, in his Cases of Surgery says, he had ope-
rated on eighty-eight genuine cancers, all ulcerated ex-
cept four, and all his patients except two recovered of the
operation;  ten however had the disease  afterwards in
other places.

   Among the  diseases resembling cancer, Mr.  Home
describes one by  which parts of a glandular nature are
often attacked, as the alra of the nose, the os tincse and
the glans penis;—this differs from cancer in not contami-
nating the surrounding parts,  and in not affecting the
absorbent glands, nor the skin at a distance; it is  pro-
perly speaking an eating  sore which is uniformly pro-
gressive ; wrhereas  in cancer,  after the  sore has made
some progress, a ridge is formed upon the margin, and
the ulceration  no longer takes that direction.  It also
differs from cancer in admitting of a cure in many in-
stances, and under different modes of treatment.
   Cancer has by  many writers been considered  as  a
contagious disease, of this opinion there is how ever no
well  grounded proof.   Some facts have been recorded
 which prove disease to have resulted from the applica-
tion  of cancerous matter to sound parts, but no instance
 has  been produced in which a cancerous sore has been
 the consequence. Mr. Pearson who has treated this sub-
ject with great ingenuity, remarks, that " virulence and
 contagion are very different things ; the bite of a viper,
 or the sting of a scorpion, may poison a part by the ma-
 lignant  quality of the venom that ts injected,  without
 communicating a contagious disease, and the fluid taken
 from a pustule or an ulcer, may erode a part by its die- 
6
ELEMENTS OF SURGERY.
mical qualities, and yet the matter formed by this new
sore shall not possess similar properties with that which
produced the ulceration.  It is not sufficient therefore to
assert, that  the fluid of a cancerous sore occasioned an
ulcer in a sound person;  it ought to be proved that the
ulcer thus produced was truly cancerous."
  Cancer has  also  been  considered  an  hereditary dis-
ease. Mr. Home is inclined to believe that a predispo-
sition to cancer, depending on local peculiarities of struc-
ture, may be transmitted  from parents to, their descen-
dants,  and in  this sense  of the word, the disease is no
doubt hereditary. This idea originated with Mr. Hunt^
er who illustrated it by  observing that of fifty persons
who may receive  similar accidents in glandular parts,
not more than one or two will be afflicted with subse-
quent cancers.
  The disease occurs at  almost every  age; it is most
frequent, however,  in advanced life.  The  period  of
the cessation of the menses in women, is supposed very
obnoxious to cancer.  Dionis  says that  he saw  very
many women in the nunneries  of France, afflicted with
cancer, and that by much  the greater part were between
the ages of forty five and fifty, and that in those who
had cancers at  an earlier period the catamenia  were
either very irregular or had been entirely obstructed.
  The female  mamma is  perhaps the most frequent seat
of cancerous affections,  and as this part is liable to se-
veral other diseases, it may not be improper to describe
some, with which cancer has often been confounded.
   In some cases the whole substance of the mamma will
enlarge gradually till it acquires an enormous size, with-
out very acute pain; the  patient complains of great ten-
derness and soreness, but the greatest inconvenience is
derived from the bulk and weight of the tumour ; some-
times the swelling is attended with  considerable heat 
               ELEMENTS OF SURGERY.              i

and redness of the part and  symptomatic fever.  The
skin of the breast in many instances, is not at all disco-
loured, in some it is reddened.   This complaint is not
peculiar to married women but occurs  also in the sin-
gle.
  In these cases copious depletion, and antiphlogistic
measures, local and general,  must be  used,  cupping;
bleeding, purging, low diet, &c.   They generally suc-
ceed, but even if they do not leave the breast of its usual
size,  the swelling J*.as no cancerous tendency and  re-
mains without  any inconvenience being sustained, but
from its bulk and weight.  These, however, are in them-
selves serious evils, and the breast is sometimes removed.
to relieve the patient from them.   Under  such circum-
stances no doubt of a recovery need exist.
  A chronic inflammation sometimes occurs in the breast,
producing considerable deep seated pain;—a tumour is
felt very hard  and deep in the  substance of the mam-
ma ;—heat and throbbing are perceived, and sometimes
shooting pains through the diseased part;—the skin ge-
nerally retains its natural appearance, but if the disease
advances to  suppuration it becomes red and sore;—it at-
tacks young women chiefly, and without any exciting
cause being evident.   Very copious depletion will ge-
nerally prevent suppuration and relieve the patient.
Local and general bleeding with the usual antiphlogis-
tic means are to be tried, and if any hardness remain
after their use,  cicuta and mercury may be administer-
ed—and these generally produce a speedy absorption of
the tumour.
  The  breasts  of females like every other part of the
body are liable to scrofula.  Scrofulous tumours have
been described  by the  ancient  writers, under  the name
of spurious scirrhi: sometimes they commence so gra- 
8              ELEMENTS OF SURGERY.

dually as to assume many of the appearances of scirrhus.
but in general they may be distinguished.
  Where the skin only is affected no danger of scirrhus
exists.  In scrofula the  disease is more  diffused, the
skin soon becomes red, and the symptoms of inflamma-
tion are more rapid, and sometimes terminate very spee-
dily in suppuration.
  Where a number of tumours exist in the breast we
may pronounce them in most cases to be certainly scro-
fulous.
  Hydatids are sometimes foiyid  to  constitute the tu-
mours, which are removed as scirrhi,  these are not rea-
dily distinguished, and when extirpated there is no dan-
ger of a return of disease.
  Notwithstanding this,  it must be confessed that it is in
many cases very difficult, nay in the present state of sur-
gical knowledge, absolutely impossible to pronounce with
certainty, what cases are scirrhus  and what scrofulous.
This should induce the  surgeon  in  doubtful cases to
choose the safest side, and to extirpate those tumours
which have a suspicious aspect.
  It is not necessary to  say much of any remedy for
cancer except the extirpation of the diseased parts.  It
will be sufficient to  state  that  certain discutient, corro-
sive, and narcotic medicines,  from the vegetable, ani-
mal, and mineral kingdoms have been employed, most
of which have had a temporary reputation but do not at
this time retain the confidence of medical men.  The use
of narcotics is proper w ith a view to alleviate pain, and
corrosive medicines are sometimes employed to destroy
fungous flesh from the surface of the sore; discutient
applications, as has been already stated, have no effect
upon genuine cancer.
   The internal  use of arsenic has  lost its character as a
remedy for cancer,  and  preparations of iron, a fashion- 
               ELEMENTS  OF SURGERY.              9

able substitute, lately introduced by Mr.  Carmichael,
will no doubt speedily share the same fate.
  The best mode of abating the pain of cancer is by a
very abstemious diet; Mr. Pearson recommends a diet
so low, as barely to support life,  such as barley water,
tea,  &c.   A milk and vegetable diet has relieved the
agonies of many cancerous patients.
  As local applications I subjoin the following list from
the article Cancer in Rees' Cyclopedia.—Fresh bruised
hemlock leaves.T-Scraped young carrots.—The ferment-
ing poultice.—Finely levigated chalk.—Powdered char-
coal.—Carbonic acid gas.—A watery solution of opium.
—Liquid tar, or tar-water. The internal remedies which
have been  most beneficial are—Very small and long
continued doses  of arsenic.—Liberal doses of cicuta.
—The  free use  of opium.—Belladonna.—Solanum.—
Martial flowers.—Corosive sublimate.—The  juice  of
clivers or goose-grass.   But neither the external nor in-
ternal remedies, however  apparently useful for a time,
can be in the least depended  on for the cure of a ge-
nuine confirmed cancer.
   Where the  operation is concluded on,  it should be
performed early, for authors agree that where the poison
is absolutely formed, and the neighbouring parts conta-
minated, the prospect of success is greatly diminished,
and in cancer of the breast where the glands of the axilla
are  affected, Mr. Cline and Mr. Home declare  it too
late to perform the operation  with any " assurance  of
success."*—But experience warrants us in differing from
the  gentlemen whose names have been mentioned.  In
this country Dr. Physick has extirpated the breast in se-

  * It is here necessary to state that the glands of the axilla may be enlarged
from sympathy, in which case they vary in size at different times j where they
are contaminated by the poison they gradually and uniformly increase, and the
knife is often useless.  To the latter case th# present observations refer.
     Vol.  II.             C 
10             ELEMENTS OF SURGERY.

Veral instances  in which the glands of the axilla have
been affected, and he has applied ligatures so as to eradi-
cate these also.   In some cases the disease has returned,
but in several he has had the satisfaction to believe that
life has been prolonged by the operation, and at the ex-
piration of several years his patients remain free from all
disease.
  Two methods of extirpating tumours are in use. The
knife and caustic. The advantages of the former are very
great;  the surgeon has it in his  power to remove the
whole of the diseased parts from  the healthy, and the
diseased may be discriminated in the course of his inci-
sions, but with  caustic it is impossible to judge precisely
what parts will  be removed.  If,  however, from the great
terror of surgical operations which exists in some patients,
or from any other cause, the caustic be preferred, Mr.
Home recommends a preparation of equal parts of white
arsenic  and  sulphur.
  When the knife is to be used, the following are en-
couraging circumstances :—First,  Where the  diseased
parts are so situated as that they may be removed with-
out wounding any large blood-vessels and nerves,  and
where the whole of them may be completely eradicated.
Second, Where the disease has resulted from accident,
and has not occurred spontaneously.   Third, Where
the patient is in good general health.   Fourth, Where
the disease  is slow in its progress, and has not contami-
nated the surrounding parts.

    OF  THE  EXTIRPATION OF CANCEROUS BREASTS.

   Previously to the operation,  the parts should be  ex-
amined with great attention, in order to ascertain the ex-
tent of the disease, and the  surgeon in this, as in every
operation for the removal of cancerous parts, should not 
ELEMENTS OF  SURGERY.
14
merely cut away the parts already indurated and diseas-
ed, but  likewise some portion of the surrounding sub-
stance in which a  diseased disposition may probably
have been excited.
  In performing the operation the patient is to be seated
in a chair in a good light.   If the skin be sound,  aud a
tumour only exists in  the breast, a straight incision may
be made through it, and the diseased part dissected out.
But if it is determined that a part of the skin should be
removed with the tumour, two incisions are to be made,
forming an oval figure between  them, in  which all the
skin to be taken away, is  included; and as dividing the
skin is the most painful part of the operation, both these
incisions should be completed before any thing else is
done; and the lower part  of the  skin should be divided
first, since, if a wound is  made  in the upper part, the
effused  blood  covers  the  skin below, and prevents the
surgeon from seeing accurately where the second incision
ought to be made.   These incisions should be nearly in
the direction of the fibres of the pectoral muscle.   If the
glands in the axilla are diseased, the incision should be
high enough in that direction to  allow of  their removal
with the tumour.   The best way to do this is to dissect
the diseased breast out first, and then to dissect upwards,
without cutting it off,  and  detach the hardened lympha-
tics and glands in the arm pit which will be pulled down
by the wreight of the tumour, and thus the operator will
be  enabled to  extirpate them more  conveniently.  As
soon as the fingers  can be passed above  the indurated
axillary glands, they are to be cut off, but before this, the
cellular membrane connecting them above is to be tied by
a firm ligature, to prevent hemorrhage from any vessel
that may be contained in  it.  This direction is of the
utmost importance; for if  it be  neglected, the vessels
will retract so high into the axilla, that the surgeon will 
it
ELEMENTS OF SURGERY.
be unable to secure their orifices.  When the tumour is
taken out, the bleeding vessels should very carefully be
tied, and the edges of the wound brought into contact,
and kept so by adhesive plasters and compresses, so that
as much as possible of the wound may unite by the first
intention.   The ligatures are to be left out at the angles
of the wound.
  Scirrhous tumours sometimes form in  the neck,  and
when they are deeply seated great hazard attends their
removal; in general, however, the tumours found in the
neck are of a scrofulous, and  not a cancerous nature.
Mr. Pearson denies that the absorbent glands, which are
found indurated under the lower jaw, are in any  case
scirrhous,  unless they have been contaminated by  can-
cerous ulcers of the lip, tongue, or fauces.  In some ca-
ses it is necessary to remove them,  even when they are
evidently not scirrhus, on account of their impeding the
functions of respiration and deglutition, or because  they
compress the blood-vessels of the neck :  no unpleasant
consequences result from their  extirpation, and the chief
caution necessary is to avoid wounding the vessels.

  The parotid  and  submaxillary glands are often
the seat of true  cancer.  The nose and other parts of
the face are also occasionally attacked by cancerous ul-
cers.  The term noli me tangere has been applied to
some of these complaints.  The ulcers described by dif-
ferent writers under this name, are so very various, that
it is  certain they have attached no precise idea to  their
definition.  One author describes it  as a disease of the
nose exclusively.*   Others have seen it  on the legs and
arms.  The term lupus has been attached to it when in
these latter situations.  I am persuaded that the disease
recently described by Mr. Hey and Mr. Burns under
                      • Cooper. 
elements of  surgery.
13
the titles of fungus hematodes, and spongoid inflam
mation, are of the same nature, as many of the cases de-
nominated by the older writers noli me tangere.
  In many of these ulcers on the face, as well as in
other situations, fungous granulations arise to a very great
height, and their growth is in  some cases so rapid  that
Wiseman asserts  it to be obvious to the eye.  The ap-
plication of caustic has proved successful in some cases ;
where the whole of the diseased parts can lie completely
extirpated by the knife, they should be removed.   In
general, however, when the parotid gland is affected,
this cannot be done, and the attempt will only aggravate
the disease, and hasten its progress.

   Cancer of the tongue is unusual, but is occasional-
ly met with; Mr. Home has seen two cases of it, one of
which occurred in a gentleman between fifty and sixty
years of age.  Upon dissection after death, a large gland
was found under  the coronoid  process of the lower jaw,
weighing two  ounces  and a half,  all the lymphatics in
the vicinity were  diseased, and the cancer extended to
the pharynx.  As cancerous ulcers are probably in the
present state of our knowledge incurable, and always
unless  the diseased parts are removed, terminate fatally,
we should not hesitate to extirpate the tongue when af-
fected  with cancer;  the  mode of effecting  this has al-
ready been described, it is however proper to add,  that
from the testimony of Desault and others, we learn,  that
patients in  whom great portions of this important organ
have been removed,  have not entirely lost the power of
speaking intelligibly.

   The  rectum is sometimes affected with scirrhus  and
cancer, no cases of recovery from this complaint are re-
corded.  Opiate clysters, and opium, introduced in form 
14
ELEMENTS OF SURGERY.
of pills into the rectum  give great relief.  The ulcera-
tion, in a case described by Mr. Home, extended through
the bladder, and faeces were voided with the urine.

   The tunica vaginalis  testis has been found can-
cerous.  Mr. Hunter once extirpated nearly the whole
of it in a scirrhus state.

   The bladder  is liable  to cancer.   Gooch  relates a
case in which the bladder of a boy, only eight years of
age, was affected with  scirrhus,—he died,—and upon
examination, the bladder was found thickened  and con-
tracted, so as to resemble «the gizzard of a fowl," and
was incapable of containing  more than a spoonful of
urine ; it contained two calculi.

   Cancer of the penis is not unfrequent,  it commences
usually with a wart or tubercle on the prepuce, frenum,
or  glands.    This often remains quiescent for  many
years, but if irritated becomes painful, increases in bulk,
and attains in a short time a very large size.  Ulceration
takes place  attended with a discharge of  fetid sanies.
When the ulcer continues long, the urethra is exposed
and fistulous openings form, through which the urine
flows, and the disease is  aggravated.   The glands in the
groin and upon the ossa pubis are affected, and the dis-
ease extends in their course.   To distinguish  venereal
warts from those tending to cancer is in general not diffi-
cult ; and when the cancer exists, the penis should be
removed before contamination is gone too far.
   Mr. Hey has  published  seven cases of  cancer penis,
in six of which the patients had a natural phymosis.  He
remarks that the occurrence is extraordinary if it have no
connection  with the disease.  In six  of these cases Mr. 
ELEMENTS OF SURGERY.
15
Hey effected a cure by amputation.   In the seventh the
disease recurred.
  The amputation of the penis is to be performed when-
ever the disease is evidently of a cancerous nature.  The
operation is very simple, a circular incision is to be made
through the skin, with a bistoury at some  distance (half
an inch if practicable) from the diseased part, the skin is
to be drawn back a little, and the body of the penis cut
through with one even stroke of the knife, at the part to
which  the skin has been retracted.   The  bleeding ves-
sels are then to be secured with ligatures.   Three prin-
cipal vessels are to be looked for, one on the dorsum pe-
nis,  and one in each corpus cavernosum.  An elastic
catheter is  now to be  introduced into the  urethra, and
the skin drawn forward so as to cover the stump, and
secured in  this situation with strips of adhesive plaster.
The catheter is objected to by Mr.  Pearson, but in some
cases where it has been omitted the external aperture of
the urethra has been greatly contracted by the healing
of the  wound.   After the first dressing is removed, a
pledgit of simple cerate is to be applied and renewed as
often as may be necessary.
  Mr. Hey says that in  amputating the  penis  he has
found great advantage from having wrapped some tape
round  the  sound part; in this way he was enabled to
divide the integuments more easily and correctly, and he
was also furnished with a useful  kind of tourniquet,
which  secured the divided vessels from bleeding, till he
was prepared to take them up with  the tenaculum and
ligature. He remarks, that " it requires great care to se-
cure the larger arteries, as they are apt to shrink and
conceal themselves under the loose integuments to which
they have no strong attachment."

  Cancer of the uterus though a rare, is a deplorable 
16
ELEMENTS OF SURGERY.
and hopeless case.   The use of all irritating injections
is improper.  The greatest benefit will be derived from
a strict adherence to a very low diet.  Pain is to be re-
lieved by the administration of opium.  I have relieved
the pain in one case very considerably by injections of
warm barley water thrown up the vagina.  An aqueous
infusion of opium may be substituted if the barley water
should not answer the purpose.   Anodyne enemata are
also very often necessary.

  The scirrhous testicle is a  frequent disease, and
sooner or later ends in cancer unless extirpated.  Mr.
Potts'  description of this complaint is extremely accu-
rate  " When  the  testicle becomes enlarged in size,—
hardened in  texture,—craggy and unequal on its  sur-
face,—painful on being handled,—attended with irregu-
lar  pains  shooting  up the groin into the back, and this
without any previous inflammation, disease, or external
violence, the testicle is said to be affected with a scir-
rhous"—he further adds that in such  cases early castra-
tion may be recommended and practised by every honest
and judicious surgeon.
  If this is  neglected—hectic supervenes—ulceration
takes place—a fungus shoots out from the surface of the
testicle, and  the patient falls  a victim to the neglect of
his  case.
  There  are several diseases of the testis comprized
under the general name of sarcocele which it is impor-
tant to distinguish from cancer.   Hernia humoralis in
its  recent stage cannot be mistaken for scirrhus, but
after the acute symptoms subside  a great degree of indu-
ration  remains,  with an enlargement and unequal sur-
face.   The epididimis  often  continues hardened for
some months, but generally we are able to produce reso-
lution, or if the testicle even suppurates the abscess very 
ELEMENTS OF SURGERY.
17
readily heals without occasioning much general disease.
None of the symptoms of scirrhus exist in this case, as
the pain ceases and the hardness subsides.
  A  scrofulous tumour  of the testis  is described by
writers which exists either in  the spermatic cord, the
epididymis, or the body of the testicle. This may also be
distinguished.  Here the inflammation runs higher, and
comes  on more rapidly than in cancer, the system sym-
pathizes, and fever is produced, the pain is very obtuse,
and rather deserves the name of soreness than of pain.
This complaint gets well very readily in some cases, and
is reproduced by exposure to cold or intemperance, and
suppuration, with collections of  matter take place in va-
rious parts of the scrotum.
  A  disease  described  by Mr.  Abernethy under the
name of medullary sarcoma, may not improperly be no-
ticed here.  It has been called  soft cancer, and appears
to be as malignant and incurable as  that which has al-
ready been described.  The following case from Aber-
nethy's writings will convey a  clear  history of the dis-
ease.
  " A tall, thin, healthy-looking man, of about forty
years of age, had,  about fifteen  years before, a swelled
testicle from a gonorrhoea; the  epididymis remained in-
durated.    Six years afterwards it became enlarged, and
a hydrocele at the same  time formed.   Half a pint  of
water  was discharged  by a puncture, but inflammation
succeeded the  operation, and  tlie testis became very
large.   An abscess formed, and burst in the front of the
scrotum, and the testis subsided in some degree.   Mer-
cury was  employed to reduce it, but without effect. The
part,  however, was indolent, and gave the patient no
trouble but from its bulk.
   " About a year afterwards, a gland enlarged in the
left groin (the same side  as the  testis:) another thenbe-
     Vol. IT              D 
18
ELEMENTS OF SURGERY.
came swollen in the right groin, and, in the course of
two years, several glands in each groin had obtained a
very considerable magnitude.   At this period, he was
admitted into St. Bartholomew's Hospital, under  the
care of Mr.  Long.  The testis was at this time, between
four and five inches in length, and about three in breadth;
it resembled  its natural form and was indolent in its dis-
position.   The spermatic cord was  thickened, but not
much indurated.   Four or five glands were enlarged in
(he groin on both sides  ; each of which was of  the size
of a very large orange; and  when  observed together,
they formed  a tumour of very uncommon shape and mag-
nitude.
  " They gradually increased in size for several months,
till at last the skin appeared as if unable to contain them
any longer.  It becames thin, inflamed,  and ulcerated,
first in the left groin, and thus exposed one of the most
prominent tumours.  The exposed tumour inflamed  and
sloughed progressively, till it  entirely came away.  As
the sloughing  exposed its vessels,  which were  large,
they bled profusely, in  so much that the students endea-
voured, but  in vain, to  secure them by ligatures : for the
substance of the tumour was cut through, and torn away
in the attempt.   Pressure by  the finger,  continued for
some time,  was  the only effectual mode of restraining
this hemorrhage.
  " The loss of one gland relieved the distended skin,
which had only ulcerated in the most prominent part of
the tumour,  and  had not become diseased.   It now lost
its inflamed  aspect; granulations formed, and a cicatrix
took place.  In the opposite groin a similar occurrence
happened. One gland,  exposed by the ulceration of the
skin sloughed out,  being attended by the circumstances
just recited.  HoAvever, before the skin cicatrized, ulce-
ration had  again taken place  in the right groin, in con- 
ELEMENTS of surgery.
19
sequence  of the great distension of the skin from the
growth of the tumour, and sloughing had begun  in the
tumour, when the patient, whose vital powers had long
been greatly exhausted, died."
  Mr. Ramsden of London has recently published some
very valuable observations on certain diseases of the tes-
ticle.   In the preface to this work he attempts to  prove,
that genuine cancer of the testicle is extremely rare; that
most of the cases of sarcocele which have been mistaken
for it, arise from latent irritation in the urethra; he does
not deny  that the testicle is liable to scirrhus and to
sarcocele, both of which may lead to an untractable state
of ulceration, but he believes that "the malignancy of the
ulcerative stage of true scirrhus in  the testicle, does not.
as has been supposed, depend on the presence of any
morbid poison, but differs from the malignancy  of the
ulcerative stage of the common indurated testicle merely
with regard to the part of the gland in which irritation
causing its derangement has  been primarily established.
In illustrating this opinion, it is to be remarked that when
a testicle  is effected by true scirrhus, as it  is termed,
its morbid ulceration will be found to originate within its
organic structure; but when the gland becomes indura-
ted and enlarged, in consequence of exterior causes of ex-
citements, the morbid symptoms  are,  in  the  first in-
stance, entirely confined to the surrounding  or interve-
ning cellular substance.   And hence, alone, it is  that
scirrhous  is attended at an early period with a peculiar
sallowness of countenance, and other  symptoms  of de-
rangement in the system; while the common indurated
testicle will exist,  and frequently advance to a great ex-
tent, without at all interfering with  the general health of
the patient."
  There can be no question as to the propriety of  em-
ploying bougies  in order to dilate a stricture  of the ure- 
20             ELEMENTS OF SURGERY.

thra if it exist, but the extirpation of the testicle is not the
less necessary because the incurable disease has been
excited by  "a latent  principle  of irritation  in the
urethra."
  The testis is doubtless liable to very numerous dis-
eases, some  of which have never been sufficiently inves-
tigated ; one of these is an obstinate sinuous ulcer, which
resists every caustic application, and refuses to heal even
when all the diseased parts are, to all appearance, dis-
sected or  burnt out.  Another is  the fungous  tumour
which has lately excited some attention,  and on  which
Mr. Lawrence has recently published a paper which I
have not been able to procure.  This fungous tumour I
have known cured in a variety of cases, by the applica-
tion of white oxyd of arsenic (or arsenious acid) a reme-
dy, therefore, which I take the liberty to recommend,
previously to removing the parts by the knife, which has
been the general practice.

                    OPERATION.

  The extirpation of the testis, when necessary, is an ope-
ration by no means difficult.  The  skin  of the scrotum
becomes contaminated sooner than any other part in the
vicinity, and therefore the first thing, as Mr. Home re-
marks, is to mark out that portion of skin which ought to
be  removed.  " This being done,  the next thing is to
dissect out the diseased testicle from its situation in the
scrotum, taking care that the incision should always be
in the sound and natural parts and that every thing con-
nected with  the disease is left  attached to the testicle it-
self. Having gone thus far, the cord is to be examined,
and dissected as  high up as  is necessary to come at a
sound part, which, in the exposed  state it is now in, de-
tached from  the skin and surrounding parts, can readily 
ELEMENTS OF SURGERY.             21
be ascertained.  All that is  necessary to complete the
operation is tying the cord, which is best done by pass-
ing a needle, armed with a double ligature, through it,
in the interstice between the portion composed of the vas
deferens and spermatic  artery, and the loose veins and
other parts, which, in a diseased state of the testicle,
are found much increased in size, and very vascular.
These ligatures are to be tied sufficiently tight to deaden
the substance which is included in them, and  then the
cord is to be divided.
   " The cut edges of the scrotum are to be brought to-
gether, and retained there by needle and ligature, adhe-
sive plaster, or, simply by compresses of lint, according
to the peculiar circumstances of the case.
   " It is a common  practice,  which is adopted by sur-
geons of eminence, to cut down upon the cord, in the first
instance; and, after exposing it for an inch in length, to
pass a ligature behind it; and, having thus included the
cord, and secured the spermatic artery, divide it below
the ligature, and afterwards dissect out the testicle, like
any other detached tumour.   The motives for this prac-
tice are  founded in humanity, since  the moment the
nerves of the testicle are cut through the patient' will be
sensible of no material pain during the rest of the opera-
tion.  This advantage  appears to me to be more than
counterbalanced by the risk there is of the operation not
being completed in the most satisfactory manner.
   " The first consideration in every operation in surgery
is, that  it should be so performed as to leave nothing to
chance, and that the patient should have every security
that the operation can afford him; its being done with a
less or greater degree of pain, however desirable it may
be that  it should be as small as possible, is therefore only
a secondary consideration.
   " From not seeing operations in  this extensive view, 
22
ELEMENTS OF SURGERY.
young surgeons,  upon slight grounds, are induced by
theoretical opinions, to vary their mode of performing
them, and too often make themselves liable to meet with
more serious difficulties than those which they feared to
encounter.
   " In this operation it is even recommended to cut down
upon the cord, expose the spermatic artery, include it by
itself in a ligature ; and, by this neat and delicate opera-
tion, save the patient much pain.   Those cases, however,
which require an operation,  have the  cord much thick-
ened, and consequently much more vascular than in its
natural state. I have known a surgeon take up the sper-
matic artery alone,  then five or  six vessels one by one;
and, after having kept the patient the time necessary for
this purpose, find himself obliged to include the whole
cord in a strong ligature, so many other vessels conti-
nued to bleed."   (Home.)
  I wish merely to add to Mr. Home's account of this
operation, that the best mode of tying the cord, is in my
opinion to pass one strong ligature round the whole of
it, including every nerve and vessel in it.  The pain is
not augmented, nor its  duration increased by this, and
the operation is greatly expedited by it.   In making the
first incision I would also recommend to carry the edge
of the knife into the substance of the testis,  which will
immediately demonstrate the nature of the tumour, and
will certainly divide all the investing membranes, which
it is useless to do by a slow, cautious, and painful dis-
section. 
ELEMENTS OF SURGERY.
23
                  CHAPTER II


               Of Fungus  Hematodes.


  Within a few years much attention  has been paid
to a disease which has received the appellation of fun-
gus hematodes, a soft cancer.  Mr. Burns of Glasgow,
is the first writer who has given an exact account of it.
He states that " it generally begins with  a small colour-
less  tumour which is soft and elastic, if there  be  no
thick covering over it, such as a fascia; but otherwise
is tense.  At first, it is free from uneasiness; but, by
degrees, a sharp acute pain darts occasionally through
it, more and more frequently, and at length becomes in-
cessant. For a considerable time, the tumour is smooth'
and even; but, afterwards, it projects irregularly in one,
or more points; and the skin at this place becomes of a
livid red colour, and feels thinner.  In this place it ea-
sily yields to pressure, but instantly bounds  up again.
Small openings now form in these projections, through
which is discharged a thin bloody matter.  Almost im-
mediately after these tumours burst, a small fungus pro-
trudes, like a papilla, and this rapidly increases, both in
breadth and height, and has exactly the appearance of a
carcinomatous fungus and  frequently bleeds profusely.
The matter is thin, and exceedingly fetid, and the pain
becomes of the smarting kind.   The integuments, for a
little around the ulcers, are red, and tender: after ulce-
ration takes place, the neighbouring  glands  swell, and
assume exactly the spongy qualities of the primary tu-
mour.  If the patient still survive the disease in its pre-
sent advanced  progress,  similar tumours form in other
parts of the body, and the patient dies hectic. 
24
ELEMENTS OF SURGERY.
   "After*death, or amputation, the tumour is found to
 consist of a soft substance, somewhat like the brain, of
 a grayish colour, and greasy appearance, with thin mem-
 brane-like divisions running through it, and cells or ab-
 scesses in different places, containing a thin bloody mat-
 ter, occasionally in very considerable quantity.  There
 does not seem uniformly to be any entire cyst, surround-
 ing the tumour; for it very frequently dives down be-
 twixt the muscles, or down to the bone, to which it often
 appears to adhere.  The neighbouring muscles are of a
 pale colour and loose their fibrous appearance, becoming
 more like liver, than muscle.  The bones are always ca-
 rious in the vicinity of these tumours.
   " The  distemper is  sometimes caused  by external
 violence, though in general there is no evident cause
 whatever."   I fully agree with Mr. Wardrop in con-
 sidering this affection distinct from cancer, although in
"some respects they are very similar.   They differ in
 structure very materially ; in the symptoms which arise:
 in the parts usually attacked, and in the periods  of life
 at which they occur.   (See Wardrop on fungus hema-
 todes, or soft cancer.)
   The  fungus hematodes occurs in different parts of the
 body.   I have seen one case in which it sprouted from
 under  the  tendon of  the biceps  flexor cruris,  and in
 another its situation was so high in the arm, that ampu-
 tation was performed  very  near the shoulder joint, and
 a third  case in which I have been obliged to amputate
 at the shoulder.
   Mr.  Hey has seen it in the female breast; in the leg,
 neck and arm; on the back of  the shoulder, and  he
 thinks, also in the eye.  Mr. Burns has seen it  in the
 hip joint; upon dissection he found the joint surrounded
 with a  soft matter resembling the brain enclosed in thin
 cells, and here and there, cells full of thin bloody water : 
               ELEMENTS OF  SURGERY.             25

tfie head of the thigh bone and the acetabulum were ca-
rious.   Mr. Wardrop describes cases in which it occur-
red in the eye, the testicle, the liver, the spleen,  kid-
neys, lungs, uterus and ovaria.
   With respect to the treatment of fungus hematodes, it
must be confessed that there is no remedy but an entire
extirpation of all  the affected parts, and unfortunately,
the patient often opposes this decisive practice in the
commencement of the disease, which is the most proper
time for it.  Mr. Hey has applied numerous escharotics
without the effect of checking  the growth of the tumour.
When the disease is seated on a limb, it ought, il possi-
ble, to be removed without amputation.  Not a vestige
of morbid  structure should be left after the operation,
but the incisions should be made in sound parts, and if
notwithstanding this, the disease should be reproduced,
amputation ought to be performed without delay.  Wher-
ever the disease is seated,  the parts ought to be freely
and carefully removed.
Vol. II.
fc 
g*j             ELEMENTS  OF SURGERY,
                  CHAPTER III


                      Of Hernia.


   The large  proportion of mankind who are  afflicted
Avith 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 preventing its evil consequences, are circumstances
Which combine to render the investigation of hernia pe-
culiarly interesting.
   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 i
   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 protrusioy^occurs^
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.

   * 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
 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; they
 are very seldom perfect 
Pla te jvi
//<
77///f
tvury
O
Antral 'I'm
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iiiruuui/ J riij, 
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                ELEMENTS OF SURGERY.             27

   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, and of other causes.  The
cellular membrane in the vicinity gives but little resist-
ance 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 neclc ;—>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
thickness; but, in  other cases, a contrary state of the
sac is  found, and it appears  to be  almost  entirely de-
stroyed.  In old umbilical hernise it is often extremely
thin, and cases are recorded  in which no sac coukl be
found ; in these cases it had probably been  absorbed, in
cousequence of pressure, which we know sometimes oc-
casions an absorption, and sometimes a thickening of the
compressed parts.*

  * The s'ernum 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. 
28            ELEMENTS OF SURGERY.

   " We should hardly have supposed, a priori, that the
peritoneum is susceptible of such considerable extension
as it frequently suffers 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 lined 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, w hen 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 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 
ELEMENTS OF  SURGERY.
29
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 hernise 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 are 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 connexion, 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,
of the (tecum, or sigmoid flexure of the colon ; as these
arc the least fi\ed 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- 
30             ELEMENTS OF SURGERY.

mach to the pubes. we shall be convinced that the natural
position of an organ cannot of itself, enable  us  to de-
termine at w hich  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.)
  Hernias 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.  In 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, hernise  are called
ventral.
  Hernia congenita is that in which the tunica vaci-
nalis testis, forms the hernial sac, the testis and intestine
being in contact.
  In addition to  these more common cases of herniee,
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
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 01 the pelvis.
  When the  sac  contains  omentum, the case is called
epiplocele, or omental hernia; when intestine, enterq, 
               ELEMENTS OF SURGERY.            31

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 vescias..
   Hernia are reducible when the parts can be passed
up into the abdomen. When 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 ori-
fice 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
occasional causes of hernia. 
32             ELEMENTS
                 CHAPTER IV.


           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 small-
er 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  compressi- 
ELEMENTS OF  SURGERY.
m
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  witli other tumours, and contains
much fluid, &c.  In a fat patient the difficulty  of discri-
mination is considerably augmented.
   " A reducible hernia, though attended w ith 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 connexion 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,
     Vol. II.            F 
34             ELEMENTS OF SURGERY.

these symptoms gradually wear away.  Still, as the tu-
mour constantly increases in size, a large part of the vis-
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
almost 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.) 
 
PLATE XVBl.
Xeck of th& Sat
gtro^S
jl««*9
Cavity of the Sac
Ahdorrurud ring
~^ttlTicLru>rv into the  Sac
*il£ ?£ i*1, a%he' Scrotum,   \^j\
J. SDor-sey d^. * So. 
ELEMENTS OF SURGERY.
35
                  CHAPTER V.


         Symptoms  of Strangulated  Hernia.


  « The first and most immediate effects of such a de-
gree 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 strangu-
lated, but it will often occur to as great a degree in that
case, and will be equally insuperable by purgative medi-
cines, 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 re-
ferred rather to that inflammatory affection of the intes-
tines, which subsists  in  this  complaint,  than  to  the
mechanical obstruction of the canal:  and must  be con-
sidered 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 strangulation has taken place. But when
these have been once  emptied, the most irritating clys-
 ters produce no effect  The  inflammation of the pro-
 truded 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 particularly violent a layer of coagulating
 lymph is sometimes thrown out on the surface of the in-
 testine.   A manifest  impression is often made  on the
 intestine by the stricture,  and this may proceed so far 
36            elements of suroery.

as to cause a considerable constriction  of the canal.  It
terminates at last, unless the stricture be previously re-
moved,  in gangrene.  These,  which  we may call the
primary effects of the incarceration, are accompanied br-
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 indicating 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 
ELEMENTS OF SURGERY.
37
takes place; it begins in the contents of the rupture, and  -
extends to the containing and neighbouring parts. The
degree and intensity of the  symptoms are  modified h}
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 hiqpough  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 with all the dangerous and alarming symptoms
of an intestinal rupture,  as insuperable constipation.
fecal  vomiting, &c.
   " The examination of a patient,  w7ho  dies while la-
bouring under a strangulated  hernia, discloses  suoh  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 Miicture, 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-
                                    j 
38
ELEMENTS OF SURGERY.
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;
and spots of gangrene  are not unfrequently observed.
 Ill 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 colic, and
thus  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 circumstances, 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
exercise, 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
easily 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 suppo-
sition that the symptoms arise  from the  hernia, would
here be  not only useless, but even injurious ;  and the 
ELEMENTS OF SURGERY.
39
surgeon would neglect those means, which the inflam-
mation 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,
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 tor
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 sus-
pected with justice: but it is  still not quite  certain."
(Lawrence.)
  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 
10
ELEMENTS OF SURGKHV.
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
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 Hi 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  pa infill,  and is 
ELEMENTS OF SURGERY.
41
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
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  hernial 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,  tlje case ought  to be
treated as if strangulated.
Vol, II.            G 
n
ELEMENTS OF  SURGERY.
                  CHAPTER VI.


           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 
               ELEMENTS OF  SURGERY,             43

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.
   u 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. 
44            ELEMENTS OF SURGERY.

   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 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
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 w hich will prevent it; if downward
it can be remedied by a shoulder strap ; but this is  sel-
dom nece.,bary except in  very corpulent persons, and in
general if  the  instrument be properly  constructed  it
maintains the proper position,
  " The pad  of  the truss  should  be  planed over the
opening at which the viscera have protruded : kence, in
a small, or recently formed inguinal rupiwe, the, p*oper 
               ELEMENTS OF  SURGERY.            45

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-
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 he  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 Uj frequently experienced in keeping it reduced.
It may be necessary, if the pad retains its situation on 
46
ELEMENTS OF  SURGERY.
the ring, and the truss in general sits  well, to tighten
the strap a little.  Some individuals find the pressure of
the truss extremely disagreeable at first, although it is no
more  than the 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 the sac empty, and
this part together with the surrounding tendinous open-
ing, contracts, 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 during life.
   Mr. Law rence dissected a patient in whom a very old
and extensive rupture had in this manner been radically
cured by an adhesion at the neck of the sac.   In chil-
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 off
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.             47

   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 umbilical 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 they 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 ring,  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 hernia?. 
48
ELEMENTS OF  SURGERY.
                 CHAPTER  VIL


          Treatment of Irreditcibk Hernia.


  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
preturnatural 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
obviate 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- 
               ELEMENTS OF SURGERY.             49

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 hernise 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 strangulation 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  should 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 much difficulty.
Vol.  H.             H 
50            ELEMENTS OF SURGERY,
                CHAPTER VIII.


         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 princi-
pal of which, are, the taxis—bleeding—the warm bath—
clys'cs of tobacco—the application  of ice or cold sub-
stances to the tumour—opium—and cathartics.

                   I. OF THE TAXIS.

  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 order 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 
ELEMENTS OF  SURGERY.
51
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 carried 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 sub-
ject 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
:*  bubonocele or scrotal hernia, after the more ordinary
methods  have  failed particularly in case6 where the 
52             ELEMENTS OF SURGERY.
strangulation seems to have been caused by an accumu-
lation to 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 a plan which
should be noticed in tliis 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 
ELEMENTS OF  SURGERY.             53
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 not be reduced by this attempt, the
natient is to be placed in a warm bath, the temperature
                      »out one hundred degrees,  and 
54
ELEMENTS  OF SURGERY.
 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.  THEr 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." 
ELEMENTS OF SURGERY.
5&
               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 01 Mr. Ciiiie 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
tcstiue 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 
 56            ELEMENTS OF SURGERY.

 in 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 
               ELEMENTS OF SURGERY.       >     57

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  he 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
under the disease, to  wait only about  two hours, that he
might try the effect of bleeding, (if that  evacuation was not
forbidden 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
     Vol. IT              I 
58             ELEMENTS OF SURGERY.

too 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 here-
after.
   Most of  the  preceding observations refer to hernia
generally.—We proceed next to speak of particular
ruptures.
* 
ELEMENTS OF SURGERY.
59
                 CHAPTER  IX.


                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. 
60
ELEMENTS OF SURGERY.
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
often unsuspected by the patient, because it requires a
careful  examination to detect it: but to a surgeon ac-
quainted with the natural feel  and appearance  of the
parts it is sufficiently obvious.  The length of the swell-
ing above the ring will be found the same as the  part of
the spermatic 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 
ELEMENTS OF SURGERY.
61
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 greater
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 immediately
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 spine 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- 
62
ELEMENTS OF SURGERY.
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- 
ELEMENTS OF SURGERY.            63
tinguished frdm 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 t 
64
ELEMENTS OF SURGERY.
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 tow ards 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. 
ELEMENTS  OF SURGERY.
65
When this disease is complicated with ascitesit becomes
distended to an enormous size.  I*t 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  with an enlargement of the testis.
This latter is sufficiently distinguishable by the form of
the *organ, which  is retained under morbid enlargement,
hy  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
vag-nalis 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.                                         3*
  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
known 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.
     Vol. II.            K
 
66
ELEMENTS OF SURGERY.
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; and 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 swelling 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 w ith 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 w ithin 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 inguinal hernia, it remains to describe
the operations which become necessary, when the stran-
gulated parts cannot by these measures be returned. 
ELEMENTS OF SURGERY.
67
  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 Avith 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
ihe parts can be pushed up without violence by the finger, 
68
ELEMENTS OF  SURGERY.
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
wound 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; I  am 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 muscle
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 
ELEMENTS OP SURGERY.
69
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 
70
ELEMENTS OF SURGERY.
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 coagulable
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 a 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, 
               ELEMENTS OF SURGERY.             71

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 isolated 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. 
72
ELEMENTS  OF SURGERY.
  " 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 a 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
the 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 faeces by the external wound.  An additional ad- 
ELEMENTS OF SURGERY.
73
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-
onner 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.  I visited
him and found a small  hernial  tumour, but so free was
it from all appearance of strangulation, that I doubted
very much w hether 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 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 caUed in.
     Vol. II.           L 
74
ELEMENTS  OF SURGERY.
 Dr. Physick recommended that the hernial tumour should
 be opened, in order to ascertain 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 ab-
 domen, but touched nothing but the 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. The annexed sketch represents
the case I have described.           ^
 f Mr. Cooper's bistoury is represented in the first plate of this volume. 
ELEMENTS  OF SURGERY.
75
 strangulation lessens or disappears, as this is a proof of
 the return of circulation in the part.  The veins on its
 surface may also be emptied by pressure, and their sud-
 den  Ailing noted, and the  intestine  should be pulled
 down a little to make these observations on the part which
 has immediately been compressed by the stricture.  If
 the intestine appears to have a free circulation the sur-
 geon 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 violence  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 bauds 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 
76
ELEMENTS OF SURGERY.
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 wrhen  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 
ELEMENTS OF SURGERY.
77
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 I 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 off.  The
wound then healed, and the patient recovered. This fa-
vourable termination  could only have happened in a case 
78
ELEMENTS OF SURGERY.
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. 
ELEMENTS OF  SURGERY.            79
                  CHAPTER X.


               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 faeces 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 faeces 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 faeces 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 space is left for the absorption of the chyle,
that the patient dies from inanition. 
80
ELEMENTS  OF SURGERY.
   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 seemed  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 faeces 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 faeces 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 faeces 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 feculent
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- 
ELEMENTS  OF SURGERY.            81
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 tlirough 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 faeces 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."

 • One of the best tests of the mortification of a portion of intestine is the coagu-
lation of blood in its vessels; this is ascertained by pressure with the finger:
if the colour disappears, and returns when the pressure is removed, it is not
mortified, otherwise it most probably is.
     Vol.  H.             M 
82
ELEMENTS OF SURGERY.
  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 fasces,* and
the intesjtine 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 round 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 faeces 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  faeces 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
heals, so as to form  an artificial anus.   When the intes-

  * The maimer in which the ligature is prevented from  escaping into the
cavity of the abdomen, has been briefly noticed in the chapter on wounds of
the abdomen, in vol. i. 
ELEMENTS OF SURGERY.            83
tine heals in such a case, its cavity is not sufficient to
transmit the fasces, 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 faeces 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.
   After the operation  for hernia, it is necessary to close 
84
ELEMENTS OF SURGERY.
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
to occasion  peritoneal inflammation.   In  general, the
Rowels evacuate themselves within a few hours after the
operation; if not, a mild injection may be given.
  In very large hernise, 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.

  Hernias 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
detected, 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 strangulation takes place great pain and soreness
are perceived 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 sac
comes in view, extending from the abdominal ring to the
 opening at which the spermatic cord quits the abdomen.
 The sac is then to be opened to the manner described iu
 a former chapter, and the intestine examined.  A probe- 
ELEMENTS OF SURGERY.             85
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
Btricture 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 abdomen 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
ef the spermatic cord,  the vessels of which in large her-
nise 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- 
gg            ELEMENTS OF SURGERY.

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 between 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 runs 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 
ELEMENTS OF SURGERY.
87
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 irreducible, 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. The tumour
is, as before, to be grasped with  one hand,  but the fin-
gers of the other are to be placed at the abdominal ring
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  manner 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 most 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. 
88
ELEMENTS OF SURGERY.
    " The operation, therefore, is to be performed in the
  following manner:—The surgeon first makes an incision
  through the integuments, 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 tjien 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
a 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 the sac, 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 
               ELEMENTS OF SURGERY.             89

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.
Vol.  II.            N 
90            ELEMENTS  OF SURGERY.
CHAPTER XI.
                  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 faeces
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 faeces 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 faeces 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 
ELEMENTS OF  SURGERY.
91
prevent a prolapsus or eversion of the intestine, which is
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 fasces.  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 Desault
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 fasces 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 faeculent 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 faeces and dilate the
canal at the injured part. When this is done air and faeces
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 
92
ELEMENTS OF SURGERY.
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 faeces 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. 
ELEMENTS  OF SURGERY.             93
                 CHAPTER Xn.


                 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 knowledge of the anatomy of the parts concern-
ed, to the investigation of which much attention has of
late been paid by several eminent anatomists and sur-
geons.   The present Dr. Monro, availing himself of the
labours of Albinus, Gimbernat, and Hey, has published
in 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 in 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
interior superior spinous process of the os ilium to the os pubis. 
94            ELEMENTS OF SURGERY.

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 vein.   The next  appearance is that of a small cir-
cumscribed tumcTur, 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, in 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* 
               ELEMENTS OF SURGERY.            95

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 saphaena 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
(he 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-
draw n,  leaving this forming a complete bag over the her-
nia.  In a email  hernia the fascials thicker than the sac 
96
ELEMENTS  OF SURGERY.
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 linea ileo-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 
ELEMENTS  OF SURGERY.
97
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 centre of the
          orifice of the sac.    -    -    -     -   2
        the centre of the orifice of the sac to the
          external iliac  artery.    -    -     -   1
        the centre of the orifice of the sac to the
           centre of the external iliac vein.     -   Of
        the centre of the orifice of the sac to the
           origin of the epigastric artery.   -    -   0|
        the centre of the orifice of the sac to the
          inner edge of the internal abdominal ring. 1
        the tuberosity of the pubis to the centre
          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
     Vol.  II              0 
98             ELEMENTS OF SURGERY.

sheath where the absorbent vessels pass.  The hernial
sac is here placed 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 
               ELEMENTS OF SURGERY.             99

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 in 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 in those women who have borne children, oftener
than in  others.
   A portion of intestine most frequently forms the con-
tents of the sac in 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. 
100
ELEMENTS OF SURGERY.
  Crural hernia is a more dangerous complaint than In-
guinal ; it is smaller and therefore oftener attended with
obsruction 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
it, 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 fasciae  are upon the stretch ; when the thighs
are bent, but the  knees turned outwards, the fasciae 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.  When 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 ihat cavity. 
ELEMENTS OF  SURGERY.
101
» 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, or limated edge
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 £he 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 
102
ELEMENTS OF SURGERY.
 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 hernia, 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.
   " 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 encloses 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 
ELEMENTS OF  SURGERY.
103
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 1 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
ef 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. 
104
ELEMENTS OF SURGERY.
  « For want of this precaution I have known great diffi-
culties occur in the operation, the incision, when single,
being to 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 w ould 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 bare;  following up this idea, the 
                ELEMENTS OF SURGERY.           105

 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.
   u It must be remembered, however, that in large her-
 nise 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
    Vol. II.             P 
106           ELEMENTS OF SURGERY.

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, when 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- 
ELEMENTS OF  SURGERY.
107
ilia, and divided all the parts which he cottld 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- 
^08            ELEMENTS OT SURGERY.

ner side of the sac, and the division be  made directly
upwards.
  " In the 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 are
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
in 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
 faeces, after the contents of the intestine have been eva-
 cuated at the wound, four ligatures should be applied,
 so as to shut the bowel in the whole of its circumference, 
ELEMENTS OF  SURGERY.
109
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 faeces will
not pass through the intestine; and if after twelve hours
no faeces 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 faeces 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 faeces  escaping into the abdomen will
destroy the patient  in a few hours.  To  prevent this,- 
110
ELEMENTS OF SURGERY.
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. It 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 unadvisable 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 offensive
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 
ELEMENTS  OF SURGERY.
Ill
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 ; 1 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,7
but taking great  care to make a very small incision  or
rather scratch with the point  of a bistoury, though 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 wre may
safely cut directly towards a blood vessel, without risk of
wounding it provided the surgeon be cautious and dex-
terous.*    As  Dr. Phy^ck'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 " vhere 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
passes around that  part of the crural arch called Gimbernat's ligament, and is
attached 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 hie operation
for crural hernia.
  " I have seen the  obturator artery sent off from the external iliac artery, about
an inch and a 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
muscle, and enters  tiie pelvis at the crural aperture.  The artery in this case
is placed behind the crural hernia."  (Monro.) 
112
ELEMENTS  OF SURGERY.
 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; fqj|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 
              ELEMENTS  OF SURGERY.           113

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.
Vol.  II.            Q 
114
ELEMENTS OF  SURGERY,
CHAPTER XIII
        Of Exomphalos or  Umbilical Hernia.


  The sac in umbilical hernia passes throngh a hole at
the navel by which in the foetus  the umbilical vessels
had been transmitted.  This aperture is situated in the
linea 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 hernise 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 
               ELEMENTS OF SURGERY.           115

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
wh'en 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 
116
ELEMENTS OF  SURGERY.
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 hernias through the sac of the large one.*
In this instance two small omental hernias 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 occasioned by 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 
ELEMENTS OF SURGERY.
117
  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 knife.  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.
                             I

   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 
118
ELEMENTS OF SURGERY.
 very thin one, intervening between the skin and the pro-
 truded viscera.   The external incision should in small
 hernias extend from the top to the bottom of the tumour,
 but in large hernias 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
 necessary to remove it by the knife.   The integuments
 are next to be approximated and retained in contact by
 one or two stitches, 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 
ELEMENTS OF SURGERY.           119
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 Ijnea 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 fasces is restored;  an
operation which has  been  successfully performed by
Mr.  Cooper.
  The colon is more frequently found in umbilical her- 
 120           ELEMENTS OF SURGERY.

 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-
tum, 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 tendineas,
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 libera-
ting 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 
ELEMENTS OF  SURGERY,            121
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 cempresses 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
     Vol. II.            R 
 122           ELEMENTS OF SURGERY.

 heals.  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 Desault'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.  Wlien 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. 
ELEMENTS OF SURGERYr
123
                CHAPTER XIV.


                Of Ventral  Hernia.


  This resembles the umbilical, except that the protru-
sion instead of being at the naval is situated in some
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 deficiencies 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 t^e  two cases. 
124
ELEMENTS OF SURGERYi
                 CHAPTER XV.


                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  inguinal 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 
               ELEMENTS OF SURGERY.            125

no lower than the upper end of the testis,  a sufficient
portion 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
Kgaments 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 hernia. 
126
ELEMENTS OF SURGERY.
                CHAPTER XVI.


                   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
testis bursts, and the water escaping into the surrounding
cellular texture, forms the anasarcous tumour, which is
gradually absorbed, and the aperture healing, the dis^
ease resumes its original form, the water being confined
within 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 complaint 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 
ELEMENTS OF  SURGERY.
127
 apertures should be made, by inserting the point of a lan-
 cet just  deep enough to pierce the cutis vera, through
 these the water flows freely, and 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  ring, in 
128
ELEMENTS OF  SURGERY.
 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 injecting 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 dangerons 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 iuvests 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, 
ELEMENTS  OF SURGERY.
129
   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,  wrhich  was a second time  cured  in 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 Sclerocelc, &c. London, 1811
     Vol. II.            S 
ISO
ELEMENTS OF  SURGERY.
                    TREATMENT.

   The administration of internal remedies has no effect
upon 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
tcater.  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. Ramsdea
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, manj
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.  W hen the tumour
however acquires  a very large  size, the inconvenience 
                ELEMENTS OF  SURGERY.            131

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 be 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  louser
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.
   In  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; the usual place of drawing off the water is at the middle of the ante.
rior part of the srrotuin, but a difference is observed in this respect, and Mr.
Hunter recommends to ascertain before inserting the lancet, the precise situa-
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
this way Mr. Hunter once succeeded in drawing off the water of a hydrocele,
by inserting the lancet where the testicle is generally found. Several previous
attempts having been made by other surgeons, who inserted thetrochar at the
usual place, where it entered the testicle. 
132            ELEMENTS OF SURGERY.

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 by 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 w^ater.   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. 
ELEMENTS OF SURGERY.
133
  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,
which lit 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 
134
ELEMENTS  OF SURGERY.
is verv 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 tunica
vaginalis when the wine is  injected,  and to  avoid irri-
tating 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
unable  to recollect wiih certainty by whom it was suggested, I think by Mr.
WheatK-. 
ELEMENTS OF  SURGERY.           135
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, evacuating 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  granulations 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
tthich are  called  by the  general  name of sarcocele 
136
ELEMENTS  OF SURGERY.
have been briefly noticed  in the chapter on cancer.
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.  In these cases (which
are denominated hydro-sarcocele) frequent evacuation of
the fluid is the safest and  best mode of treatment.
  As 1 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. 
ELEMENTS OF SURGERY.            137
                 CHAPTER  XVII.

                   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 tunica
 vaginalis.  Ecchymosis in the substance of the testis,
 constitutes another species of haematocele.
   The cause of this affection is a rupture or puncture of
 a blood-vessel, 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.
 I 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 watefr
 were absorbed.
     Vol. II.            T 
138
ELEMENTS  OF SURGERY.
                CHAPTER XVIII


            Of Varicocele and Circocelc*


   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 attentiou, 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
return of the tumour can  take place whilst  the pressure
is continued, whereas this pressure, encreases the swel-

  * These terms are often promiscuously used, but they may very properly be
applied with more precision to express two very distinct morbid affections.
Celsus and after him the classical Mr. Percival Pott applied the term circocele
in the sense which I have adopted. 
ELEMENTS OF  SURGERY.
139
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. 
140
ELEMENTS OF SURGERY.
CHAPTER XIX.
           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 with 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- 
               ELEMENTS OF  SURGERY.           141

pable of  contracting, 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,  1 pass  over many arguments  which
might be  advanced to prove the contractile power of 
142
ELEMENTS of  surgery.
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 urinas 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
irritations aggravate the disease, and sometimes occasion
-a suppression of urine.   Mr. Home ascribes this to a
closure 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
spasmodic 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- 
ELEMENTS OF  SURGERY.
143
charge*! 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
PER1NE0.
   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 stricture* ex-
ist.  Mr. Hunter has known six in one urethra. 
144           ELEMENTS OF SURGERY.

   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 irri-
tating injections,  although Mr. Hunter doubted whether
these were  frequent sources of the  disease.   Mr. An-
drews  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 liis 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 w ithout
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. 
               ELEMENTS OF SURGERY.           145

temporary relief, succeeds no doubt in curing completely
a great many cases of this complaint.  The manner in
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  w hich 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  can ion 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
    Vol. II.             U 
146
ELEMENTS  OF SURGERY.
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, be 
ELEMENTS OF  SURGERY.
147
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 
148
ELEMENTS  OF SURGERY.
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 blootl 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
this shape, and the  surgeon must either scrape it thin enough, or fuse the
common lunar caustic and cast it in an iron mould. 
              ELEMENTS  OF SURGERY.             149

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 ap-
plication of caustic to strictures, which consists of a hol-
low globe with 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 this 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
readily.   The urethra is generally distended behind the 
150
ELEMENTS  OF SURGERY.
 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  clown 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. 
ELEMENTS  OF SURGERY.
151
                 CHAPTER XX.


               Of Fistula  in Perineo.


  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- 
152
ELEMENTS OF SURGERY.
 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
 impracticable.   It should be  attempted, however, by
 destroying 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 en-
 tering 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 possi-
 ble 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 always 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 fis-
 tula, 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 stricture which is  often  extremely difficult,
 in such a case it has been recommended to perform a
 more decisive  operation.
   Mr. Charles Bell on this subject remarks :  " It often
 happens that  in these  diseases  of the perineum,  the
 urine obtaining a free discharge by the fistulous open-
 ing,  the original stricture  is more  and more contracted,
 and  a considerable  part  of  the canal is  totally obli
 terated.  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  were better to  take 
ELEMENTS OF SURGERY.
153
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
necessary.   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 to
require the most stimulating applications  to induce gra-
nulations.  In such cases caustics and escharotics are to
be used.   1 have tried  the  harelip suture  in a case of
large opening into the urethra at the perineum, bttt no
    Vol.  II.            X 
154           ELEMENTS OF SURGERY.

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 in  most cases lost,  and succeeded by an
indurated indolent substance.
   Fistulas 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 fistulas too small to ad-
mit the finest probe,  and these fistulae  have remained
open during life.
   Fistulas 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.
/' 
ELEMENTS  OF SURGERY.
155
                 CHAPTER XXI.


               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.
   When 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 
156           ELEMENTS OF SURGERY.
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 in 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 Jbecomes 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
be extracted by means of an eyed  probe bent at its per- 
ELEMENTS OF  SURGERY.
157
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 suppression 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
esseutial 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 more  serious, and fatal.  In  the inte- 
158
ELEMENTS  OF SURGERY.
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 w ith 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 the silver catheter is in general preferable
to every other;"—The surgeon who uses it should be also a " dexterous" silver-
smith. 
ELEMENTS OF SURGERY.
159
 highly finished, and for the mere purpose of drawing off
 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 instrumentto 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 have 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 
160            ELEMENTS OF SURGERY.

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 introduc-
tion 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 the
stilet of wire is introduced in order to give to the instru-
ment agreater 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
varying the form  of the instrument. I have myself been
accustomed 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
that 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 
ELEMENTS OF  SURGERY.
161
enlargement either 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.
     Vol.  II.            Y 
162
ELEMENTS  OF SURGERY.
  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 urine.   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-
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. 
J-LATE XVUl.
 
 
ELEMENTS OF  SURGERY.
163
  The string d, is  intended to  give greater security to
the instrument, and in case of a separation of the poinj
from the catheter it would serve for the extraction of the
former.  Dr. Wistar generally passes the string through
the 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 been repeatedly performed by Dr. Physick, has
never been followed by any unpleasant consequences,
and it  has in  several  cases obviated the necessity of 
164
ELEMENTS OF  SURGERY.
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  attesting its
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 catheter in the female subject
is an operation of no  difficulty  to a person acquainted
with the anatomy of the  parts.  Before the operation the 
 
PLJTEMX.

J.SDersrv. del K Sculp.
 
ELEMENTS  OF SUlKiERY.
165
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 iu-
froduced 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. 
166
ELEMENTS OF  SURGERY.
                CHAPTER XXII.


              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 operations is considerable, and the extent
of incision comparatively great.   It has nearly gone into
disuse, but I have been informed that it has lately been
performed in London ; Mr. Astly Cooper plunges a lan-
cet boldly into the bladder from the perineum, an ope-
ration 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. 
ELEMENTS OF SURGERY.
167
   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 piMed 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 a 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. 
168            ELEMENTS OF SURGERY.

  Desault performed the operation frequently with suc-
cess.

OF 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
little 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 vesiculse 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 
ELEMENTS OF  SURGERY.
169
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.
Vol. IT.
7. 
170
ELEMENTS OF  SURGERY.
               CHAPTER XXIII.


              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 
ELEMENTS OF SURGERY.
171
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 bladder is  distended with
urine, to void it forcibly in a full stream,  bending the
body forward so as to render the neck of the bladder it*>
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 mostusual 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 in considerable quantity, and vein-
frequently a  sandy matter is mixed with it, the smell be-
ing extremely fet id.  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 
172           ELEMENTS OF SURGERY.

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 stoue 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. 
ELEMENTS  OF SURGERY.
173
   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,  ami  therefore  unless  some more powerful
 solvent can 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 stones 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- 
174
ELEMENTS OF SURGERY.
   ceed to describe the manner of performing the operation
   which I consider most advantageous.*
     The instruments  necessary for performing the opera-
   tion,  are, strong garters or bauds  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
   it 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.f
     All the instruments which  the  surgeon can possibly
   need should be at hand, and carefully put in order before
c  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
   the 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.
     ■j-  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. 
 
Plate x x
PayclSOVel 2
-V
k
t.,1   "*
 
ELEMENTS  OF SURGERY.
175
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.
     ft.  The blade.
     b.  The stem.
     c.  The screw.
     d. The beak.
     e.  The cutting edge.
   Fig.  2. The stem of the  instrument comprehending
♦he 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.
   Fig.  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.  1. A section of the gorget of a proper size, de-
scribing the angle formed by uniting the blade and stem.
   Kigs. 5, 6, 7, 8, 9,10, represent six blades, of various
sizes, adapted  to  one common beak, m hereby the sur-
geon is furnished  with a gorget proper for patients of

  • This instrument is extremely well  made by Mr. Bishop, from Savigny's
manufactory, London, who published a description of it in Coxe's Medical Ma-
-ff.m, in 1804 
176           ELEMENTS OF SURGERY.

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 cenema of laudanum and water
may be administered, an hour or more before the opera-
tion, or what is equivalent a few grains of solid opium
may be  introduced  into the rectum, 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, 
ELEMENTS OF SURGERY.
177
the patient is directed to grasp his feet with his hands,
and by means of the fillets they are securely bound to-
gether.
   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 which is im-
mediately opposite the lower end of the arch of the pubis,
of course the incision begins at the raphe of the perineum
just behind the scrotum; the knife is to be carried stea-
dily in a right  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 there  is  no danger
io be  dreaded at this stage of the operation, except  a
wound of the rectum which is easily avoided.   This in
ci>ion  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-
versals perinei  muscles completely divided—when this
    Vol.  II.            A a 
178            ELEMENTS OF  SURGERY.
 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
 bistoury the point of which he 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
  * This direction is not always necessary t» be observed, as the staff is ofteti
 exposed very readily by means of the scalpel. 
               ELEMENTS OF  SURGERY.           179

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
nearly at a  right angle, and the beak of the gorget will
consequently take a direction nearly in 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.  The 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 stone.   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 
 180            ELEMENTS OF SURGERY.

 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
 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 wrater 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 bold 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, ail  then the larger fragments are to  be
 successively taken out  by the  forceps, the smaller ones
 by means pf 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 
ELEMENTS OF  SURGERY.
181
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 such a manner
as to enlarge the wound, the surgeon cutting down upon
his finger, runs no risk of wounding any important part,
the proslrate 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 cousi
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 in 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 which
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, although a boy, I had the honour
of assisting  Dr. Physick in his first operation for stone. 
182
ELEMENTS OF  SURGERl.
 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 between his finger and the
 ramus of the ischium.  It was evident that if the flesh
 between his finger and the bone could be compressed,
 the hemorrhage would be commanded.  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 passed under the projecting
 point and handle of the tenaculum, and wras firmly tied,
 it included consequently a portion  of flesh, 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 de-
 scribing 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 exe-
 cuted, 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 per-
 formed, but  have no doubt  that  it could easily be
 done.
  After the operation is completed, the patient is to be
placed on his side, on a mattress, 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, and to prepare
 the mattress, a piece of  waxed linen may  be  placed
 under the sheet.  A low diet  and rest are the only reme-
dies 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 
 
PLATE XXI.
\ *, -  -, -     :n
jStS^A. /"'y
-.;,.. ■■jrj/gg&Zi-
. Ecrsfy  a.ei,.  X. S.-uip. 
ELEMENTS  OF SURGERY.            183
 Bell says he has known " the violence of the operation,
 without hemorrhagy or inflammation, to kill the patient
 in about tt^ii 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
 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 after
 the operation through the wound,  but in two instances
 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  completed,
 a circumstance which I ascribed to the smallness of the
 stone, and the consequent absence of contusion.   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  after-
 noon 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 hesitation
 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

 * 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 
184
ELEMENTS OF  SURGERY.
of operating, now in use in Europe.  The knife has
many 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 I am per-
suaded that most of the objections to the gorget have ori-
ginated from the use of  bad gorgets, I have no hesita-
tion in recommending a sharp gorget  as  the most con-
venient knife with which the bladder  can be opened in
lithotomy.
  An operation called nephrotomy has been proposed
for  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  iucision into it,  and  extract the stone.
The great blood-vessels being in  this case anterior  to the
abscess would not be endangered. 
ELEMENTS  OF SURGERY.
185
   The operation of lithotomy in the female, consists in
simply enlarging the urethra, laterally by means of a
scalpel or gorget,  and a short straight director or staff.
It may also be done by cutting through the vagina upon
the staff,  but incontinence of urine is apt to follow;  as
it does indeed in some cases after the former operation.
Lithotomy in the female, is an  operation of no more
difficulty, than the dilating of a sinus with a scalpel and
director.   Indeed it may often be done with sponge tent,
and many cases of success by this plan are recorded.
Vol. II.           B b 
186
ELEMENTS OF  SURGERY.
                CHAPTER XXIV.


                 Of Fistula in Ano.


  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
symptomatic of that disease.   In all the instances I have 
ELEMENTS OF  SURGERY.
187
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 be 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 speak 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 
188
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.
  Fig.  1. The instrument in the handle half open.
  Fig. 2. 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 1.  The extremities of the blade and  of the
guard to shew the manner of their conuexion.
  When the instrument is furnished with the guard it
resembles a probe, and may be passed down to the hot- 
Plate xxu.
Guarded 13 is toury
 
 
               ELEMENTS OF SURGERY.            189

 torn of the sinus,  and by pressing forward  slightly the
 guard it is detached, and the naked blade remains verv
 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  iuto 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 lan-
 cet, after which the treatment is  similar to that of a com-
 plete fistula.   But 1 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 or 
190           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
he 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 complete, 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 byBichat.
  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.
191
                CHAPTER XXV.


                  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.  In some chronic
cases the tumour  appears  to consist of  a solid fleshy
mass without any enlarged blood-vessels.  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 dyspeptic symptoms are occasioned.  Extreme
pain is experienced in going to stool, followed by violent
tenesmus, by profuse bleedings, aud 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 abdomiual viscera, and other circumstances which
interrupt the circulation of blood through  the bowels are
frequent causes of hemorrhoids. 
192
ELEMENTS OF SURGERY.
  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,
thoilgh 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 ouly 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
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 
               ELEMENTS OF SURGERY.           193

m 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 spine-
ter muscle. , 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 1 think it safe to cut
off, are those which are completely external, and these
should always be removed by the  knife.
Vol. II
Co 
194
ELEMENTS OF  SURGERY.
                CHAPTER XXVI.


                 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  m
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.
195
ed 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 lie 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 here-
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 lessen the effort of the ab-
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-
 noirs of the French Academy, the  case  of a child is 
196
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 ccecum, 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 hemorrhoidal
tumours, these ought certainly to be removed in the man-
ner already directed. 
ELEMENTS OF SURGERY.
197
               CHAPTER XXVII.


                   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 found  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. 
198
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,
 Zisteatomatous 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 opiuion,  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.
199
made and witnessed, 1 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 1 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 disease,
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 evideuce 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, 1 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 
200           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 I 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, cedema  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.            201

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, produ-
cing 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 aueurism.
   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 soixmte-trois stir un seul homm'e depu'.s le volume d'une
aveline jusi;u'a celui de la moitie d'un ocuf de poule." Clinique Chirur. torn. ii.
     Vol.  II.           D  d 
202
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, appeai-s 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   j
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."t                                  *
   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 tranalated bowls, generally signifies four
ounces, so that three bowls or porringers, implies twelve ounces.
                  fClin. Chir. torn. 1. p. 73. 
               ELEMENTS OF SURGERY.           2Q3

  Although I would not be sanguine in my expecta-
tions of curiug 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
he applied to aueurisms in other situations. 
204
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 rouud
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 along 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.           205

  The operation of Mr. Hunter for popliteal aneurism,
*n some instances terminated in fatal hemorrhage, and
Mr. Abernetby 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 blood-vessels of an ampu-
tated limb were less apt to bleed, than the femoral artery
when tied for the cure of popliteal aneurism, Mr. Aber-
netby 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 oil', 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 iu which the
accident has occurred 
206
ELEMENTS OF  SURGERY.
       Or 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, and 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 anil 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 and most other instances it is safest to
operate early, because the advantages which some sur-
geons have expected from delaying it until the anasta-
mosing vessels are enlarged, is more  than counter-bal-
lanced 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. 
ELEMENTS OF  SURGERY.
207
   Two years ago he perceived, for the first time, a small
tumour in the right groin.  Having never had the vene-
real, nor indeed any other disease, and not having met
with any accident, 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 eight 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.   Iu June last (1811) he applied to Dr. Irwin of
Easton, the place of his residence, who instantly apprized
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 to a  lowr 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
Or. Physick and Dr. Hartshorn, surgeons to the hospital, 
208
ELEMENTS OF  SURGERY.
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-
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 dirept the extremity of the needle. 
ELEMENTS OF SURGERY.
20V
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
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;
:.i 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^
don, 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 he complained of extreme pain in the
back and belly, and also of some pain in the limb.   He
\> as 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 20th.  Passed a restless night, in great paiu.
To t^e 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
     Vol.  II.           E e 
 210           ELEMENTS OF SURGERY.

 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
 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 day of the opera-
 tion and several 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 fceces 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 
ELEMENTS OF  SURGERY.
211
and  walked across the room, and has taken  exercise
every ciav since without inconvenience.  The tumour in
I he 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, vyhich does not uniformly
happen  after the operation for popliteal aneurism.
   i  wish, before closing this paper, to  call the attentiou
of those surgeons, who may have occasion to perforin
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
              *  Abernethy's Surgical Observations
              |  Fj-ccv on Aneurism. 4- 
2f2'
ELEMENTS  OF SURGERY.
he confesses was the most « difficult and dangerous pavf;
of the operation."  These dangers and difficulties  are;
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 au operation for which the world is
mdebted 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. The operation has,
now been done in more than thirty cases, and has suc-
ceeded in. a lar^o majority.

       OF ANEURISM  OF THE CAROTID ARTERY.

  In November 1805, Mr. Astly Cooper tied up the ca
rotid 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

   The adjoining1 sketch is intended to point ou' the part where the operation
was performed, and the instrument used to convey tiie ligature rpund the ar.e-
ry  It need& no particular explanation. 
/'Ljfrtf .rj
^\>&S&

■ r:'lr'.r,..'%'i:',lf ,'
Q
T) ,.,<#>
 
 
ELEMENTS" OF SURGERY.
2td
completely, and the 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 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-
ele, 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 ever 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 ligature's being thus, conveyed under the 
21-1
ELEMENTS OF  SURGERY.
 artery the lower was  immediately tied.  Mr. Cooper
 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 needle and thread were passed
 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,
 of the 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 ^lie internal carotid artery passes
 through a  foramen intjie 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, otving to the number of commitni- 
ELEMENTS OF  SURGERY.
215
eating vessels, he would not have been equally sanguine
in his expectation that the pulsation would have ceased.

I have great pleasure in subjoining 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
artery, 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 tumoui-.  A tumour was, however, soon after
discovered on examination, which very  slowly and gra-
dually increased in size, until abo*ut 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.
   ! ie 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
initiation of blood to the head.
   The tumour  upon  being accurately measured at this
time was found to possess the following dimensions. 
S16
ELEMENTS OF  SURGERY.
                                           INCHED
     Length    -     -     -          -     -    6?
     Breadth   --..-.    4
     Height or projection from the neck more
       than    .-.-..    2
     Half circumference   -.   -     -         8|

  Being of a full habit of body with a strong pulse, he
was  bled from the arm to Jxvj, took some cathartic me-
dicine, 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 artery 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 12 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 arincd with a small crooked needle, the lower one was 
               ELEMENTS OF SURGERY.            217

 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
 altogetlier  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 after 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 tb.6  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,  how ever,
 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 was verv 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.
     Vol. II.            F f 
218
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 which 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.  Aiumon.  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. Ai
ten in the evening  his pulse  being 84, strong, full and in
some 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 abcut the throat, but has no pain.   Having
had  no alvine evacuation since the  operation,  was or-
dered the Tart. Potas. and Sodse in divided  doses—
Pulse 86.
  Jauuary 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.           219

  January thirteenth.   Passed a comfortable night—Is
troubled occasionally with fits of coughing, for which he
was ordered Tinct. Opii.  gtt. x in Jss. 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 harassing.   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 :


     Length
      Breadth
      Projection
      \ Circumference

   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.
    February  twenty-second.  The wound is reduced to
  a small sinus of an inch and a half in depth—At a soft
  prominent point,  near the lower part of the tumour, an
  obscure pulsation is still perceptible.
INCHES


  2
  7| 
220           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 the tumour to day gives the following result.
                                           INCHES.
     Length    -                            4£
     Breadth   -----    2|
     Projection       -     -     -      -    1|
     | 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 lesseued,  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
operatiou, there would not have been  room enough to
have taken up the artery.
  Dr. Post has since operated ou another case of carotid
aneurism,  and the tumour having  been reproduced by
anastomising  vessels,  he  intends to  tic up the other
carotid of the same patient.  I feel no small share of
interest in the result, and am truly solicitous that suc-
cess may crown so cutcrprizing an effort.
  Mr. Charles Collier took up the carotid artery, to pre-
vent a fatal hemorrhagy from a wound in the mouth; and
Mr. Goodladtied it up  previously to removing a tumour
from the face and neck, in neither case did auy serious
consequences result.

        ANEURISM  OF THE AXILLARY  ARTERY.

  Another situation in which aneurism sometimes occurs 
ELEMENTS OF  SURGERY.
221
■<s 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 disease, 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-
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 au 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 
222
ELEMENTS OF  SURGERY-
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 I know the first case
in which  an axillary aneurism has been successfully
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 w ounded 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 wray, 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 determinned 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 success?' 1. no  gan-
grene resulted, and the patient gradually acquired the
use of his arm as well as before the accident.
   Mr. Hamsden 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- 
ELEMENTS OF  SURGERY.
223
crihed 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 in the following manner.
  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 mv
thumb and linger 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 wounding 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 <o direr!
me  to the artery, 
224
ELEMENTS OF SURGERY.
  " 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 I
had distinctly brought into sight the edge of the anterior
scalenus muscle, immediately below the angle, which is
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 1 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-

  • " 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 with the operation." 
ELEMENTS OF  SURGERY.
225
 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 ligature, 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-
 strated by the case, and there occurred nothing in the
 subsequent symptoms to forbid a similar attempt in a
 similar instance.
   With respect to  the best situation in which to apply
 the ligature in the present instance, that must be'de-
 rided 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 iu 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 tying the pudic and iliac ar-
 teries, would  greatly facilitate the passing of a ligature
 round the subclavian.

        OF TYING THE ARTERIA  INNOMINA I \.

   A case  has recently occurred in which Dr. Mott, pro-
 fessor of  surgery, in the  university of  New York, se-
cured the  artcria innominata.  \ n account of this opera-
    Vol. 11.           Gg 
226            ELEMENTS OF SURGERY.
tion will speedily be published, and the medical world
will then be enabled to estimate their obligations to this
intrepid surgeon, who has certainly demonstrated that
the circulation in the arm will not be necessarily de-
stroyed by securing this vessel; his patient having sur-
vived the operation nearly four weeks.
  I heartily regret  the  fatal result of this operation,
which promised to throw additional lustre on American
surgery, and on the distinguished name of the gentleman
who performed it.   Until I have an  opportunity how-
ever of examining the details of the case, I can offer no
opinion of the proper method of  performing  such an
operation, nor of the cases demanding it.

               OF TYING THE  AORTA.

  To complete my account of aneurism, it is necessary
to insert Mr. Cooper's case, which I regard as the most
daring deed recorded in the annals of chirurgical history,
but I must add, perfectly justifiable and highly honour-
able to a name already celebrated in all quarters of the
globe.
  " I fear that the title of this paper may impress the
reader with an idea that nothing could justify me in per-
forming the operation w hich 1 am about to describe ; for
that a ligature made upon the  aorta must  necessarily
prove fatal.  But I trust, that it will be seen in the se-
quel,  that the operation was not attended with the im-
mediate danger w hich might have  been  apprehended:
that the patient complained of but little pain during its
performance, that it afforded the  only hope of safety^.
and that we had to lament, not that the operation wa«
performed, but that it had not been sooner done.
  " Sorry indeed should I be, to sport with the life of a
fellow-creature who might repose a confidence either in
my surgical knowledge or in my humanity; and I should 
ELEMENTS  OF SURGERY.
227
be equally disposed to consider myself culpable, if I did
not make every possible effort to save a person, whose
death was rendered inevitable, if a disease were suffer-
ed to continue which it was possible for surgery to re-
lieve, as in the  case which forms the  subject of  this
essay.   In the  performance  of our duty one feeling
should  direct us; the  case we  should  consider as our
own,  and we should  ask ourselves, whether, placed
under similar circumstances, we  should choose to submit
to the pain and danger we are about to inflict  Guided
by this  principle, and having  collected all the evidence
which applies to the case, we  perform our duty without
the reproaches  of conscience  which  must await those
who unnecessarily subject their patients to pain  and
danger.
   " Those who feel disposed to  condemn the attempt
which I have here described,  will have the kindness to
recollect, that although my first  operation  for carotid
aneurism proved equally unfortunate with this,, yet in
the second operation, I was gratified by the  successful
issue of the case.
  " In collecting evidence upon any medical subject, there
are but  three sources from which we can hope to obtain
it;  viz. from  observation on  the  living subject; from
examination of the dead; and from  experiments upon
living animals.  By the first, we learn the history of
disease; by the second, its real nature, so far as it can
be certainly known;  and by  experiments  upon living
animals, we ascertain the processes resorted to by nature
for restoring  parts which have  sustained injuries,  and
then apply that knowledge to  accidents in man.
   (i In applying ligatures upon the  arteries generally, the
only circumstance to be considered is, the probability of
the blood being conveyed by means of  anastomosis to
the parts beyond; but in operations upon those  arteries,
which are seated in the larger cavities of the  body, it 
 2ti8           ELEMENTS OF SURGERY.

 becomes a subject of consideration, by what mode  the
 ligature shall be prevented from occasioning destruction.
 In common parts, it produces suppuration and ulceration,
 which end  in the separation of the ligature; but amidst
 the vital organs,  a  suppurative  process may endanger
 life.
  " The Aorta is so rarely obstructed, that the opportu-
 nity of ascertaining the power of anastomosing vessels
 in propelling the  blood is extremely unfrequent.  The
 first impression arising on examination of the structure
 of the aorta at its curvature would be, that an anastomo-
 sis  would not be  sufficiently free to permit the blood to
 find its course by circuitous channels ; and the only op-
 portunity that I have had of seeing  a contracted aorta
 in the human subject w ould serve to confirm that opin-
 ion  : but Mr. Graham has met with a case (which will
 hereafter be detailed) which shews that even in that part
 of the aorta, the communication may be sufficient to allow
 a passage to the blood.
  " With respect to the case of contracted aorta, which
 1 had the opportunity of seeing, the following are the par-
ticulars,  as given to me by Mr. Winstone, Surgeon, of
 Charter-house Square, who solicited me to inspect the
 dead body:—
  " 6 The gentleman, who formed the subject of it, was
 57 years of age, of a full habit, accustomed to free living;
 had been in good health for years, excepting in the win-
 ter, when he was always troubled with a violent cough;
 more violent than I  ever witnessed in any other person.
In the night of April  the  7 th, 1809, he was affected
 with cough and difficulty of breathing to a greater  de-
 gree than usual;  and at five in the morning I saw him.
 He  complained of pain under the sternum, the extremi-
 ties were cold, the countenance exhibited marks of inex-
 pressible anxiety: the pulse was rather weak, but regular,
 and much altered in frequency.   These symptoms con- 
ELEMENTS OF SURGERY.           229
tinued with but little alteration, notwithstanding cupping
on the sternum,  blistering and volatile medicines, until
about eleven o'clock, when he was prevailed upon to go
to bed.   He walked up stairs, and fell on the bed life-
less.' "
  "Upon our opening the body, the pericardium imme-
diately presented itself, exceedingly distended; and on
making an incision into it, a large quantity of blood was
discharged; upon examination of the heart, one  of the
coronary veins was found ruptured on the anterior sur-
face of the right ventricle.   At first I supposed this was
the source of  the blood found in the pericardium ;  but
upon more minute examination of the heart, when I had
brought it to my house, I found an opening leading into
the right ventricle, and that the rupture had begun in
this part of the heart and extended through its substance,
bursting the vein in its progress.  I opened the pulmo-
nary artery, but found it free from disease ; the left side
of the heart was also healthy, but the lungs adhered in
some degree to the inner side of the chest, and a small
quantity of fluid was found  in each remaining portion of
the cavity of the thorax.  The  finger being thrust into
the  aorta, opposite to that part at which  the canalis
arteriosus terminates, a stricture was discovered in it,
which with difficulty admitted the little finger, and which,
on more particular examination, was found to be a thick-
ening of the circular fibrous structure of the vessel,  ac-
companied  with some  ossification of its coats.  This
state of contraction in the aorta  impeded the passage of
the blood through the heart and lungs,  and under  the
extreme degree of distention thus  produced, the right
ventricle, from  its less power of resistance, gave way,
and occasioned  the sudden termination of the patient's
existence.
   "The following case has  been published in the  Medi-
co-Chirurgical Transactions, by  Mr. Graham, Physician 
230
ELEMENTS OF  SURGERY.
 to the Infirmary, Glasgow.—(Vide Medico-Chirurgical
 Transactions, Vol. V.)

   " < The  case which I take the liberty of transmitting
 to the Medical and Chirurgical Society, has, as far as I
 know, but  one parallel on record;  and in it the appear-
 ances on dissection only are mentioned;  no  history is
 given of the case.   I believe, I have extracted from the
 books of the infirmary,  such parts of the reports taken
 at the patient's bed-side  as are of  any importance, and
 have noted some anomalous symptoms which may now
 appear  trifling; because it may perhaps be  found that
 an improved state of knowledge may give importance to
 what at present seems  adventitious, and without value.
 I am sorry to say, that as I can see no diagnostic symp-
 tom, the occurrence of this derangement adds but another
 chance to our guessing wrong during life, at the diseases
 of the heart.
   " Henry Frere, 14 years of age, a weaver, admitted
 into the infirmary the 3d of August,  1813, where the
 following history of his symptoms was  entered on the
journal  of the house:—
   " i Two weeks ago, after exposure to cold, was affect-
 ed with dry cough, which, for the last eight days has
 been attended with tolerably copious expectoration and
 pain, impeding respiration,  and excited by the cough,
 in the left side of the chest; pulse  100, somewhat firm;
 little appetite ; much thirst; tougue rather white; bowels
 regular; sleeps ill; sweats considerably ; has used no
 medicines.'"
   " The disease  was regarded as a case of pneumonia,
 but of such standing,  that suppuration  seemed to have
 taken place, and in which, therefore, no  material benefit
 was likely to result from any treatment. However, under
 the ordinary means, bleeding,  blistering, expectorants,
 and the free use of cathartics,  I had the satisfaction of 
ELEMENTS OF SURGERY.
231
seeing the symptoms decline.  The blood from the first
bleeding presented somewhat of the buff coat.  The
pulse, however, generally ranged from 92 to 104, and
is variously marked in the reports; full, strong, sharp :
it was always regular.  The sputum became more copi-
ous, gross, and tinged with blood. He perspired chiefly
from the upper parts of the body, moaned in his sleep,
and took little food.   On  the 8th he was  affected with
nausea and vomiting.   On the 19th he had a febrile at-
tack, which lasted a few days.  On the  20th there was
much pain in the left eye-ball.   On the 27th  he com-
plained only of palpitation—the first time that symptom
is noticed in the journal, though I rather think this was
an oversight.  No report  was taken  from this date till
the 6th of October, when he was dismissed from  the
hospital "cured."
  "The palpitation had subsided as the  strength increa-
sed ; which encouraged a hope I was willing to entertain,
that this symptom proceeded from weakness, though I
could not but express  fears that  the inflammation had
extended to the pericardium or the heart.  The uncer-
tainty of the diagnosis in cases of this kind,  is but too
well  known to every practitioner.   I  was inclined to
suspect the effusion of serum within the pericardium, or
perhaps adhesion of the heart to its capsule,  though I
had seen at least two cases about that time of  the most
intimate and general  adhesion, without the circulation
having been in any degree affected.
   " These fears were much strengthened by the boy's
appearance on returning  to the  hospital on the 13th of
November, when the throbbing of the carotid  and sub-
clavian arteries was  very remarkable.   On his re-ad-
mission, the following report appears on the journal:—
   " i 13th JVayem&er.-Dyspncea, palpitation at the heart,
and pain in the left side of the thorax returned soon after
he left the house, and have been gradually increasing; 
232           ELEMENTS OF SURGERY.

pulse 88, regular, bowels kept open by physic; received
temporary relief from the application of a blister.' "
  " Blisters and cathartics were again employed,  and
the symptoms for a time declined.  The pain, which had
been removed, returned to the left side of the chest on
the evening of the  29th.   A blister was repeated next
day, which gave much pain, till he was suddenly seized
with a febrile attack on the 2d of December, when the
part became quite easy.  There was no strangury. The
fever was gone next day.  A similar attack, accompani-
ed with nausea and  vomiting, was experienced on the
12th,  and immediately removed by the operation of an
emetic.  He had acidity at the stomach, and cardialgia
after meals.  On the 23d, he is reported as having been
affected for ten days with pain in  the right side of the
chest, increased by motion, and by full inspiration, ac-
companied by frequent cough, most troublesome in the
night.   The  pulse had again risen; he was blistered,
used cathartics, and was twice bled; the blood, espe-
cially after the first operation, being very buffy.  The
pulse  subsided, and the pain was removed, but the cough
and palpitation continued.  The circulation was again
quickened  on the  27th, and  remained hurried  till his
death; he sunk at length; was drenched in perspiration:
took no food; was  attacked with frequent vomiting; the
urine  became  sandy;  his sleep  was  disturbed:  the
dyspnoea and palpitations increased, and he  expired
about noon on the 2d of January.   The pulse, while he
was last in the hospital, fluctuated from 90 to 116, and
was of various degrees of strength and firmness ; latter-
ly only, weak :  it was always regular.

                    DISSECTION.

  " There  was  nearly a pound of serum in the cavity of
the  abdomen, and the bowels were distended with flatus. 
                ELEMENTS OF "SURGERY.            ^66

 but the viscera seemed natural. Immediately on turning
 up the sternum, the pericardium presented itself  very
 much enlarged, obscuring the left lung, and adhering to
 the pleura costalis.   Thi» capsule, which was thin and
 beautifully transparent,  contained about an ounce  of
 fluid, and a heart nearly  twice its natural size for a boy
 of this age.   The arteries and trachea were distended
 above the arch of the aorta;  the contents of the thorax
 were turned downwards ; and the aorta,  being div ided
 below the whole, was removed from the  body.  The
 walls of the left ventricle were about an inch iu thick-
 ness, but no other  derangement in the structure of the
 heart or its valves,  was observed.  The  capacity of the
 cavities seemed natural.  The aorta expanded unusually
 near its origin, so as to form a kind of pouch, but after
. having given off the branches to  the head and superior
 extremities, its diameter was preternaturally contracted.
 It was continued of this  diminished  size  till  after its
 union with  the canalis  arteriosus, where it was  com-
 pletely impervious.   The coats were not thickened, or
 in any  way diseased, except that about half  an inch
 below the stricture, there was a smooth elevation on the
 inner surface, less raised, but having nearly the diame-
 ter of a split pea; otherwise the appearance was exactly
 such as if a  ligature had  been tied tightly round the
 artery.   The obstruction was about a line in breadth.
 The artery then received three trunks about the size of
 crow quills, and near them three smaller  ones,  after-
  wards  resuming its natural  size along the  vertebrae.
  These three trunks are evidently the uppermost of the
  inferior intercostals ; their coats were remarkably thin,
  like those of veins. A probe passed from the pulmonary
  artery along the canalis  arteriosus to the obstructed por-
  tion of the aorta:  but from its thickened appearance, it
  did not seem  probable much communication by means
  of it could have been allowed, and the florid countenance
       Vol. II.           H h 
234
ELEMENTS OF SURGERY.
of the boy during life establishes the same conclusion.
There having been no suspicion of this singular devia-
tion from the natural structure till  after the contents of
the thorax were removed from the body, it was impossi-
ble to trace, with the accuracy that could be wished, the
anastomosing branches by which the circulation had been
carried on in the inferior parts of the body; but I think
enough has been observed to lead us very near the truth.
The arteria innominata, the left subclavian, the superior
intercostals, and the mammary arteries, were much en-
larged.  The epigastric was reported to be  of its natural
size.   These facts, and the aorta acquiring at least very
nearly its natural size immediately below  the stricture,
shew that the blood did not pass to the inferior extremi-
ties,  in any material quantity,  as  might perhaps  have
been  expected,  by the inosculations of the mammary
and epigastric arteries, but chiefly by the communications
of the superior  intercostals and the mammary arteries
with the three large branches entering  the aorta below
the stricture:  also  from the  mammaries and thoracics
through others of the intercostal and diaphragmatic ar-
teries.
   " The lungs  were very light coloured;  the left  lobe
much collapsed.  In each  side of  the thorax there was
a small quantity of bloody serum."

   " After the aorta has formed its curvature, it gives off
numerous intercostal arteries within the  cavity of the
chest; and  though these  vessels are small, they com-
municate sofreelv  with each other, that under a gradual
obliteration  of the aorta, the blood would be still readily
transmitted  to  the  inferior parts of the body.  An ex-
ample of this  kind is  related  by Mr. Paris,  and is
quoted by Mr. John Bell, in his Surgical Observations.
   " Mr. Paris,  Dissector for the Amphitheatre  of the
Hotel-Dieu, in  the year 1789, injected the  body  of a 
               ELEMENTS OF SURGERY.           235

*very lean old woman, about 50 years of age, whose ar-
terial system  was found to be singularly deranged, and
the circle of the blood changed altogether by a complete
contraction of the aorta a little beyond the arch.  Mr.
Paris had his attention  particularly excited to the con-
dition of this subject by the unaccountable enlargement
of the small arteries upon the fore part of the chest. He
had filled the arteries  with  an injection composed of
equal parts of suet and resin, coloured  with lampblack;
and this injection, thrown in from the mouth of the aorta,
passed  along  so easily, that far from suspecting an obli-
teration, he felt that  he could have thrown in more in-
jection  than is usually required for filling an adult body.
   " The subject was so meagre, that, without dissecting,
 Mr. Paris felt the thoracic arteries running down the
 sides of the chest tortuous and remarkably enlarged. It
 was natural for him to be very careful in the dissection
 of this  subject.   He found the aorta immediately beyond
 its arch contracted  to the  size  of a writing quill; the
 coats of the artery were of their usual thickness, and its
 cavity of course  extremely  small;  the  arch of the aorta
 above this contraction was but very slightly dilated ; the
 part below had lost nothing of its natural size. Nothing
 could be found either in its own structure, or in the con-
 dition of the  neighbouring parts, to account for this con-
 traction of the artery.
   "The carotids were in  the natural  state; the arteria
 innominata,  and the left subclavian were enlarged to
 twice their natural diameter; all their smaller branches
 were increased in the same proportion, and had assumed
 a curled and zigzag course :  the internal mammary and
 phrenic arteries were  greatly enlarged and very tortu-
 ous.   The transverse arteries of the neck were of twice
 their natural size ;  their posterior branches were tortu-
 ous, extending  to a great  distance over the back, with
 long inosculatione which were  met from below by the 
236
ELEMENTS OF SURGERY.
branches of the upper intercostal arteries, and they were
also remarkably enlarged;  the thoracic and scapular
arteries which run along the  side of the  chest, were
twice their natural size.
  " Below the constricted part of the aorta, the lower in-
tercostals  were remarkably enlarged,  even to three or
four times their natural size; each of them was dilated,
but those were most affected which were given off near-
est the contracted part; and the posterior branch of each,
which penetrates to the muscles of the back, was more
dilated than that which runs between the ribs : indeed,
those posterior  branches were so remarkably dilated
with contortions so closely succeeding each other,  that
they resembled a necklace of beads ; and their inoscu-
lations with the branches of the transversalis cervicis
were very remarkable.   The  lower phrenic artery was
enlarged, forming considerable inosculations with  the
superior phrenic; the epigastric artery was dilated to
the size of the enlarged mammary, and was joined with
it by very numerous  and conspicuous inosculations!"
This case clearly demonstrates, that the greater part of
the  blood, usually conveyed  by means  of  the  aorta
through  the  thorax,  is capable of finding  a circuitous
course by the branches of the subclavian and intercostal
arteries.

   " With respect to the aorta in the abdomen, I have met
with no instance in the human subject of its obliteration
or contraction; but if such  an event  were to occur, little
difficulty could  arise in the  transmission  of blood by
collateral channels:  the mammary and epigastric, the
superior and inferior mesenteries, and the lumbar arte-
ries would furnish abundant opportunity for a collateral
course of the blood.
   " Although in the human subject we are thus deficient
in  evidence  concerning  a circuitous  circulation  in the 
               ELEMENTS OF  SURGERY.           237

cavity of the abdomen, yet with respect to other animals,
it  is  probably generally  known,  that I  have several
times made ligatures upon  the  aorta  of  the  do£. and
found that the blood  was readily carried  by anastomo-
sing vessels to the posterior extremities of  the animal.
Of which experiments an account has been published in
the Medico-Chirurgical Transactions.
   " The incision was, in eacli experiment, made on the
left side  of the spine, the aorta was drawn to the surface
of the skin by an aneurismal  needle,  and all the sur-
rounding parts being separated from  the vessel, so as
to perfectly bare its coats, a  ligature was applied around
it.   An animal under these circumstances was kept for
a few weeks,  and then killed:  being injected and dis-
sected,  the lumbar  arteries,  which were considerably
enlarged, were found to be the chief agents of the new
circulation.   We have  a beautiful  preparation in Che
collection at St. Thomas's Hospital,  shewing the obli-
terated aorta,  and the numerous and  enlarged anasto-
mosing  vessels which carried on  the circulation; thus
establishing, as far as analogy could go, the possibility
of the blood being transmitted in a similar maimer in the
human subject.
   " I shall now proceed to detail the circumstances of the
case, which forms the principal object of this Paper,
leaving the remarks  upon the  kind of ligature to be em-
ployed till a description of the operatiou has been given.

                       CASE.

   " Charles Hutson, a  porter, aged 38 years, was ad-
mitted into Guy's Hospital April 9, 1817, for a swelling
in the left groin, situated partly  above, and partly below
Poupart's ligament.  An obscure pulsation could be per-
ceived in it,  and it  was concluded to be an aneurism.
The  history which he gave of himself was, that thirteen 
238
ELEMENTS OF  SURGERY.
months previous to his admission, he had fallen against
the corner of a chest,  by which accident he received a
violent blow upon the left groin, and was so much hurt
as to be unable to walk to his home.   On the following
day, his thigh became so much discoloured and swollen,
that he could not rise from his bed.
  " After a confinement of three weeks, he began to re-
cover, and the limb soon returning to its natural size, he
resumed  his employment, but was never able to exert
that limb with the same freedom as the other : however,
he continued to work, though with the greatest difficulty,
till within a fortnight of his admission into the hospital:
for some time previous to which, he had been occasion-
ally troubled with a pricking sensation in the limb,  but
it  was only transient, and  seemed  to arise from  the
pressure of the swelling upon the anterior crural nerve.
Some degree of swelling had remained in the groin from
the time of the  accident; and for some weeks previous
to his admission, he  had been  obliged  to  loosen  his
clothes on the left side.
  " At this period the  swelling was considerably diffu-
sed, several large veins crossed its surface, and pressure
upon it gave considerable pain.  On the third day after
he had been in the  hospital, the  swelling increased to
double its former size, and  the pulsation became less
distinct, excepting in the course of the iliac and femoral
arteries.   The swelling  extended from  three to four
inches above Poupart's ligament, to an  equal distance
below it, and was of great magnitude.  Just below the
anterior and superior spinous process of the ilium, a dis-
tinct fluctuation could be perceived in the  aneurismal
sac above Poupart's ligament, so that the blood had evi-
dently not yet coagulated; and the peritoneum was car-
ried far from the lower part of the abdomen, in such a
manner as to reach the common iliac artery, and to ren-
der an operation impracticable without opening the ca- 
               ELEMENTS OF SURGERY.           239

vity of the peritoneum.  I therefore determined to avail
myself of other means, or to wait the efforts of nature
towards  a spontaneous cure, before  I performed any
operation; a circumstance which it is well known every
now and then occurs.
  " May 16.—The swelling had  suddenly increased;
and the pulsation becoming more distinct, twelve ounces
of blood were  ordered to be taken from the arm.
  " 21.—Pressure was applied upon the fore part of the
swelling, by means of a cushion bound down upon it by
a broad  roller; twelve ounces of blood  being drawn
from his arm,  the patient declared himself to be more at
ease.
  "27.—The pressure upon the tumour being removed,
the skin was found abraded and discoloured, with the
loss of its sensibility.
  " 30.—In the morning he reported, that he had passed
a restless night, and appeared to labour under consider-
able constitutional irritation.   The swelling had very
much increased; a tourniquet was ordered to be applied
upon it, with directions to adjust it in  such a manner  as
to press upon  the aneurism,  but upon the surrounding
parts as little as possible.
  "June 1.—He had borne the  pressure of the tourni-
quet tolerably well, but it made no  difference in the size
of the tumour.
  "4.—When the tourniquet  was loosened, a slight
ulceration of the skin over the sac  was observed, and it
was therefore  ordered not t© be re-applied.
  "5.—He complained of the limb feeling so excessively
heavy, that he had  difficulty in raising  it.   The skin
over the aneurism is shewing a disposition to slough.
  " 19.—A slough was observed on the exterior part  of
the swelling below Poupart's ligament, which had nearly
separated with a deep ulceration around it.
  " 20.—At ten in the morning he had a bleeding from 
240
ELEMENTS OF SURGERY.
the external part of the sac, but the loss of blood was
not considerable.  A compress of lint was applied, and
confined by adhesive  plaster.   He  had no  return  of
bleeding on the following day.
  " 22.—At 7 o'clock in the morning, after some slight
exertion, he bled again; but still the bleeding was hot
profuse.
  " 24.—The bleeding  again  recurred,  but stopped
spontaneously.
  " 25.—About  half-past two o'clock in the afternoon,
in consequence of a sudden  mental agitation, he bled
profusely.  My  apprentice, Mr. Key, fortunately suc-
ceeded in preventing his immediate dissolution by pres-
sure, but the man was so much exhausted, that the faeces
were passed involuntarily.
  " At 9 o'clock the same evening I saw him,  and found
him in  so  reduced a state, that he  could not survive
another haemorrhage, with which he was every moment
threatened.  Yet, still  anxious to avoid opening the ab-
domen,  to secure the aorta near to its bifurcation, I de-
termined to ascertain whether it were practicable to pass
a ligature around the artery from within the aneurismal
sac; for I  was of opinion, that  if the artery  had given
way near the centre of the  sac,  as  it usually  does  in
aneurism, I might compress it with my finger, and pass
a thread around  it.  With this  view, I made a small
incision upon the aneurism, about two inches above Pou-
part's ligament;  and having made a very small opening
into the sac, I passed my finger easily into it, and felt
for the artery upon which it was formed ; in doing which,
my finger so completely filled the opening, that it pre-
vented the  escape of any blood by its side.  I moved
the finger to feel for the artery,  but found only  a chaos
of broken coagula,  and that the artery entered the sac
above and quitted it below, without there being  any in-
tervening portion of vessel;  and therefore,  was con 
ELEMENTS OF  SURGERY.           241
strained to abandon  that mode of operation.   When I
was about to withdraw my finger, I directed two of the
students to compress  with  their hands  the aorta upon
the spine, and they succeeded in stopping the pulsation
in the artery of  the  right groin.  As  I  withdrew my
finger, I put a dossil of lint by its side, and closed the
opening which I had made into the sac.
   "It is proper here to observe, that the aperture made
into the aneurism by the sloughing process, was  situa-
ted too far from the  natural seat of the  artery, to allow
a hope of my finger reaching it from thence.  As I was
quitting the patient's bed-side, I felt a great regret, in
which all the students by whom I was surrounded joined
me, that the  patient  should be left to  perish, without
giving him the only chance which remained of prevent-
ing his immediate dissolution from haemorrhage, by tying
the aorta; and I  therefore said, " Gentlemen, this only
hope of safety I am determined to give him."
   " The operation was performed as follows : The pa-
tient's shoulders were  slightly elevated by pillows, in
order to relax, as much as possible, the  abdominal mus-
cles ; for  I expected  that a protrusion of  the intestines
would produce embarrassment in  the operation, and was
greatly gratified to find that this was prevented by their
empty state,  in consequence of the involuntary evacua-
tion of the faeces ; and here let me remark that I should,
in a similar operation, consider it absolutely necessary,
previously to empty the bowels by active aperient medi-
cines.
   " I then made an incision three inches long into the
linea alba, giving it a slight curve to avoid the umbili-
cus : one  inch and a half was above, and the remainder
below the navel, and the inclination of the incision was
to the left side of the umbilicus in this form ( fc).  Hav-
ing divided the linea alba, I made a small aperture into
the peritoneum, and  introduced my finger into the abdo-
     Voi. II.           I i 
242           ELEMENTS  OF SURGERY.
men; and then, with a probe-pointed bistoury, enlarged
the opening into the peritoneum to nearly the same ex-
tent as that of the external wound.  Neither the omen-
tum nor intestines protruded; and during  the progress
of the operation,  only one small convolution projected
beyond the wound.
  " Having made a sufficient opening to admit my finger
into the  abdomen,  I then passed it between the intes-
tines to the spine,  and  felt the aorta greatly enlarged,
and beating with excessive force.   By means of my fin-
ger nail,  I scratched through the peritoneum on the left
side of the aorta, and then gently moving my finger from
side to side, gradually passed it between the aorta and
spine, and again penetrated the  peritoneum on the right
side of the aorta.
  " I had now  my finger under the artery, and by its
side, I conveyed the blunt aneurismal needle armed with
a single ligature behind it; and my apprentice, Mr. Key,
drew the ligature from the eye of the needle to the ex-
ternal wound;  after which the needle  was immediately
withdrawn.
  " The next circumstance, which required considerable
care, was the exclusion of the intestine from the ligature,
the ends of which were brought together at the wound,
and the finger was carried down between them, so as to
remove every portion of the  intestine from  between the
threads: the  ligature was then  tied, and its ends were
left hanging from the wound. The omentum was drawn
behind the opening as far as  the ligature would admit,
so as to facilitate  adhesion; and the edges of the wound
were brought together by means of a quilled suture and
adhesive plaster.
   " During the time of  the operation, the faeces passed
off involuntarily, and the patient's pulse, both immedi-
ately, and for an  hour after the operation,  was 144 in a
minute j he was ordered thirty drops of tincture of opium 
ELEMENTS OF  SURGERY.
24S
and camphorated mixture, and the involuntary discharge
of fasces soon after ceased.   1 applied my hand to his
right thigh immediately after the operation, and he said
that I touched his foot; so  that the sensibility of that
leg was very imperfect.
   "For the following particulars I am indebted to Mr.
Cox, one of my apprentices.
   "At midnight his pulse was 132.
   " 26.—At one  o'clock in the morning, the  patient
complained of heat in the abdomen, but he felt no pain
upon pressure; he said that his head felt hot, and that
he had pain in the shoulders; his lower extremities,
which were cold soon after the operation, were now re-
gaining their heat; his body was in other parts covered
with  a cold sweat.   The sensibility of the lower extre-
mities has  been very indistinct since the operation.
   " At 2 o'clock,  he felt so comfortable from his medi-
cine that he wished to have more of it, and ten drops of
tincture of opium  were given him;  his legs were wrap-
ped in flannel, bottles of hot water were applied to the
feet, and he then  said that the heat  of his belly was
lessened.
   " At 6 o'clock the sensibility of his  limbs  was still
imperfect.
   " At 8 o'clock A.M. he expressed himself as feeling
quite comfortable; he however passed no urine, and had
no evacuation; his right limb was warmer than the left,
and the sensibility was returning.
   " At noon the temperature of the right limb was 94,
that of the left or aneurismal limb 87 f.
   " At 1 o'clock P.M. Mr. Cooper visited him, and as
he walked up the  ward he  appeared  much gratified at
seeing his patient,  who was at the point of death the
evening before, and who was now adjusting  his bed-
clothes, and smiled as Mr. C. approached his bed.
   "At 3 o'clock after a fit of coughing,  the man was 
244
ELEMENTS OF  SURGERY.
much alarmed with the idea of the thread having slipped
into the wound : it was a false alarm ; but,  to prevent
the idea of its occurrence,  it was fastened  to a quill:
soon after this he complained of pain in the abdomen;
it  was not very severe, nor did it last long; readily
yielding to fomentations.   As he had no evacuations, he
was ordered an enema.
   " At 6 o'clock, P.M. he vomited, soon after the glys-
fcer had been administered: the heat of the right leg was
96, that of the left or diseased limb 87 \.
   " At nine in the evening he took half a glass of port
wine in warm water, which he immediately rejected:
he complained of pain  in  the loins;  his pulse was 104
and feeble; he was very restless, and had an involun-
tary discharge of faeces.
   " Eleven at night, his pulse 100 and weak; he still
vomited.
   " 27.—At 7 A.M. tin? report was, that he had passed
a restless  night; the vomiting had returned at intervals ;
his pulse 104, weak and fluttering; he complained  of
pain all over his body, more particularly in his head;
and the carotids beat with  considerable force; he had
great  anxiety expressed in the countenance, was  very
restless,  and the urine dribbled from him, with some
degree of pain at the end of the penis.
   " At 8 o'clock, A.M. the aneurismal limb appeared
livid and felt cold,  more  particularly around the aneu-
rism, but the right leg remained warm.
   "At 11 o'clock his pulse was 120 and weak;  he ap-
peared to be sinking.   To the questions which were put
to him he did not  return any answer; he appeared to
have an uneasiness about the heart as he kept his hand
upon the left breast.
   "He died at 18 minutes after one, P.M. having sur-
vived the  operation 40  hours.
   " After being informed of his death, I requested Mr. 
ELEMENTS OF  SURGERY.
245
Brookes of Blenheim Street to attend with me at the
inspection of the body.   Mr. Travers, surgeon of St.
Thomas's Hospital, Mr. Stocker, apothecary of Guy's,
and a large concourse of medical students attended the
examination.
   " When the abdomen was opened,  we found not the
least appearance of peritoneal inflammation,  excepting
at the edges of the wound.   The  omentum and intes-
tines were free from any unnatural colour ; the edges of
the wound were glued together by adhesive inflamma-
tion, excepting at the part at which the ligature project-
ed.  We were much gratified to find that  the ligature
had not included any portion either of the omentum or
intestine : the thread had been passed around the aorta
about | of an inch above its bifurcation, and about an
inch or rather more below the part at which the duode-
num crossed  the  artery.  Upon carefully  cutting open
the aorta, a clot of more than an inch in extent was
found to have sealed the vessel above the ligature;  be-
low the bifurcation, another, an inch in extent, occupied
the right iliac artery, and the left was sealed by a third
which extended as far as the aneurism; all were grati-
fied to observe the artery so completely shut in 40 hours.
The aneurismal sac, which was of a most enormous size,
reached from the common iliac artery to below Poupart's
ligament, and extended to the outer side  of the thigh.
 The artery was deficient from the upper  to the  lower
part of the  sac,  which was occupied by an immense
quantity of coagulum.
   " The neck of the  thigh-bone had been broken within
 the capsular ligament, and had not been  united.

   " Upon consideration of all the circumstances of the
 case, to what are we to attribute this man's death ?   It
 did not arise from inflammation, for  the viscera of the
 abdomen were perfectly free from it. 
 246     »      ELEMENTS OF  SURGERY.

   " His death appears to me to have been owing to want
 of circulation in the aneurismal limb ;  for although the
 warmth of the other limb was  preserved, that on which
 the aneurism was seated never gained its natural heat,
 which must  have arisen from the great bulk of the aneu-
 rism, and from the disturbed state of the coagulum which
 it contained, which  would prevent the free course of the
 blood through the aneurismal sac.  That limb never re-
 covered its natural heat, there being seven degrees dif-
 ference between the two extremities ; the sensibility also
 in the right  limb was  returning, which did not appear
 to be the case in the left.  In an  aneurism therefore
 similarly situated,  the ligature must be applied before
 the swelling has acquired any  very considerable magni-
 tude.
  " There is still a circumstance, however, that remains
 to be decided respecting a ligature upon the aorta; which
 is, in what  manner it is to be afterwards  separated:
 whether  it should be left suspended at the wound, or
 cut oft' close  to the vessel: whether the presse-arle re of
 that ingenious surgeon Mr. Crampton should be employ-
 ed ; or some unusual material should be used as a liga-
 ture. Although the patient whose case I  have  here given,
 did not suffer from  inflammation of the abdomen, yet I
 should much fear that if he had lived longer, an extra-
neous substance suspended  amidst the intestines would
have produced that  effect.
  " My friend  Mr. Lawrence has proposed that the
silk  usually employed for  ligatures  should be cut off
close to the knot, so as to heal  the wound over it. It has
occurred to me that catgut would answer the purpose
better, and I shall  give  the result of the trial which I
 have made,  wishing it to be understood that I consider
the subject at present as undecided, and only as one for
future investigation.
  " Catgut,  employed as a ligature, being more of the 
ELEMENTS OF  SURGERY.
247
nature of  the animal  matter in which it is embedded,
will be more easily absorbed than silk;  or, if even not
absorbed,  will  be less likely to excite irritation in the
parts.
  " I have reason to hope that  the  following case will
be considered as highly interesting and important, as the
operation  was performed upon a person so advanced in
life as to lessen the hope which would have arisen from
the more usual operation for aneurism.
  " I performed the operation at Guy's Hospital, where
the patient, who is the subject of it, at present remains ;
the notes of the case were taken by Mr. Hey,  the son
and grandson of the celebrated practitioners of that name
at Leeds,  who is now my pupil and  clerk at Guy's Hos-
pital.  From the assiduity he has discovered in his stu-
dies,  and  the acquirements made in his profession, there
is every probability that he will confer additional bril-
liancy on  a name which ranks amongst the highest in the
present race of the medical profession.

                       CASE.

   " October 15th, 1817, William Heydon, aged 80, of
a spare habit, but enjoying  good health, has been  for
some years without any regular employment on account
of his age, but  accustomed to take more or less of walk-
ing excercise ; his habits of life have been always regu-
lar.  About three months ago he perceived a pulsating
tumour situated very low down  in the ham, and which
at that time was  about the size of a pullet's egg; he
could assign no cause for its appearance, and took but
little  notice of it.  In a few weeks, however, it increa-
sed so much in size, and the pulsation became so strong,
that he was induced to shew it to a surgeon, who, find-
ing it to be an aneurism, recommended him to come into
the hospital. 
248           ELEMENTS OF SURGERY.

   " The tumour was now larger than an egg, compres-
sible, the pulsation very strong and perceptible, and the
skin of a natural colour.   The pulse,  though slow and
not weak, intermitted;  and the pulsation in the tumour
exactly corresponded with it.  He complained of a con-
siderable pain in the leg at times,  and when the  pain
was most violent the leg was very much swelled.  The
motion of the joint was somewhat impeded.
   " 24.—The usual incision for popliteal aneurism was
made, and a single ligature was applied round the arte-
ry, both ends of which  were cut off close, and the edges
of the wound brought together by adhesive plaster; the
substance made use of for the ligature was catgut, which
had been previously soaked in water, about the tempera-
ture of 100°.  The coats of  the artery were very much
relaxed,  so as to occasion some difficulty in passing the
ligature round it.
   " 5| P.M. About four hours after the operation, com-
plained of a sense of coldness and uneasiness in the limb
which had been operated ou; its temperature was  80°,
and that of the sound limb 84°.   The  pulse which beat
76 times  in the minute  was full and very irregular, but
did not intermit.
   " 25.—Has not passed a very good night, but feels
comfortable  this morning.  Temperature of the  limb
that has been operated  on 84u,  that of the sound limb
92°; pulse 60, and intermits ; but very rarely.
   " 26.—Has had a good night, and  feels  more com-
fortable,  though he still complains of violent pain in his
leg at times; temperature of the affected limb 89°, that
of the sound limb 92°; pulse intermits once in every 10
or 12 beats.
   "27.—Much in the  same  state  as  yesterday; tem-
perature of the affected  limb 89°, sound limb 87°.
   "28.—The wound  was dressed for  the first  time
since the operation,  and  was found to be completely 
ELEMENTS OF  SURGERY.
249
united; the pulse varies very much in its intermissions,
but upon the whole they have been much less frequent
since than before the operation.
  " 29.—Temperature of the affected limb 89°, sound
limb 87°.
  " 30.—Temperature of the affected limb 89°, sound
limb 93°; the tumour in the ham is considerably lessen-
ed and has no pulsation; nor is any pulsation to be yet
felt in the  anterior or posterior tibial artery, though a
free circulation appears to be carried on in the super-
ficial  veins.
  " 31.—Temperature of the affected limb 90°, sound
limb  91°.
  " November 1.—Temperature of the affected limb 91°,
sound limb 91°.
  "7.—Nothing material has occurred since  the last
report; there has  been very little  variation in the tem-
perature of the limb,  or in the state of the aneurismal
tumour, which continues gradually to subside.  The
wound remains perfectly united and free  from irrita-
tion.
  " 15.—The tumour continues to diminish in size and
is much softer; no pulsation can yet be felt in the ante-
rior or posterior tibial artery:  his health is very good,
and he can walk about the ward with the  assistance of
a crutch.
  " 24.—Continues to improve, no appearance of irrita-  ^
lion from the ligatures ; no pulsation in the anterior or
posterior tibial artery.
  " In three weeks after the operation he walked in the
ward with the aid of a crutch, and in the first week, he
had no other complaint than coldness in the foot on that
side,  with some pain in the heel.
  "December 17.—His health is perfectly good;  he
walks without the aid of crutch or stick;  the swelling
     Vol.  II.            K k 
250           ELEMENTS OF  SURGERY.

is reduced to a small size; and the part at which the
incision was made has been and now is quite free from
irritation.

  " I confess that this case gave me much pleasure; the
great age of the patient, the simplicity of the operation,
the absence of constitutional irritation and consequently
of danger, and  his rapid recovery, lead me to hope that
the operation for aneurism may become at some  future
period, infinitely more simple than it has been rendered
to the present moment." 
ELEMENTS OF SURGERY.            251
               CHAPTER XXVIII.


                Of False Aneurisms.


  Spurious or false aneurisms are always occasioned by
a wound or rupture of an artery, in consequeuce 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 case* 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 was 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-
                 • Scarpa says by GuattanL 
252
ELEMENTS OF SURGERY.
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- 
ELEMENTS OF SURGERY.
253
dily conceive, who understands any thing of arteties 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 
254           ELEMENTS  OF SURGERY.
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- 
elements of surgery.
255
vered with his finger the gush of warm blood, and dis-
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 1 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 
256            ELEMENTS OF SURGERY.
approve of my reasoning, cut the artery across in the
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. Yon 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 in those  cases in which you can tie the  vessel above
where it has been wounded, 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 
ELEMENTS OF  SURGERY.
257
over the artery.   These cases sometimes occasion very
little trouble to persons who do not use the arm violent-
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 in
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 aneurism 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. 1 have marked in italics.
     Vol. H.           L 1 
258
ELEMENTS OF  SURGERY.
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-
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, was so slow as not to be  observed, though
the basilic vein running over it began to enlarge.
   " On examining the arm I 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 iu  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 on 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
                     * See par-- ?54, 
ELEMENTS OF SURGERY.
259
no doubt been punctured by the lancet, pushed  into it
through the vein by the bleeder;  the pulsating tumour
was a sac formed in the cellular membrane between the
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,  1801; 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 unneces-
sary to describe the operation further tlufn to mention,
that after dividing the skin and cellular membrane cover-
ing 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. 
260
ELEMENTS OF  SURGERY.
           EXPLANATION OF THE PLATE.

Fig. 1.  A A.  The basilic vein distended above and be-
           low the puncture.
        B.  The cicatrix from bleeding.
        D.  The aneurismal sac.
        CC.  The brachial artery.

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
           artery and the aneurismal sac.
        CC.  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. 
Plate xxmi
Fir, /
PY</ 2.
 
 
ELEMENTS OF  SURGERY.
261
  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 was 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 thigh.  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 ankle, which greatly reduced
his strength, and although the bleeding was 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 below
the knee.

   Before concluding the subject of aneurism I  shall
briefly notice a species of tumour consisting chiefly of en- 
262
ELEMENTS OF SURGERY.
 larged blood-vessels, which has been called by Mr. John
 Bell, ANEURISM FROM ANASTOMOSIS.
   This complaint exists in some cases of nsevi 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 injury.   It is attended
 with  constant throbbing,  and great turgescence 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 freeh
 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
 which 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
easily detached, and the arteries  which  supplied it can
be secured.
  Mr. Pelletan relates a case somewhat analogous to
this disease, in which all  the branches of the temporal
artery were morbidly dilated, and I have very recently
seen a case of aneurismal  tumour in which the whole
scalp was pervaded by very large arteries.   The princi- 
               ELEMENTS OF SURGERY.            263

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 blood-vessels, and suf-
fered 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. 
264
ELEMENTS OF SURGERY.
               CHAPTER XXIX.


               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 cedematous 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 
ELEMENTS  OF SURGERY.
265
usual causes of inflammation 5 and in other instances no
evident cause can be assigned.
  The remedies for this complaint differ in nothing from
the common remedies for inflammation.  Blood-letting
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 cedamatous 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.
Vol.  II.            M in 
266            ELEMENTS OF SURGERY.
                CHAPTER XXX.


              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 ihe 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 attempts te 
ELEMENTS OF  SURGERY.
267
straighten the affected limb.  The 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 osfemoris ; 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. 
268            ELEMENTS OF SURGERY.
   I have known the bottom of the accetabulum 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  are highly recommended, do but
little service—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 difficultto carry this last prescription into effect,
and it is found extremely convenient to have 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.
xThe 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.
   The appearances of a diseased hip joint on dissection
vary according to the period of the disesse at which it is
mad".  Mr. Ford gives an account of two dissections,
 one in an  early and the other in a later stage of the, cf"*i- 
ELEMENTS OF  SURGERY.
269
plaint.  In the first the head of the  os femoris wa^ in-
flamed ; the capsular ligaments were somew hat thicken-
ed, the round ligament retained its usual connection both
to the head of the thigh bone, and to the acetabulum;
about, a teaspoonful of pus was 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 irihominatum 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 ailectious  of the joints,  I refer  to Mr. Sa-
muel Cooper's valuable treatise  on  the diseases of the
joints. 
270
ELEMENTS OF  SURGERY,
                 CHAPTER XXXI.


              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 psoae 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 eften commence with a difficulty in
 walking, with some sense of  weakness or uneasiness hi
 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 lower and points at the middle of the
thigh, travelling  under the tendinous  fascia femoris;
 sometimes in the loins, and sometimes on the hack.   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 
ELEMENTS OF  SURGERY.
271
patient very speedily and happily recovered his general
health, though a fistula in ano was the consequence, and
this was cured by an operation.
  Psoas abscess is often connected with a curious 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 unable to stand  erect, and
to exert the muscles of the loins, and paralysis of the
lower limbs comes on.
  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 instan-
ces recorded, although  fatal hemorrhage  has in some
cases resulted from absorption of the great blood vessels
in the vicinity of the abscess.
JThe danger of opening the abscess depends upon the vio-
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 
'272
ELEMENTS OF  SURGERY.
that the imperfection merely of a large cavity without its
exposure to the air. would 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 iuto 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 are now to be brought
into contact, and kept so by adhesive plaster—they unite
readily.  In performing this operation great care is ne-
cessary, if the abscess, point in the groin,  to avoid the
large vessels—probes or  cauulas  are never to be intro-
duced.  After the operation the  matter collects in a
few weeks, and is to be again opened in 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 vertebrae (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, 
ELEMENTS  OF SURGERY.
273
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.
Vol.  IT.            N n 
274
ELEMENTS OF SURGERY.
                CHAPTER XXXII.


                  Of Curved Spine.


   By this name is designated a disease, or caries, of the
 vertebra;, whkh 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 following observations from his excellent trea-
 tise 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  w ill appear to whoever will ex-
 amine the two complaints with any degree of attention. 
               ELEMENTS OF SURGERY.           275

  " In the true paralysis, from whatever cause, the mus-
cles of the affected limb are  soft,  flabby, unresisting,
and incapable of being put into 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 with a kind of spasm, the
legs of the patient are either constantly kept stretched
out straight, in which case considerable force  is required
to  bend the knees, or they are by the  actiou of the
stronger muscles  drawn across each other, in such man-
ner as to  require as much 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 are 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. 
276
ELEMENTS OF SURGERY.
  " The majority of those who labour under this disease
are infants, 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 uuguardedly,  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 others
which are different in different subjects. 
               ELEMENTS OF SURGERY.           277

  " If the incurvation be of the neck, and to a consider-
able degree, by affecting several vertebrae, the child 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 fasces 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. 
278
ELEMENTS OF  SURGERY.
   " In infants, the curve is seldom noticed till it has got
to such a size and state, as to demand attention from the
deformity: previous to this, all the marks of distemper
which 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
gome length of time;  in infants this  is  the sole cause,
and external violence has nothing to  do  with 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 
                ELEMENTS OF SURGERY.           279

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 vertebrae
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 vertebra; 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, iu 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
of which the arms only were affected, in the other both legs and arms.
  " Mr.fi. Ford, of Golden Square, has favoured me with the examination and
case of a lad, who lost the use of bo h legs, and bo h arms, from a curvature
which Mr. Ford cured by means of (he causiics. Mr Park, of Liverpool,  has
also obliged me with an account of two p rsons, both under his care, both with
useless arms and legs, and both cured by the same means." 
280
ELEMENTS OF SURGERY.
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 in an armed chair without much
trouble or fatigue, others cannot sit ftp 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 inquiry it will
always be found that  the curvature from within outward,
preceded  the other deformity, and was, 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 a hectic, or by a
drain from an abscess formed withiu the body.
   " That this is the case frequent and melancholy expe- 
ELEMENTS OF  SURGERY.
281
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 mischief, 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, which 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
hends forward only because the rotten bone, or  bones in-
 tervening between the sound ones give way, being tunable
 in such state to bear the weight of the parts above. The
 most superficial reflection on this must point out to every
     Vol. II.           O o 
 282           ELEMENTS OF SURGERY.

 one, why attempts 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,  w hen the disease is at all advanced, are in-
 capable  of bearing such a degree  of violence  without
 being much hurt thereby : this, if  it were 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 tot bear the use of them to such 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 known 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 in 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 tl em. i would not attempt to roh the affiicted
 of what  they seem to derive  such comfortable expecta-
 tion from : but as  1 am satisfied of their mischievous ef-
 fects, not only in the case of the present subject, but in
 many others ; I 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
 farmer they cannot do. and in all cases where the  spine 
               ELEMENTS OF SURGERY.            283

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 mauifest 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 w eak 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 res-
piration,  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  he
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.
   " 1 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 
284
ELEMENTS OF  SURGERY.
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 uuiform 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 exci-
ted in my mind,  were confirmed by what I had a few op- 
               ELEMENTS OF  SURGERY.           285

portunities of observing, in the dead bodies of some who
had died affiicted 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 mu^t have demanded judgment in adapt-
ing them to particular persons  and constitutions; and it
must also,  in the nature of things, have happened that
many individuals could not have  been benefited at all.
But fortunately lor the afflicted, the means of relief are
simple, unifornt, aud safely applicable to  every indivi-
dual, under almost every possible circumstance, not at-
tended by the smallest decree of  hazard, and capable of 
286
ELEMENTS OF SURGERY.
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 mem-
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 will 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 bv
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 ihat it is absolutely without limitation.
and must depend on their beneficial effect." 
               ELEMENTS OF SURGERY.           287

curvature in such a manner as to leave the 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 powder, aerugo asris, 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, w hen 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 ca- 
288
ELEMENTS  OF SURGERY.
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.
  " After the discharge has been made some time, very
uncertain what, the patient is found  to  be better in all
general respects,  and  if of age to distinguish, will ac-
knowledge that he feels himself to be in better health ;
he begins to recover 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 for the cure of
this distemper.  I have seen it perfected in two or three months, and I have
known it require two years; two thirds of whkh time passed before there was
any visible amendment." 
ELEMENTS OF  SURGERY.
289
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 stand some time  without making any farther
progress;  this in  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 patient 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
 he is suddenly thrown down.
     Vol. II.           P P 
290
ELEMENTS OF SURGERY.
  " 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 enclose 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 vertebre
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 qua non of the cure, and this must in such
cases render the curvature, and consequently the  defor-
mity, permanent:  the issues will restore the use of the
limbs, but not the lost figure of the spine."  (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- 
               ELEMENTS  OF SURGERY.           291

gular, and the spine is bent in several different direc-
tions—in cases of caries a few of the vertebras 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 forwards and outwards ;-the knees are bent in-
wards ;-the tibia is unusually convex and prominent ;-and
the feet turn outwards.  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. 
292
ELEMENTS OF SURGERY,
              CHAPTER XXXIIL


             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-
cause 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 expend so far as in the third
species. 
ELEMENTS OF  SURGERY.           298
  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 changed 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 palinaris, 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 seen, 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 aba-
ting the inflammation.  A blister should be applied over 
294            ELEMENTS OF  SURGERY.
 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 therefore 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. 
ELEMENTS OF SURGERY.
295
               CHAPTER XXXIV.


            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 operation is occasionally demanded.  The modem
improvements of surgery have  lessened the number of
cases which 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 w ith 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 
296           ELEMENTS OF SURGERY.
(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
stated 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 blood-vessels 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 
ELEMENTS OF SURGERY.
297
want of blood, or from excessive inflammation,  the ab-
sorbents if left to themselves will 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
for 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 clays, from the brink of
the grave the patient was 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 hematodes—
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.
     Vol. II.           Qq 
298
ELEMENTS of  surgery.
  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. Boyer
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 alw ays 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.'1 
elements of surgery.
299
                CHAPTER XXXV.


              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 pillows, 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 
300
ELEMENTS OF SURGERY.
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 ou 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- 
              ELEMENTS  OF SURGERY.            301

excusable. The retractor, a piece 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 wish 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
choaking 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.   If 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 drawrn 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.  The liga-
tures are to  lie brought out at each angle of the wound,
and a small piece  of  lint interposed between the  edges
of the shin,  in order to prevent the union of the skin be- 
302
ELEMENTS OF  SURGERY.
fore 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 tow, which is to be secured by a roller.
The malta  cross—the elongates—the knitted cap—are
all ussless 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, 
ELEMENTS OF SURGERY.           303
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 enclosing
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. 
304
ELEMENTS  OF SURGERY.
               CHAPTER XXXVI.


               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 successive 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,
1owt 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 the knee, and
the surgeon standing if convenient* on the inside of the
knee, makes an incision with the amputating knife  about
five inches below the putella, 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 circumstances, may interfere with
this arrangement. 
ELEMENTS OF  SURGERY.
305
divide the skin and adipose matter down to the fascia co-
vering the muscles.   With a scalpel the integuments are
to be dissected loose and  turned back, the surgeon ta-
king 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 greater
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 tihia, 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
     Vol. II.           R r 
306
ELEMENTS OF  SURGERY.
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 believe 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. 
ELEMENTS OF SURGERY.
307
              CHAPTER XXXVII.


              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 oft* 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 are
easily howrever 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. 
308
ELEMENTS OF  SURGERY.
             CHAPTER  XXXVIII.


         Of amputation of 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 analogous 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 adopted, 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 caracoid
process to the internal angle of the firsthand 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, cuts 
ELEMENTS OF  SURGERV.
309
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 single
stroke, by using a double edged knife, with  which the
surgeon may divide 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.
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
 see it for the first time, and if the surgeon have formed 
310
ELEMENTS OF  SURGERY.
his flap of the proper size, it covers the wound with great
accuracy."
  This operation, once considered among the most ter-
rific in surgery, has become familiar among military sur-
geons, and in consequence of its frequent performance of
late years, has almost ceased  to be an object of dread,
and Mr.  Guthrie declares " that  this once  formidable
operation may be considered as safe, as simple, and as
little hazardous as any other of importance performed on
the human body." I shall subjoin some of his observa-
tions respecting it.
  " This operation has until lately been  considered of
the utmost danger and importance, not only to the  life
of the person who is unfortunately the sufferer, but to the
reputation of the surgeon who has the performance of it:
many and various have therefore been the methods re-
commended for  conducting it, all  impressing on  the
mind of  the operator the great  extent of danger,  and
tending  to  disturb the  steadiness of  his  judgment.
Anatomy, which has thrown so much light on operative
surgery in general,  has not failed in the last few years
to dispel the cloud that obscured this part of military
surgery ;  and experience has proved it to  be as simple,
easy, and safe an operation, as any  other of importance
performed on  the field of  battle.   The knowledge ac-
quired from this source of its success, has given to mili-
tary  surgeons a confidence in performing it, that divests
it of half its former terrors, and by removing from  the
mind of  the patient the idea of his having suffered a
hopeless operation,  diminishes the  subsequent  danger,
and most materially aids  his recovery.  The dread for-
merly entertained of this operation was very great, even
by men of the best  abilities ; and under certain  circum-
stances in domestic surgery, it may  still be tedious.   It
can never however again be considered  formidable in 
ELEMENTS OF SURGERY.
311
military surgery, except under bad management,  and
from extreme ignorance.
  The  distinction  between the necessity of the opera-
tion, and the possibility of avoiding it, requires in many
cases the exercise  of the  nicest judgment, and a due
consideration of  attending circumstances;  for there is
no part of military  surgery, in which  an operation can
be performed with  more advantage at the  instant;  or,
delayed for a few days with a view of gaining informa-
tion, with more prejudice: inasmuch  as  the nectfssary
incisions are made in the first instance, in parts  dis-
posed to take on  healthy actions, and in the best possi
ble state for undergoing surgical operations.   The con-
stitution of  the patient being also at that  moment gene-
rally good,  and  able  to sustain the  demands upon it,
under untoward circumstances ; or of supporting, with-
out future injury, the restraint  and control requisite for
the successful accomplishment of the cure.
  The  difference between cutting in sound and diseased
parts is justly appreciated  by every surgeon, both as to
his  personal convenience and ease in operating, as well
as to the future healing of  the  wound ; and the advan-
tage here is particularly great,  as from the contiguity of
the wound to the chest and the principal organs of life,
it is advisable to  avoid any excess  of action; and expe-
rience has demonstrated that the evil to be apprehended
from the equilibrium of the circulation being destroyed,
is infinitely less than it would be at a subsequent period
of three or four weeks, after high suppurative action has
been going on.   In the latter,  the  operation is delayed
until the parts to be divided have been long carrying on
an increased action, and may even be diseased.  The
health and  strength of the patient  have  been so much
reduced, that he may be unable to support the additional
pain and  shock of the operation,  which  increase with
the delay, or of giving that assistance requisite for* the* 
312
ELEMENTS  OF SURGERY.
consolidation of the wound.  Another and  great con-
sideration, is the ease and safety with which a person
can be moved after the  operation, compared with the
danger and pain resulting from the disturbance of broken
bones, the increase of inflammation, and other attendant
evils under the same circumstances.  It cannot be there-
fore too strongly impressed on the mind, that the neces-
sary examinations should take place; and the operation
be performed in those cases demanding it, as soon after
the injury as possible, consistent with the state of the
patient;  and the surgeon should not satisfy himself with
the idea  of being able to accomplish it as safely, or as
successfully, when suppuration  has  been established,
and when perhaps he may have better assistance at hand;
a kind of self deceit that is occasionally permitted, but
which cannot be too much reprobated.
   The importance of the  arm is so great,  and even a
limited use of it so valuable, that much should be hazard-
ed to save it, when there is a tolerably fair prospect of
success:  the situation also and  structure of the upper
extremity, together with the command the surgeon has
over it, and the less proportionate inconvenience resulting
from a severe wound in that part to  any other of equal
value, renders its  preservation  after a serious  injury,
more  practicable, and less dangerous than is  frequently
supposed.  The operation should not therefore  be per-
formed, unless simple amputation by the flap operation
cannot be successfully  accomplished;  or,  where  the
limb  is  evidently destroyed,  or, the  injury  seriously
affecting  the articulation  itself, while the general health
of the patient, or the unfortunate circumstances of situ-
ation, render the  attempt at a farther perseverance in
saving the limb improper.
  Injuries from musket-balls  penetrating the capsular
ligament, attended  with fracture  and destruction of the
head and adjacent parts  of the humerus, and wounding 
ELEMENTS  OF SURGERY.
313
the axillary artery, require- immediate operation.*  A
simple  penetrating  or  incised  wound of the joint, of
small extent, does not call for any operation, as the pa-
tient, with due care, will escape with a  certain degree
of loss of motion, and of debility in the joint; nor is it
proper in a wound  from a  musket-ball,  where there is
even some partial injury of the bone, as these cases fre-
quently do well, and the patient preserves the use of
the fore-arm.                                         «
  Mr. Guthrie proceeds to  state at great  length, " acci-
dents in  the field," and  " subsequent  occurrences,"
which may demand the operation: for these the reader
is referred to his work.—
  It  is now  time  to correct another misapprehension
that the fear of haemorrhage  has introduced into this
operation ; I allude  to the idea prevalent amongst many
surgeons, that it is to be performed in a different manner
from  any other of importance ; that instead of the calm,
steady  determination that  distinguishes a  surgeon of
ability, who feels himself master of his subject, he is to
forget or lay aside,  what on all other occasions is con-
sidered most valuable,  and endeavour to attain a pecu-
liar precipitation and haste of  manner, that is excluded
from all other parts of  surgery.   There  is still a prac-
tical point usually overlooked,  that in military surgery
there is little or no arm left to  use as a lever in facilita-
ting the operation,  and  that the separation of the  head
of the bone depends upon the surgeon, and not upon the
assistants.
  The  patient should  be placed on a seat lower  than
the surgeon ; (in the field a hospital pannier is the best)
and so supported that  he may not be able  to slide off
during the operation, the assistant in charge of the  tour-

  * General Scott of the United States army, happily recovered from  such a
wound and lias a very useful arm.
Vol,  II.            S - 
314
ELEMENTS OF SURGERY.
niqtiet, or instrument described,* standing behind, and
regulating  the  support in  such manner  that he may
always be able to make steady compression  when re-
quired.   The shattered arm or stump is then to be raised
from the  body,  sufficiently to enable the hand  of the.
operator  to examine the axilla, and ascertain that his
assistant can  compress the artery when he pleases; for
this  simple motion  of raising the arm to near a right
angle with the body, to afford access to the axilla after
the pressure is  made, will frequently render some alter-
ation of it  necessary.  The arm should be also raised,
so as to point out more clearly the insertion of the pec-
toralis major, and the posterior fold of the arm-pit; and
as being  more convenient to the operator, who, placing
his finger on the lower end of the acromion process in
the centre of the shoulder, (the hair in the axilla having
been previously removed) with the smaller amputating
knife commences his incision immediately below it, and
with a gentle curve carries it  downwards and inwards
through the integuments only, a little below the anterior
fold  of the arm-pit,  and which the raising of the arm
readily points out.   The second  incision outwards, is
made after the same manner, but something lower down,
and is continued underneath,  so  as to shew  the long
head of the triceps at  the  under  edge of the deltoid,
without dividing any of the muscular fibres;  by which
means the  skin has time and freedom to retract,  which
is a great object, being the part in general most wanted,
and  when retracted allows of subsequent  extension.
The third  incision commencing at the same spot as the
first, but following the margin of  the retracted skin, di-
vides the deltoid on  that side to the bone, and exposes
the insertion of the pectoralis major, which must be per-
fectly cut through, to shew the short head of the biceps
  * The hanll'- of the common tourniquet covered with a linen bolster, is to
be pressed by an assistant on the subclavian artery where it crosses the first rib 
ELEMENTS OF SURGERY.           315
flexor cubiti, and the coraco brachialis, which are then
readily known  by their longitudinal fibres, and  the
freedom the arm or stump receives from losing its attach-
ment to the fore  part of the chest: these two  muscles
however are not  to be touched, although the flap thus
formed is to be separated, and raised so as to  expose
the head of the bone, nearly as far as the coracoid pro-
cess of the scapula.  The fourth  incision outwards, in
the same manner divides the deltoid muscle down to the
bone, and extending to the long head of the triceps,
which it is not necessary to touch, as it would be after-
wards divided:  this flap is to be well turned back, so
as to shew the insertions of the teres  minor and infra
spinatus, coming across  horizontally from the scapula,
to be inserted into the great tuberosity of the humerus;
the posterior circumflex artery will be divided close to
the bone,  the anterior circumflex,  and the continuation
of the  thoracica  humeriana on the integuments of the
arm, and  some other small vessels  may bleed, if the
compression  be  not correctly applied; they ought not
however to be tied, but merely stopped with the finger,
and particularly  the posterior circumflex, as this must
again be divided, and pressure on the subclavian readily
commands it; both the  outer and  inner flap being now
raised,  the head of the bone may be rolled a little out-
wards, and the teres minor and infra spinatus cut across
upon it with a large scalpel, opening  at  the same time
into the cavity of the  joint; by which means the error
of slitting up the  bursa under  the  acromion,  instead of
the capsular ligament, will be avoided, and continuing
the incision upwards,  cutting through the capsular liga-
ment, the tendon of the  supra spinatus,  and the long
head of the biceps flexor  cubiti as close  as  possible to
the edge of the glenoid cavity.  The  surgeon  placing
his fingers on the head of the bone, cuts through  the
inner side of the capsular ligament, and with it the sub- 
316
ELEMENTS OF SURGERY,
scapularis muscle, going to be inserted into the lesser
tuberosity of the humerus. The edge of the knife being
constantly towards the bone, he divides the under part
of the ligament, separating the head of the bone from
the glenoid cavity : resuming the small amputating knife,
he cuts through the long head of the triceps, to prevent
its hanging too much into the wound, and then with one
sweep he connects the points of the two first incisions
underneath, separating the arm from the body, dividing
again the circumflex arteries above the first incision, the
teres  major,  latissimus dorsi, coraco  brachialis,  long
head  of  the triceps, axillary artery, veins, and nerves.
This being the only dangerous step of the operation, the
surgeon should inform himself if the artery be sufficient-
ly compressed, which  he will know by  the  posterior
circumflex artery not bleeding, and the want of pulsation
in the axilla :  he should caution the assistant to pre-
serve the steady position of the patient, and have another
ready to press  his closed hand  upon the artery,  if it
should bleed.   Laying down the knife, he takes the ar-
tery if bleeding between the finger and thumb; or if com-
pressed pulls it out with a tenaculum, and ties it firmly
with a small ligature of two good threads.  The vessel
is found  contracted amongst the nerves in the lower third
of the wound ;  all pressure being removed, the anterior
and posterior circumflex arteries will  bleed, and must
be secured; or, if the artery subdivides  high up, there
may be a fourth large branch.
   In recent cases of injury I have seldom had occasion
to .take up more than three  arteries, and no cutaneous
or other  vessels,  besides those divided by the last inci-
sion.   The nerves,  if hanging  in the wound must be
shortened, which though painful, prevents a source of
irritation hereafter from their adhering in the neighbour-
hood of  the cicatrix.   The  axillary vein, if it continue
to bleed, should be  secured with  a single thread, as it 
ELEMENTS OF SURGERY.            317
allows some blood to pass into the wound after it has
been brought  together,  and,  what  is of  more material
consequence, permits it to pass into the loose cellular
membrane surrounding  the vessels down to the clavicle,
which may cause  considerable mischief, as the position
of the patient is favourable to its gravitation.
   All compression having been taken off the artery, the
wound should be  well cleansed, and here a little delay
may be allowed.  If the tendon of the long head of the
biceps flexor cubiti be  left long, it ought to be cut oft"
with the scissars,  as well as  any ragged portions of the
capsular ligament.  The glenoid cavity need not be de-
prived of its cartilage.   The pectoralis major will be
observed to have  retracted  considerably,  and to have
doubled or folded in the  skin covering it; through this
(the parts being brought  together,) a suture should be
put to the opposite side,  and the  whole properly sup-
ported and compressed  by  strips of adhesive plaster
and bandage, the ligatures being brought  out  direct.
The incision then forms but  one line from the acromion
downwards, curving at the bottom to the fore part of the
chest, the skin at the axilla being always a little wrinkled,
and much inclined to retract.   The flaps of the deltoid
meet firmly, sink a little into the hollow uuder the acro-
mion, lie close upon the glenoid cavity and the coracoid
process ; and from the pressure of the adhesive plaster
and compress, with the evenness of the  wound, the skin
of this part nearly unites by the first intention; the hol-
 low round the  glenoid cavity is comparatively sina-l to
what might be expected, and the consolidation in healthy
 subjects, where  every thing has done  well, goes on
 steadily, so as  not to  leave  any cause of future incon-
 venience.  The  surgeon, in all  his dressings,  should
 take care that no collection forms any where by keeping
 up a regular and proper  (.impression in  the  course
 of the artery, the coracoid process, the pector,alis major, 
318
ELEMENTS OF  SURGERY.
       and the muscles from the scapula and back.   The pain
       and sensation principally complained of is from the hand
       and arm ;  there is seldom any haemorrhage, and the pa-
       tient does not  suffer more than in any other common
       amputation.
         I have insisted on the arm being raised from the first,
       because in all operations that require the principal artery
       to be compressed, it should not be  done until the limb
       be placed  in the situation in which the operation  is in-
       tended to be performed, as the mere alteration of posture
       removes the  pressure from  its destined point, as must
       frequently have been observed,  when the  tourniquet is
       applied without this caution in the axilla,  or  thigh.
       This elevation also allows more freedom to the knife in
       every  direction, and points out more clearly the situation
       of parts.   1  beg, however,  to be understood  as not re-
t       commending the arm to be raised in secondary cases,
       when  there  is partial anchylosis, or thickening of the
       ligaments, or other fair obstacles to its being done with
       ease to the patient.
         It is not necessary to lay bare the acromion, on the
       contrary, the finger should be placed immediately upon
       it, to insure the first  incision, being near  half an inch
       below it, if the eye of the  operator be not a sufficient
       guide; the flaps turn aside sufficiently without it, the
       head of the humerus is extricated with equal  ease, and
       there is no subsequent danger if the stump should slough,
       or of the acromion coming  through and being a future
       inconvenience to the patient.
         In making the last incision  of separation, care should
       be taken to save as much of the integuments as the na-
       ture of the operation will permit;  and this is done by
       keeping the  head of  the bone as far from the glenoid
       cavity as the attachment of  the  teres major and latissi-
       mus dorsi will allow, and by then cutting as close to the
       bone as possible.  The long head of the triceps muscle 
               ELEMENTS OF SURGERY.           319

is divided before the last incision, to prevent its hanging
too long in the wound, and interfering with the approxi-
mation of the integuments.  The anterior and posterior
circumflex arteries require only a single thread; the lat-
ter will be divided about three quarters of an inch from
its origin, and the axillary artery in general near an inch,
from where it gives off the subscapular! s.
  From Mr. Guthrie's  statements  it appears that the
amputation at the shoulder,  succeeds vastly better when
performed on the field of battle, than when the patients
are taken into hospitals. Of nineteen cases in which the
operation was performed, soon  after  the  wounds were
received, one only died.—Whereas of an equal number
of operations performed in the general hospitals, fifteen
diet!, a strong argument in  favour of promptness in ail
such cases.
   I have once been called to perform this operation in
a case of fungus nematodes  near the shoulder, and shall
describe my mode of operating,  which is that taught by
Dr. Physick.—An assistant was charged to compress
the subclavian artery, where it crosses the first rib—an
incision was then  made with a  large scalpel, from the
anterior to the posterior edge of the axilla,  in a  direc-
tion somewhat curved  downwards—this  incision was
only through the skin and cellular texture, which were
dissected  upwards from  ihe deltoid muscle—another
incision was next  made in a straight line through the
skin of the axilla, meeting the first—the joint was now
cut into through the top of the deltoid-—the head of the
humerus luxated, and the  amputation completed by
passing the knife through the vessels, nerves, and other
soft parts in the axilla—the axillary artery was evident
at first glance,  but did  not bleed;  it was secured by a
strong ligature,  as were all  the  other bleeding vessels.
The whole operation was over in eleven minutes,  and a
very small portion of that time was consumed in the 
320            ELEMENTS OF SURGERY.
incisions.  The  flap was now brought down, and the
edges of the skin were found to approximate very well—
ft better flap could not have been formed  in  any other
way.*  It healed up very readily and my patient got
well.
  From what I  have seen  and read on this  subject, I
cannot hesitate to believe that in a great variety of ways,
the arm may be  safely amputated at the shoulder—the
plan  I selected was of  course  that which-*.struck  me as
best adapted to the particular case.
  I have  no doubt that the operation has often been per-
formed  without  necessity.  I  have once amputated1 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.

  * It woidd be as easy to include the deltoid in the flap, but this would be
>oon absorbed, and without being useful,  would render the operation more
difficult from the blood vessels which would be cut, but in most instances the
surgeon has no choice,  and is compelled to make his flap,  (if indeed he can
effect it at all) wherever there may be flesh enough left to afford him one. 
ELEMENTS OF  SURGERY.           321
              CHAPTER XXXIX.


            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 Surgery, for an essay on
the present subject in 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  and 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-
tes, in which they declare that the operation has been
successfully performed  by two  French surgeons, La-
croix and Perault.
   I)r. 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-
     Vol. II.           T t 
 322            ELEMENTS OF SURGERY.

 ses 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 down to the articulation—divides the cap-
 sular and round ligaments—dislocates the bone—forms
v 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.
   The following remarks, taken  chiefly from Mr. Guth-
 rie's treatise on gun-shot wounds requiring amputation,
 will  convey  to the reader  the latest information on the
 present subject.   The military surgeons are almost ex-
 clusively those who are called on to perform this opera-
 tion, and they have of late years, had several opportuni-
 ties of testing its value.
   " I have not much to offer from  actual experience of the
 operation, having performed it but once unsuccessfully.
 1 have however seen  many cases in  which it ought to
 have been  attempted, and  which  died.  I  have seen
 many in w hich the operation would have been necessary,
 if the constitution of  the  patients could ever have re-
 covered the  shock it had received at the moment of in-
 jury.  I know that many cases have died after long con- 
ELEMENTS OF  SURGERY.           323
tinuecl disease of the thigh bone from gun-shot wounds,
that would have had a chance of recovery, if the opera-
tion had been performed; and I have several times am-
putated so  close to the  trochanters,  that  I could with
ease have removed the head of the bone without any
increase of the external incisions.
  This  amputation is of course either primary or secon-
dary ; but the nature of the injury or disease differs very
much in these two stages; for very few, or none of the
cases  that render its performance necessary on the field
of battle, ever live to the period when secondary ampu-
tation is usually recommended.
  Wounds demanding amputation of  the hip joint on
the field of battle, arise from cannon or grape  shot, or
the explosion of shells.   Few surgeons would think of
performing it for a wound by a musket ball,  although
cases  may occur that require  it, and  the principal one
that will render it necessary, will be a fracture of the
head or neck of the  bone, with a wound of the great
vessels, or some other arterial trunk causing haemorrhage,
and stuffing the thigh with  blood.  A grape or small
cannon shot, may strike the fore part of the thigh, and
without wounding the inguinal artery itself, may,  in its
passage to the neck of the femur, wound some  large ar-
terial branches, causing considerable haemorrhage : the
wound shall not be large,  and yet  the chance of saving
the life  of the patient will be but very small indeed.  I
recollect two cases of this kind in  particular;  one after
the battle of Vimiera, by  a cannon shot, which proved
fatal on the second day after the injury, no one at that
time thinking of the amputation at the  hip joint.  The
other  occurred at Salamanca,  by a large ball, which
shattered the neck of the femur and the body of the bone
below.  I did not see this person for near  forty eight
hours after the injury, but was informed that qn his first
presentation for assistance, an artery, supposed to be a 
324
ELEMENTS OF  SURGERY.
large branch of the femoral, had thrown out its blood
per saltum, and was stopped  by pressing some lint on
the wound.  The limb soon swelled to nearly twice its
natural size,  with much external inflammation.  The
patient himself thought his case desperate, as did every
one about him, and declared his willingness to submit
to any operation that might be proposed; but the time
for operating was past, even if any operation could have
been agreed upon.
   After two months of severe  suffering, in which there
were even some  prospects of life being preserved,  this
man died.  The latter period of the time  was  passed,
however, without any hope of recovery, and surgical' aid
was  given merely with the view of rendering his  last
moments as  easy as  possible.   The great strength  of
constitution shewed by this man during the whole course
of his illness, and his great endurance of suffering, have
always  inclined me to  think  the operation at  the hip
joint would  have succeeded, if it  had been performed
shortly after the receipt of the injury.
   A shell bursting near a  soldier  may drive  a large
piece of an  inch  in  thickness, and a  pound or two in
weight, into the inner part of the thigh, without  wound-
ing the femoral artery,  yet  fracturing  the head of the
bone: here several large vessels, and perhaps the great
sciatic nerve would be divided,  and the only chance of
life, in my mind, would be in the immediate removal of
the whole.  I saw a fatal case of this  kind during the
siege of Ciudad Rodrigo, where the patient lived  long
enough to shew the necessity of performing this operation.
   A piece of a shell may strike between the trochanter
and the ilium, go through the neck of the bone, and tear
its way out below the tuberosity of the ischium, destroy-
ing all the parts in its course, without either killing the
soldier by, haemorrhage, or by the shock of the blow to
the constitution.  This accident happened to a man of 
ELEMENTS OF  SURGERY.           325
the 40th Regiment, at the battle  of Salamanca, about
four o'clock in  the afternoon.   He was in a good state
to undergo the operation when I saw him next morning,
but none of the surgeons present with me would agree
to it; all allowed nothing could save the man ; but the
opinion entertained of the cruelty of the operation, and
of its certain failure prevented its being done.   I took
this man into Salamanca with me,  and his appearance
for six successive days before he died, made me reproach
myself for  my want of courage, in not contemning any
remarks that might be made, on my having undertaken
it in opposition to  the opinion of  my colleagues ; and I
declined it, not because the general opinion was against
it, but in consequence of the bad  success of one, and of
the good success of the other, of the two next cases to be
related.
   When a cannon-shot carries away the thigh above its
middle, so as to exclude the more common flap opera-
tion close to  the trochanter, it is almost always fatal.
These accidents  generally  destroy at  once.   On  the
field of battle, I have seen many, having searched par-
ticularly for them, but have found them dead, or beyond
the reach of surgical aid.
   I have seen a case  of a cannon-shot striking the out-
side of the thigh,  tearing away the trochanter and sur-
rounding parts, without wounding the femoral artery, or
any great vessel that  wrould cause any serious haemorr-
hage, or so great a shock to the constitution as to render
the operation impracticable; yet  this man died without
any attempt being made for his relief,  which was neither
good surgery nor humanity.
   When the femoral  artery has been tern through by a
cannon-shot  there is, at the moment,  a great loss of
blood, but the  patient does not bleed to death, neither
does he appear to die ultimately  from the effects of the
haemorrhage; for I have seen several  men lose a greater 
326            ELEMENTS OF SURGERY.
 quantity from the same vessel without any such effect,
 but from the shock to the constitution ; and this observa-
 ble in  many cases of amputation of the thigh,  where
 there has been little loss of blood ;  and  yet the patient
 dies,  during, or immediately after the operation. A con-
 siderable haemorrhage, on the other hand, renders a pa-
 tient less able to bear an operation  than he otherwise
 would do, and where there has been much  and sudden
 bleeding, the  powers of life are so exhausted as not to
 be able to bear any further disturbance.   This effect is
 most frequently caused by wounds of the  femoral artery,
 and where it has occurred,  the chance of success from
 the operation, will be very small: and the combination
 of injury arising from the loss of blood,  and the shock
 of the blow, will have so much  diminished the powers
 of life, that the operation in addition, will destroy the
 remainder.
  If (as I have seen in  many instances) the bones of the -
 pelvis are injured, in any of the preceding kinds of ac-
 cident, the result will be fatal, and the operation should
 not be performed; but some little destruction of the soft
 parts, should not prevent it, if the patient be otherwise
 in a favourable state.
  A very extensive injury of the soft parts of the  thigh,
 if the bone  be not  broken, and the  femoral artery not
 divided, does not authorize the operation, although the
 artery be laid  bare for three or four inches of its course.
  An officer of the 88th Regiment, was wounded in the
 trenches, at the siege  of Ciudad Rodrigo, by a twenty-
 four pound shot, which struck the outside of  the ante-
rior part of the left thigh, and carried away the fore part
 of it from the  groin to within  a hand's  breadth of the
knee ;  the femoral artery lay bare at the bottom  of the
upper part of  the wound,  and was  seen pulsating for
near three inches; the sartorious and rectus muscles
were carried away, and  all  the muscles on the outer and 
ELEMENTS OF  SURGERY.
327
inner side of the thigh more or less mangled by the shot,
or torn by the  laceratiou;  it was altogether the  most
frightful looking wound I had seen, not even excepting
where the limb has been completely torn off.  Having
the superintendance of the  3d and 4th divisions of in-
fantry, the greater part of  the medical  officers of both
were with me at the time;  and on  this officer's being
brought to our field hospital in the rear of the trenches,
they all, without an exception, declared he must shortly
die, if the limb was not removed.  In compliance with
this opinion, I proposed to tie the artery below Poupart's
ligament,  and  to endeavour to save flaps to cover the
great trochanter, the bone  being sawed off below, as I
have since done in several instances; and if this was
not practicable, the head of the  femur was to be remo-
ved.  On placing him on the panniers  for the purpose
of operating, he was so exceedingly faint,  the pulse at
the  wrist  being scarcely perceptible, .that I  conceived
the operation would be useless, as  he would certainly
die under our  hands.   He was  removed to a corner of
the  hospital, and  placed on a hay mat amongst  other
cases of wounded supposed in a  dying state, a little lint
being laid over this  enormous  surface. By the  next
morning he had much  recovered, and as his thigh be-
came very painful, he was desired by the surgeon of the
division arriving in  succession,  to  wet it  with warm
water ; this was done, but his countenance was so ghastly
that he  was considered by  every one as dying: indeed
his regiment actually returned him dead, and his com-
mission was filled up in England.  In this state he re-
mained till the day after the  storming of Ciudad Rodri-
go, when, from the advance  of Marshal Marmont, the
wounded were sent  across  the  Agueda.  Desirous of
knowing  whether  any stragglers  of the  corps I belong-
ed to might still be at the field hospital,  I rode to  it on
leaving the town, and found every one s;one except this 
328
ELEMENTS OF  SURGERY.
poor gentleman, who requested my assistance; having
conveyance  in  the town, I offered to take him to my
divisional hospital,  five leagues distant,  where all the
other wounded had  been conveyed,  which offer he
gladly accepted, and reached the village of Aldea del
Obispo, with less inconvenience than I expected; I daily
feared the femoral artery would give way, but nothing
of the kind occurred, the slough from the whole surface
of the wound soon separated, and there was much less
of it than is usual on such occasions, but  this may be
attributed in  some measure to the attention  paid him,
and to the extreme  coldness of the weather in a room
without a fire-place.   The  discharge of  pus was very
great, and the artery lay in a channel completely cover-
ed by it;—I hourly expected it  would ulcerate, but
granulations soon began to shoot out, and by the end of
three weeks the artery was covered in, although its pul-
sations were still ^visible at a distance; the sore gradu-
ally contracted in a surprising degree, and in two months
it was diminished to half its original size, very little new
skin having been formed.   At this period he left me on
his  way to the  rear, on the army moving clown to the
siege of Badajos.   The attention paid to this officer  in
regard to diet,  attendance,  and  surgical  aid, was very
great; more, indeed, than he could have received  under
any other circumstances.  His recovery was considered
so unlikely, that no one looked at his  wound after the
first day; all supposed him past relief, as was really the
case with an officer of Engineers,  lying  beside  him.
whose arm was  shattered to pieces by a shell, and the os
ilium bared  on  the outside of the glutaei muscles, and on
the inside of the iliacus internus, as if it had been for
some time in maceration.  The insertions of the external
and internal oblique, and the transversalis muscles were
torn out without the peritoneum being opened, which alone
prevented the intestines from coming out at the wound. 
               ELEMENTS OF  SURGERY.           329

  Although this gentleman's life was saved, still, I am
of opinion, that very few would  have recovered under
the same injury.
  The secondary operation  has seldom, I believe, been
performed during the high suppurative stage succeeding
to injury from  gun-shot  wounds ; and as  1 do not be-
lieve it can be successful, if done at this period, I would
not perform it after the, second  day,  until the third or
fourth week.  There are not  many cases that will de-
mand it at this period, as the femur, in most compound
fractures of the thigh,  can in general be sawed off, at,
or immediately below the little trochanter."
  The operation has been twice performed in England:
in one case it was completely  successful; and in the
other, the patient lived thirty days.
  " Mr.  Brownrigg, Surgeon to the Forces,  has per-
formed the operation four or five times : on one occasion
the patient lived eight days, and died from fever,  sup-
posed to arise from causes foreign to the  operation.
  In the last case he was completely successful.  The
man received a gun-shot wound in the thigh, which
fractured the bone  close to  the trochanter, on the 29th
Dec. 1811,  near Merida, in  Spain.  On the 12th of
December, 1812, the operation was performed, and the
man is now living at Spalding, in Lincolnshire,  in per-
fect health.
  Mr. Brownrigg intends, I believe, to publish the par-
ticulars of this  case.  1 have also been  informed,  that
the operation has been performed in the West Indies.
  These cases prove, that the operation  is not only ne-
cessary, but practicable, and that it may be effected with
success under certain circumstances.  This being grant-
ed, it necessarily follows that the operation ought to be
recommended and  performed in every case in which it
can alone bring relief, or  offer a prospect  of success.
No man should, therefore, be allowed to die without iU
                         Uu 
330            ELEMENTS OF  SURGERY.

being proposed to him ; and if it be a case for primary
operation,  the sooner  it is done on the field of battle,
consistent with propriety,  the greater will be the chance
of success, for the patient cannot live to  the period for
secondary amputation.  It is in this, and other opera-
tions high in the thigh, that the question of time is most
important,  for haste is as  injurious as delay, when im-
properly applied.
  If the patient has suffered much loss of blood, or is
in a state of syncope, or nearly approaching to it, unable
to articulate, with a pulse scarcely perceptible, and the
skin clammy and  cold, an immediate operation would
Only hasten his death; but if excited by stimulants and
cordials, he w ill have some chance of recovering himself
in an hour or two, so as to undergo the operation with a
better prospect of success, or he will in that period sink
and die.  If, on the contrary,  he is brought to the sur-
geon, although much alarmed and reduced by the  sud-
den shock  and loss of blood,  with strong sensations of
pain, expressed by his cries for  assistance, convulsive
motions of the limb and  body,  and the  powers of the
seusorium not destroyed,  the  operation should be per-
formed  immediately: or, instead of becoming more  calm
and collected, he will gradually sink into the state of
the first described, and be unable to bear the operation.
On the  other hand, the first mentioned, if he be excita-
ble, will in time rather approach to the state of the lat-
ter, and from the  f>aiu, &c.  he suffers, will call for the
performance  of the operation.   This violent nervous
commotion, however,  is not common ; it depends upon
par':cular  idiosyncrasies, and will never in the first be
so excessive as in the last.
   T'se  operations being decided upon, it is, I confess,
not like that at the shoulder-joint, to be  done by every
one of moderate ability.  No surgeon should attempt it,
unless he  is conscious of possessing  great coolness, a 
ELEMENTS OF SURGERY.
331
 presence of mind equal to any emergency, and a correct
 knowledge of the parts to be divided.       *
   I consider  the operation to be best performed in the
 following manner.   The patient should be laid on a low
 table, or two field panniers  placed together,  covered
 with a folded blanket to prevent the edges giving pain,
 and properly  supported in a horizontal position. An as-
 sistant leaning over, and standing on the outside, should
 compress the  artery against the brim of the pelvis, with
 a firm, hard compress of  linen; such as is usually used
 before the tourniquet; he should also be able to  do it
 with his thumb,  behind the compress, if it be found in-
 sufficient.  The surgeon standing on the inside, with a
 strong pointed amputating knife of a middle size,  with
 the back curved, makes  his  first  incision through the
 skin, cellular membrane,  and fascia, so as to mark out
 the flaps on each side, commencing about four  finger's
 breadth, and in a direct line below the anterior superior
 spinous process of  the ileum in a well-sized man;  and
 continuing it round in a slanting direction at an almost
 equal distance from the tuberosity of the ischium, nearly
 opposite to the place where the incision commenced.
 Bringing the  knife to the outside of the thigh,, he  con-
 nects the point of the incision where he left oft* with the
 place of  commencement,  by a  gently  curved  line, by
 which means the outer  incision is  not  in extent  more
 than  one third of the size of the internal one.  The in-
 teguments having retracted, the glutaeus  maximus  is to
 be cut from its insertion in the liuea aspera, and the ten-
 dons  of the glutaeus medius and minimus from the top
 of the trochanter major.   The  surgeou  now placing the
 flat edge of the knife on the line of the retracted muscles
 of the first incision,  cuts  steadily through the whole of
 the muscles,  blood-vessels, &c. on  the  inside of the
 thigh. The artery and vein, or two arteries and vein,
if the profunda is given off high up, are to be taken be- 
332
ELEMENTS OF SURGERY.
hveen the fingers and thumb of the left hand, until the
surgeon can draw each vessel out with the tenaculum,
and place a ligature upon it.  Whilst this is doing, the
assistants should  press with their  fingers on any small
vessels that bleed.  The surgeon then cuts through the
small muscles running to be  inserted between the tro-
chanters, and those on the under part of  the thigh, not
yet divided:  and with  a  large scalpel opens into the
capsular ligament, the bone being strongly moved out-
wards,  by which its round head puts the ligament on
the stretch.  Having extensively divided it on the fore
and inside, the ligamentum teres comes into-view, and
may readily be cut through.  The head of the bone is
now easily dislocated, and two or three strokes of the
knife separates any attachment the thigh may still have
to the pelvis.  The vessels are  now carefully to be se-
cured.   The capsular ligament, and as much of the liga-
mentous edge of the acetabulum maybe removed as
can readily be taken  away.  The  nerves, if long, are
to be cut short,  the  wound  well sponged  with  cold
water,  and the integuments brought together in a line
from Jhe spinous process of the ilium, to the tuberosity
of the ischium.  Three sutures will  in  general be re-
quired,  in addition to the straps of adhesive plaster, ta
keep the parts together; the ligatures are to be brought
out in a direct line betwreen the sutures, a little lint and
compresses  are to be placed  over the wound,  and on
the under flap, to keep it in  contact with the cotyloid
cavity,  and assist the union of the  parts.   A piece of
fine linen is to be laid over them, and the whole retained
by a calico bandage put round  the waist, and brought
over the stump.
   It is recommended to pare the bone of its cartilage;
and if this could be readily done, I would willingly
agree to it, but the cartilaginous surface of the acetabu-
lum is not to be cut  away without much difficulty and 
ELEMENTS OF SURGERY.
333
some time, which cannot be spared : for I consider the
success of the operation to depend very niucji upon the
quickness with which it is performed, not on  account of
haemorrhage, but to avoid the shock the constitution re-
ceives  from the continued exposure and irritation of  so
large a surface in the immediate vicinity of the  trunk
of the body.   It is proved by experience to be unneces-
sary at the shoulder joint; and will, I think, be  found
equally so at the hip joint.
   When I wrote  these  observations, and shewed the
method of  performing the operation in the Peninsula, I
thought I was the first to recommend  that the artery
should not be tied previous to commencing  the opera-
tion.   M.  Baffos, however, has  the priority in practi-
sing it, which I readily grant to him, and am gratified
in  having his authority  to adduce in  support of the
measure.
   Union by the first intention is to be wished for in a
great degree, as lessening the surface of the wound; but
as all the parts beneath the skin cannot unite, and espe-
cially about the acetabulum and the inside of the glutaeus
muscle, it is not advisable to let the skin adhere on the
middle and lower part of the stump;  for as the parts
deep-seated must suppurate and granulate, a fair open-
ing for the discharge should be preserved, and collec-
tions of matter in any part should be carefully guarded
against by gentle pressure, compress, and bandage.
   The after treatment will be the same as in other cases
of amputation :  the  shock, however, of the  injury and
the amputation will  be so great, that the antiphlogistic
regimen to the extent of blood-letting will not be neces-
sary.  If  the patient be  very low,  cordials in  small
quantities, w ith opiates, should be given, and a light
nourishing diet.  If inflammatory  symptoms come on,
the appropriate remedies  formerly recommended  must.
be employed without delay.   If  there  be  heat or un- 
334
ELEMENTS  OF SURGERY.
easiness in the wound, it  must be kept wet with cold
water.
   If the surgeon called upon to perform this operation,
has not been in the habit of dealing with large arteries,
he may feel an  unconquerable repugnance  to cutting
through the femoral artery before it has been tied ; and
although I can most positively ^assure these  gentlemen,
there is nothing to fear in doing it, still they may tie the
artery  first, if .they cannot overcome this feeling of dan-
ger.   It is to be  done by cutting  through the integu-
ments in the  usual manner, and then dissecting for the
artery  and vein,  previous  to cutting through the mus-
cles." 
ELEMENTS OF  SURGERY.
335
                 CHAPTER XL.


        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  kuown.  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
in an operation described by many writers, but one which
is rarely necessary.   I believe it will be found easier in
most cases to  cut clown to the diseased bone, and remove
with a trephine or  saw resembling Mr. Hey's the af-
fected part. 
336
ELEMENTS OF  SURGERY.
                CHAPTER XLI.


         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 langour 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 bleeding results from the slipping off
 a ligature which had been carelessly tied.  This  event 
ELEMENTS OF SURGERY.            33.7
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 refuse
to heal.  This is only to be  prevented by general reme-
dies 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 dangerous,
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 uupleasant
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 hemorrhage 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
     Vol. IT.            X x 
838           ELEMENTS OF SURGERY.

sufficient to remove the stricture,  and this method  ha*
immediately suppressed the hemorrhage."   1 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 are
taken up afresh with the needle,  the  hemorrhage will
now and then return in the course of two or  three days^
Iu 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  the  stump,
by making first an incision through  the integuments. My
colleague Mr.  Logan has clone this twice within the last
year, with  complete success, when repeated ligatures,
applied in  the usual way, had failed.
  " In the morbid sloughy state of the stump  above-men-
tioned, the application of lint soaked in  a liquid, com-
         *  See Cases in Surgery, by Charles Whi'e, F. I»  S 
ELEMENTS OF  SURGfcRY.
339
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 which 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. 
340
ELEMENTS OF SURGERY
                CHAPTER XLII.


              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 happed.   The best
mode of relieving the pain and of preventing injury to
the stump, is to  have it held by a succession  of  assist-
ants, 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
instances. 
ELEMENTS  OF SURGERY.
341
                CHAPTER  XLIII.


              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 which in popular language are
called wens, ought to be cut out, for although they have
no tenfrency 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
openiug into the  sac.   The method of dissecting  out a 
 342           ELEMENTS OF  SURGERY,

 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.
   Great  improvements in surgery have  resulted from
 the boldness with which large arteries are tied up, among
 others, the extirpation of tumours is greatly facilitated
 by securing those vessels which may be liable to injury,
before the operation, Mr. Groodlad, secured for example,
the carotid, previously to cutting a tumour from the face.
It is often  sufficient however, to expose the vessel so as
to place it under the command  of an assistant.
  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 altl 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.
  In order to prove that the size of a  tumour furnishes
no objection to its removal,  I shall insert a  case, from
the American Philosophical  Transactions.  I believe it
to have been the largest steatomatous  tumour ever suc-
cessfully removed from the human body.  A French 
 
PLATE V.YV
%&M%SM
J. S.fier-tg, jui. A* Sf, 
ELEMENTS of surgery.
343
surgeon Mr. Dela Croix, extirpated a diseased testicle
weighing 29 pounds, but this was an  entirely different
operation.

                       CASE.

  The patient, Julia Richards, a negro woman,  from
Carlisle, in Pennsylvania, was aged  about forty-five
years, and enjoyed good health; she was corpulent, but
active, until her  exertions  were restrained by the in-
cumbrance of her tumour.
  She stated that if had been first noticed about eighteen
years before I saw her;—that it had grown gradually,
and had never been painful.  When she applied to me,
her attitude in walking resembled that of a woman carry-
ing a large and heavy sack.  On examination, I found
the tumour arising at the upper part of the back, extend-
ing equally on both sides, and although pendulous from
its weight, yet the root of  it  was very large.   The di-
mensions were as follow:
  Circumference  at the neck or narrowest part of the
tumour, two feet ten inches.
  Circumference  at the thickest part,  vertically, three
feet nine inches.
  Circumference  horizontally, three feet one inch and a
half.
  The circumference of the waist after the wen was re-
moved, was two feet nine and a half inches, so that the
narrowest part of the tumour was thicker than the pa-
tient's body.
  The surface of the tumour was tolerably regular, but
very large and numerous  veins were  seen in various
parts of it.
  The patient was admitted into the Pennsylvania Hos-
pital, and on the 22d of February, 1815, I proceeded 
344           ELEMENTS OF SURGERY.

to remove the tumour.   Having previously administered
an opiate, I placed her (at the suggestion of Dr. Phy-
sick,) on her face upon the table, fifteen minutes before
commencing the operation,  and directed assistants to
elevate the  tumour in such a manner  as to  empty it as
completely  as possible of blood, and 1 was  groetly de-
lighted to perceive the change in the size of the super-
ficial veins, which resulted from this simple expedient,
many of them contracted  and could not be perceived.
  The operation was commenced by »xiernal incisions
calculated to preserve skin enough to cover the surface
left by the removal of the tumour,  and this skin being
dissected and turned back, which was the most tedious
part of the operation, the tumour by large and rapid in-
cisions, was  detached  from  its base and rem o\eu   It
adhered to some of the spinous processes of the verrebrce,
and to the muscles and tendons near  the spine.   The
operation occupied twenty-one minutes ; and the io$s of
blood was very trifling.—The skin  was found to tdapt
itself very well to the  denuded parts,  and was secured
by strips of adhesive plaster, compresses and band^s.
  The greater part of the sore united by the first inten-
tion ; no unpleasant symptoms occurred, and the patient
was  discharged cured, on the 15th April.   She  is at
this time, and has been ever since the operation, per-
fectly well.
  The tumour was found to  weigh twenty-five pounds,
but when filled with blood, was probably much heavier.
  The tumour of Eleanor Fitzgerald, described by Mr.
John Bell; and that of a negro woman, published in the
Medical Repository of New York, (Vol. III. New Se-
ries) were of enormous magnitude, but adherent by small
bases.  The basis in the present instance was very great,
and I am not aware that so large a tumour has been ever
before extirpated. 
ELEMENTS OF  SURGERY.
345
                      REMARKS.

  The most important practical precept derived from
this case, is the influence of position on the circulation
of the blood. I once attended an operation on a tumour
of comparatively small size, seated on the back, the ex-
tirpation of  which was found impracticable, in conse-
quence of bleeding from the superficial veins.   In the
treatment of hemorrhagy from blood vessels in the ex-
tremities, and on certain local inflammations, an elevated
position is often found of great importance.  I have seen
a bleeding  from an artery in  an aneurismal arm,  in
which circumstances precluded the use of a ligature  or
tourniquet, effectually arrested by an elevated posture,
the hand being constantly kept in a vertical position.
  These remarks, although somewhat digressive, are in
my opinion of too much importance to be omitted.  The
practice  of  employing position to empty blood-vessels
for surgical  purposes, in the case alluded to, and others,
so far as I know, originated with Dr. Physick. and my
own experience has  afforded  numerous proofs of its
value, and convinced me  that it has been too much ne
glected by surgeons.
Vol. H.
Yy 
346
ELEMENTS  OF SURGERY,
                CHAPTER XLIV.


                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 Johns 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 relievethe inconveniences of corns it is essential
that  the patient  wear loose and soft shoes.  When the
corn i« 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 
ELEMENTS OF SURGERY.
317
the pressure of the shoe,  when the patient walks, is to
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 treat-
ment is  to be continued without  interruption until  the
corn is  totally extirpated,  which generally happens in
eight or twelve days." 
348            ELEMENTS OF SURGERY.
                CHAPTER XLV.


              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
pa,in when 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.
349
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.
After 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 to 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 maybe consistent with
1 certainty  of removing the whole offending part. 
350           ELEMENTS  OF SURGERY,
                CHAPTER XLVI.


             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 anterior spinous process of the  os
ilium.  The left side was chosen to avoid the liver.  It
has however happened in  several instances 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 linea 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 ope-
ration, by substituting  for the trochar a  lancet, which
makes a clear incised wound, through which a flattened
canula is inserted.  The incision heals readily without
inflammation.
   The most convenient mode of performing  the opera-
 'on is, to place the patient near the edge of the bed, and 
ELEMENTS OF  SURGERY.
351
under him a piece of oil cloth to prevent the fluid from
wetting the bed  clothes.   The  lancet is then inserted
ib rough 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, how ever, 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.   Tn  order to prevent the unpleasant effects
which sometimes result from the sudden removal of  the
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  he enlarged,  or  a  canula intro-
duced  open at the  extremity.  The only dressing  the
wound requires  is a dossil of lint, or a strip of adhesive
plaster.
   It is generally necessary in cases of dropsy to repeat
this operation frequently.  In  these cases the puncture
should never be twice made in  precisely the same spot,
because it has happened that adhesion has formed, con-
net ting an  intestine to the cicatrix, and the intestine  has
been wounded in a subsequent operation. 
352
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 nvavy 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 1 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 in cases of Tympanites. It may
be performed in the same way as for the evacuation of
water. 
ELEMENTS OF SURGERY.
853
                CHAPTER XLVI1.


               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  lie carefully cut through
by an incision smaller than the external one.   The pleu-
ra costalis is now exposed, and a small puncture may he
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.
  Mr. Richerand of Paris,  has proved in a very bril-
liant and  successful operation, that the thorax may be
freely opened by removing portions  of the ribs, if requi-
site, for the  removal of cancer.  He proposes  in cases
of dropsy of the pericardium,  to cut clown to this sac,
     Vol.  II.            Z z 
354            ELEMENTS  OF SURGERY.

and evacuate the water.   This operation has never been
performed ;  but in a clearly marked case (if such could
occur) may certainly be regarded as  practicable,  and
Mr.  Richerand's opinion that the heart and pericardium
might be made to adhere,  as the testicle and tunica va-
ginalis, in cases of hydrocele, is not void of plausibility.
I regret that 1 received his interesting  memoirs too late
to notice.it in its proper place. 
ELEMENTS OF SURGERY.
355
               CHAPTER  XLVIII.          "W*
                                                 ■ &

                  Of Bloodletting.


  For the cure of numerous morbid affections, blood
must he 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.
  Typical or local. J^oodletting 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 *!ie
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 (-s-crman fleam.  Tf
the  lancet is to be used (and  most surgeons recommend
ii) 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 lan-
                         right hand, the  thumb of the 
356
ELEMENTS OF SURGERY.
left hand is  to be placed  on the vein a little  below
where the puncture  is to be made in order to fix tin
vein, but care should be taken not to alter the relative.
positiou 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 desired, the
patient should exert the muscles of Uie arm by grasping
a stick, or moving the fingers.
   After the  blood is drawn the arm is to he 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 sternocleidomastoid 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, sue!  to  eucrease the bleeding
from them it is useful to immerse the iimb in warm wa-
ter.
   The German fleam or spring lancet I prefer greatly to
the coma-on English lancet for phlebotomy ; it is now in
-om" pari- of -i:«: United ;il::*e<- almost exclusively used.
1 shall insert sonic remarks on i..is sunset which I pub- 
ELEMENTS OF SURGERY.
357
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 large*
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.
   " 1 he 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, Midperhaps 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, ami 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 the  English lancets, and who is  particular in
using none but the best,  must necessarily consume half 
358
ELEMENTS OF SURGERY.
the emolument  derived  from the operation, in the pur-
chase of his instruments. One spring-lancet, with anoc-
•isionsl 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 contract-
ed 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 neces-
sary punctures  of a proper depth; the depth being re-
gulated by means of a screw.  The  small cutaneous
vessels only are divided in this operation, and it is ne-
cessary to  promote  the  bleeding  by applying the cups,
exhausted of air, or rather filled with air greatly ratified,
over the punctures.  This part of the operation is effect-
ed 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 practice, but is cer-
i 'inly the best  method) or by a piece of paper, or tow 
               ELEMENTS OF SURGERY.            3o9

dipped in spirits of wine and inflamed, which is thrown
into the cup immediately before its application.  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
1)1 eed more freely after this manoeuvre.

                     LEECHING.

  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 leechesi with
warm water to enliven them. 
360
ELEMENTS OF  SURGERY.
                CHAPTER XLIX.


                     Of UUers.


  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, but 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 
ELEMENTS OF SURGERY.
361
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-
able 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 iu 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
     Vol  II             3 A 
362
ELEMENTS  OF SURGERY.
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 a 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.  During  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 
               ELEMENTS OF SURGERY.            363

mch 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 leugth 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 iu 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 exteuding 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 ctiticuiar co- 
364
ELEMENTS OF  SURGERY.
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 which 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 
ELEMENTS OF SURGERY.
365
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 quantitj' of blood, which circulates  in the old and
new skin.  For the new  is far less  vascular than the
edd ; or, at least, {he 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 are
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 papiiL,  which
are supposed to be the principal seat of the sense of feel-
ing in the skin. 
 366           ELEMENTS OF SURGERY.

   " 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 clown 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
 differ very essentially  from it.
   Mr. Moore observes that " in some cases 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, 
ELEMENTS OF SURGERY.
367
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, 
368
elements  of surgery.
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,
w hether 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 which are prevented from healing
by a varicose state of the superficial veins of the upper
part of the limb. 
                 fcEEMENTS OF SURGERY.             369
   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.        m
   3. Ulcers seated in cedematous 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.
vol. n.                   3  b 
370
ELEMENTS OF SURGERY.
                  CHAPTER L.

                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  seen—a 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,
the symptoms  and appearances just described, and that
such ulcers are inflamed there can be no doubt. 
                ELEMENTS OF SURGERY.             371
  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, beeause  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 blood-letting.  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. 
372
ELEMENTS OF SURGERY.
                   CHAPTER LI.

                 The Fungous  Ulcer.

   Instead of the healthy appearance of florid pointed
 granulations of a firm texture, the fungus ulcer is covered
 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 disposi-
 tion to cicatrize.  In some cases the  sensibility of the
 granulations is greater than in healthy sores, and bleed-
 ing 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 answers 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 disposi-
tion will be  effectually checked by an application of blue
vitriol. The use of burnt alum is in many cases extremely
serviceable in repressing fungous granulations.  Various 
                ELEMENTS OF SURGERY.             3^3
astringent lotions  are  also useful; a decoction of oak
galls;  solutions of white vitriol, and other metallic salts
have been found beneficial.  It is my custom therefore
always to vary the escharotic medicines 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. 
374
ELEMENTS op surgery.
                  CHAPTER LII.

           Of Ulcers 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 pro-
ceeds from fractures, sprains, and bruises.  Interruptions
to the circulation of a part in some cases  produce this
effect, and oedematous swellings result from the pressure
of a tumour upon the principal vessels of a limb.  In the
latter months of preguancy  oedematous legs are  very
common.
   An oedematous limb is usually cold, swollen, and of a
pale colour.  It retains the mark or pit made by the pres-
sure of a finger.  An ulcer seated in such  a limb is ge-
nerally  painful and somewhat inflamed.  The granula-
tions 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 oedematous limbs very frequently are attend-
ed by so much fever that blood-letting is indicated, and
repeated purges are often necessary.  In 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  ulcer.  In addi-
tion to this, gentle  pressure is to be made by means of a
roller of muslin or  a laced  stocking extending from the 
                ______J OF SURGERY.            375
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 consi-
derable time, to prevent its recurrence.
   It is the custom with many practitioners to recommend
exercise to patients with ulcers  in oedematous legs; this
treatment I believe  to  be  very injurious, and although
cases are brought forward to attest its efficacy, it is ex-
tremely 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 oede-
matous 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 healing of the sore. 
376
ELEMENTS Ot SUKGERY.
                  CHAPTER LIH.

                The Sloughing Ulcer.

   In consequence of deficiency in the strength of the
 constitution or part affected, the granulations of an ulcer
 very frequently  mortify, and sloughs fall off from various
 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 constitutional
 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 general pain and
fever attend a sloughing ulcer.
  Analogous to  this species of ulcer 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 constitution, leav-
ing the  ulcer as  broad and as  deep as it was before, the
granulations  not being strong enough to preserve them-
selves from.decay.
  " Ulcers may  from  the beginning exhibit these appear-
ances of want of strength  in the newly  formed parts, or 
                 ELEMENTS OF SURGERY.             3^
they may at first go  on for a few days in every respect
like those in healthy parts,  but become unable to  do so
beyond  that period,  and the granulations begin then to
shew sigus  of weakness;  for  granulations of the most
healthy  kind if  they are not skinned  over in a certain
time appear to lose their original strength and fall into a
weak state."
   In the treatment of the sloughing ulcer and of such ul-
cers 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 pa-
tient pleasanter,  and I believe in general answers better
than any of these remedies.  It is prepared by boiling
scraped  carrots in milk.   Sometimes advantage is deriv-
ed from  washing the  ulcer with diluted laudanum,  or an
infusion  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 mortifi-
cation, this application  is sometimes the means of pre-
venting it."
   The sloughs having separated, the ulceT 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.
VOL. n.
3g 
378
ELEMENTS OF SURGERY.
                  CHAPTER LIV.

                 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 round-
ed. 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 sepa-
rated  from the surface of the granulations, so that when
the ulcer is wiped clean the coagulating lymph adheres in
several places giving a white appearance to these parts of
the ulcer.  The bottom of the ulcer 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 marled;" 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.
  The treatment of  indolent ulcers is  a subject of ac- 
                ELEMENTS OF SURGERY.             3^9
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 caus-
tic ; 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 minutes
upon  them, and care should be taken completely to ac-
complish this end.   After tlie sloughs separate the  gra-
nulations which arise will probably require very repeated
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-
ringly  used, but still it must  be used,  and applied chief-
ly to the middle of the ulcer. 
ggO             ELEMENTS OF SURGERY.
  In order to stimulate the granulations of indolent ul-
cers,  an  almost endless  variety of applications  have
been recommended; all  the escharotic medicines—red
precipitate—corrosive sublimate, green, blue, and white
vitriol—nitric, muriatic, and sulphuric acid—caustic, and
mild potash—carbonate of soda—alkohol, and numerous
tinctures—gastric  liquor—rhubarb—powdered   galls—
Peruvian bark, and a thousand other stimulating articles,
all of which have in some cases proved beneficial, 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
in 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 whenever
they cease to produce a good effect.
  I  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 being
retained, may become acrid,  and inflame  the skin, and
that the dressings may be removed with ease  at  each 
                ELEMENTS OF SURGERY.             gg£
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  I 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, with 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
well 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 dis-
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
breadth,  and four or five yards in length, or rather as 
38g            ELEMENTS OF SURGERY.
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 should
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 be 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 
                   ELEMENTS OF SURGERY.          383
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 narrower
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. 
384
ELEMENTS OF SURGERY.
                  CHAPTER LV.

                 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, the fcetor 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 bone 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
saw, and the crown of  a trephine.   Gouges and chisels
are also in some  cases necessary. 
              ELEMENTS OF SURGERY.               385
  It is in general a very bad practice to inject corroding
liquors into sinuses leading to carious bone, 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.
vol. n.                   3 D 
386
ELEMENTS OF SURGERY.
                  CHAPTER LVI.

         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
 varicose, 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
 persons.
   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 direc-
 tion of the veins, and is increased to a very great degree
 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 natural
 drain from the constitution, which it was improper to dry
 up; and the  strong argument advanced in favour of this
 opinion has been,  that whenever it was healed, it broke 
                 ELEMENTS OF SURGERY.             387
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 readily explain-
ed ; since the pain, in such cases, arises more from the dis-
tended  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
conducted,  and it is probable that the  success of tight
bandaging 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 va-
ricose 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 woollen cloth will an-
swer best, as its elasticity allows it to yield to the  motion
of the  muscles,  and always preserves an  uniform com-
pression.
   " 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- 
 338             ELEMENTS OF SURGERY.
 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, aud 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 posi-
 tion,  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 
                 ELEMENTS OF SURGERY.             389
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 practised 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 has 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, 
gnQ             ELEMENTS OF SURGERY.
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 wounding the vein.   After this, a silver crook- 
              ELEMENTS OF SURGERY.               391
ed needle,  with the point rounded off, will readily force
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 stat£ 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 degree of pressure upon the vein, both above
and  below the part included in 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 
gg*}            ELEMENTS OF SURGERY.
sapheua has been  taken up, afterwards becomes enlarg-
ed, and continues the disease;  when that is the case,
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 tha 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 in an ex-
tremely varicose state,  forming  large projections, the 
                 ELEMENTS OF SURGERY.            393
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:
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  are affected, the disease
extends  no further;  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, when 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.)
vol. 11.
3e 
394
ELEMENTS OF SURGERY.
                 CHAPTER LVII.

     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 dis-
 ease, but such only as are produced by other diseases of
 the general system, or of the parts which yield to the ef-
 fects of this medicine.
    " It was natural when  the beneficial effects of mercury
 in the venereal disease were first discovered to  suppose
 that every complaint which  yielded to mercury must  be
 venereal.   It was, however, to be expected that observa-
 tions accurately made would soon ascertain that this ac-
 tive medicine is capable  of producing salutary effects in 
                 ELEMENTS OF SURGERY.            305
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-
sition peculiar to themselves.  Mercurial frictions are in
these 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.
  "The mercurial ointment  made either by calomel and 
gqg             ELEMENTS OF SURGERY.
hogs-lard,  or the  unguentum hydrargyri mitius  mixed
with camphor answers in some cases better than any
pther application.
  "Camphor in general  renders the  mercury more ac-
tive than when employed alone, and the mouth has been
frequently known to be affected 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 portiou 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."

H. OF ULCERS  WHICH YIELD TO  THE USE OF THE DIFFERENT
  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 couium maculatum is
a much more certain medicine, and I do not hesitate to
declare myself convinced, that there are cases of diseased
ulcers on the legs which  are cured by  it more readily
than by other means.
  "The ulcers which are  most generally benefited  by 
                 bi^MttSTS OF SURGERY.            397
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 from, 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
lie boiled in a quart of water, to  a pint.  A poultice made
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 
398
ELEMENTS OF SURGERY.
 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.
   " In such cases  the foot or leg at the times the poul-
tice is to be  changed will receive benefit by being im-
mersed for ten minutes in tepid salt water.
   " In some superficial ulcers attended with a thicken- 
                ELEMENTS OF SURGERY.             399
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  THE ARGENTUM
                       N1TRATUM.

   " There is a species  of ulcer which 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
 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- 
^00             ELEMENTS OF SURGERY.
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-
tnm 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  per-
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
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. 
                ELEMENTS OF SURGERY.             40 j[
  "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 skiu 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.
   "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
   VOL. II.                   ** F 
^Og             ELEMENTS OF SURGERY.
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 wliere 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 consider 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, which it was
impossible for me or the officer of the 75th regiment at
Plymouth to have received by  infection.
  "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 
                 ELEMENTS OF SURGERY.             4,03
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 secret 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 cases  of can-
cer,  by a number of empyrics, as a caustic; but from the
violence of its  effects, regular  practitioners have in ge-
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. 
  404              ELEMENTS OF SURGERY.
    " Those ulcers in which I have been led to employ if*
  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.  I was,  however, induced  to try it some
  years ago in St. George's hospital, in the  following case,
  in which nothing could be well applied  to the part it-
i  self.
V   " A woman,  sixty-five  years  of age,  came into  St.
  i&eorge's hospital on  the  15th of Juue,  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 fry  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
  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 
                 ELEMENTS OF SURGERY.             4Qg
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
ulcer being the central point,  and the  external surface
(which is always  increasing) the circumference.   This 
£06                ELEMENTS OF SURGERY.
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 water; 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.
   "In ulcers connected with diseased bone, which 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- 
                ELEMENTS OF SURGERY.             407
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 system must be always
kept in view.  If  an inflammatory disposition be mani-
fested,  the remedigs 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. 
408             ELEMENTS OF SURGERY.
                 CHAPTER LVIII.

                      Of Caries.

   Having treated of ulcers in the so^fc 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 are most liable to caries, and when it
 attacks the long bones,  their spongy extermities  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
absorbents  to remove the effused blood which occasions
ulceration or caries. 
                ELEMENTS OF SURGERY. ■            40$
   "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.
   "Seurvy  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:
spots or ecchymosee manifest themselves,  first  in  the
   vol. ir.                  3 g 
j^O            ELEMENTS OF SURGERY.
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 caucers of the mammae,  the sides of the sternum
are often found carious ; which proves that cancerous uIt
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 exist-
ence 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 foreigu body introduced into the wound. It will
be prudent, therefore, in  dubious cases,  to trust chiefly
to the history of the disease. 
                ELEMENTS OF SURGERY.             4U
  "If a persons affected with a certain constitutional dis-
ease, feel  deep-seated and acute pains  in any  of his
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 affected 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 scapulae
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
fie remedied by this operation.   The same may be said 
 41gJ             ELEMENTS OF SURGERY.
 of caries  of the spine,  also  named gibbosity, in which,
 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 cancer-
 ous 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  danger-
 ous 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-
  * Not always: there is reason to believe it sometimes cured. See the Chap-
 ter on««Curved Spine." 
                ELEMENTS OF SURGERY.             418
siderable masses after the venereal disease is cured.  It
is uo uncommon thing to find the ossa spongiosa coming
away almost entire;  large portions of the  alveolar pro-
cess of the upper jaw, the vomer, and other masses ef
bone, are often detached by the absorbent  vessels, in
consequence of venereal  affections  which  have  been
previously cured by the administration of mercury.
  To remove the diseased action of the system, which
had produced the  caries appears in such cases to be all
that is necessary, the parts readily heal when this is done,
" Causa sublata tollitur effectus." As I shall not enter
on the treatment of the venereal disease on  the present
occasion I refer to Dr. Adams' excellent edition of Mr.
Hunter's  treatise  on  that  subject in which  the  proper
mode of administering mercury is most judiciously de-
tailed.  The time necessary for the separation  of por-
tions  of bone  which  have been destroyed by  syphilis,
varies considerably,  and is sometimes extremely tedious.
  If the caries have  arisen from  scurvy, the remedies
for this disease are  to be  administered.  A vegetable
diet with acid drinks  are to be prescribed.
  Where the  disease, however, is local, local remedies
are to be applied.  It is an important principle in the
treatment of certain ulcers,  to destroy the life of the dis-
eased parts, so that an eschar may be formed, and when
the eschar separates, a common healthy  sore  may  be
left.  In like manner  a carious  bone may often be treated
with  advantage.  Lunar  caustic is  to be  applied  with
this view to the carious part, by which it will be  reduced
to the state of  a necrosis or mortified bone,  which will
be  detached by the  action of the absorbents, and the
healthy bone left  underneath in general granulates and
heals.
  The  French surgeons  in many cases, especially in
what they  denominate a humid caries,  which  is attended 
*a£             ELEMENTS OF SURGERY.
with a copious serous discharge, prefer the actual cau-
tery to the lunar or  vegetable  caustic.  The following
remarks from  Boyer on  its use are entitled to great at-
tention.  " This remedy is applicable to  every case of
humid caries where the  surrounding soft parts have not
a manifest tendency to  caneer.  Sometimes, however,
the soft parts surrounding a carious bone  have that ten-
dency in so advanced  a degree, that the  actual cautery
would necessarily occasion the  developement  of that
morbid state.   The general rules to which the use of the
actual cautery may be reduced are as follow :
  " In the first place,  all the carious part of the bone
must be  laid   bare, whether  by cutting-away the soft
parts,  or destroying them by caustic.  The  latter me-
thod being tedious,  inconvenient, and uncertain, should
not be used unless when the patient will not submit to
the knife.  The bone being in this manner laid bare and
scraped,  the   surgeon  provides himself with  several
cauterizing irons of the same form, because  the applica-
tion of one is seldom sufficient. It will also be necessary
to provide a number of canohe when the cautery is to be
applied on a bone from about which the soft parts cannot
be completely raised; as, for instance, on the os coccygis,
or sacrum : by means of these canul*, the  hot iron can
be introduced without injuring the soft parts.   In every
case it will be necessary  to protect the surrounding parts
as much as possible from the action of the cautery.
   "The iron, whatever may be its size, should be heated
white, as the hotter it is, the more rapid and less painful
is its action.   On the instant of its application, a black
thick smoke rises from the surface  of the burning bone,
the smell  of  which resembles  exactly that of burning
horn : the great quantity of sanies quickly  diminishes the
heat;  for which reason  a second is to be  immediately
applied with  the same precautions:  and a third, if the 
                ELEMENTS OF SURGERY.             41 g
two preceding have not burned deep enough. Care should
be taken to extirpate the disease by burning  every part
that is affected; and if  the use  of  the cautery has not
always had the success expected from it, the failure of
it is to be attributed to the timidity of the operator.  A
carious bone becomes worse by the application of the
actual cautery, if the evil be not entirely rooted out, just
as a  cancerous  tumour becomes irritated, and makes a
more  rapid progress, if imperfectly cauterized.
   " The actual cautery acts by evaporating the noxious
fluids in which the  carious bone  was immersed;  by
changing the caries  into necrosis, and  by  irritating the
subjacent sound parts, and exciting that action of the
vessels by which the dead  part of the bone must  be
thrown off."
   The particular situation of a bone often influences the
treatment necessary.  The skull sometimes becomes ca-
rious in consetpience  of the venereal disease, and here
the  actual cautery cannot be applied.  The trepan is
therefore to  be used, and with it the  diseased or dead
bone  is  to be removed.   Boyer recommends,  however,
the application  of the hot iron, when  the  mastoid pro-
cess of the temporal bone is the part affected, because the
thickness of its substance is sufficient to protect the brain
from  the effects of the heat.
   The bones of the face are not often affected with ca-
ries,  except from scurvy or syphilis,  and the constitu-
tional remedies  for these diseases generally effect a cure.-
   Caries of the vertebrae has already  been particularly
noticed.
   A  caries of the sternum is not unfrequent.  The affect-
ed bone should, if possible, be removed by means of a
trephine, or cutting instruments.   The internal mam-
mary artery should be carefully avoided in the operation,
although it could probably be secured if wounded. After 
41 g             ELEMENTS OF SURGERY.
trepanning the sternum, the pleura beneath it is found to
thicken and gradually becomes  hard and cartilaginous,
supplying in some measure  the deficient  bone.  Boyer
recommends after  the wound is completely healed, the
application of firm  leather or pasteboard, over the  aper-
 ure  for the purpose of defending the contents of the tho-
rax from accidents.  He adds, " if the carious part can-
not be totally removed, it will be necessary to make tw*e
perforations in the lower part of the sternum in order to
give  a free passage to the purulent matter.  Though the
disease will not be  radically removed by this means, yet
the sufferings of the patient will be considerably  alle-
viated."
  In the other bones, especially in those of the extremi-
ties,  the carious part, when practicable, should be remov-
ed by means of a trephine or  Hey's  saw,  together  with
chisels, gouges and knives;  but if this cannot be done,
the caustic, or hot iron, should be used.   Large portions
of carious bone have been removed by these  instruments
in a variety of cases, with the  effect of producing a
speedy cure. 
ELEMENTS OF SURGERY.             417
                 CHAPTER  LIX.

                    Of Necrosis.

  Necrosis as has already been mentioned, denotes the
entire de*Hh of a bone or part of a bone.
  All the bones  are occasionally affected by necrosis.
The affection may be partial or total.   It may be super-
ficial  or extend through  the  whole  thickness  of the
bone.
  " The middle  portion of long  bones,  or that part of
then}  which is most compact,  least porous, and conse-
quently least endued  with the vital  principle,  is that
which necrosis most generally  attacks.  The extremi-
ties of these bones, and in general, all spongy bones are
much less liable to it.   It  never extends to the articula-
tions even when  the whole diameter of the middle part
of the bone is affected by it.  The extremities covered
with cartilage separate from the dead part of the bone,
and if this be removed by  nature or art, they unite  with
the ossified  periosteum which  occupies the place of the
separated portion.
   " When the necrosis  is superficial,  the  superior la-
mellae are separated from  the rest of the bone ; but this
separation is always  preceded  by a suppuration pro-
duced by the irritation given to the surrounding soft  parts
by the dead portion of bone.  It is  to be observed, that
no part of the substance  of the dead portion of bone goes
to the formation of this  purulent  matter;  for it seems to
be not only incapable  of furnishiug matter for formation
of pus,  but is entirely  without the sphere of vital action.
   " If a broad bone as  the os  frontis, for instance,  be
attacked,  the skin over  the affected parts  tumefies, be-
   VOL.  II.                 3 H 
418                 elements of surgery.
comes inflamed, and assumes a brown  or violet colour;
it grows gradually thinner,  bursts at length, and  gives
issue to the purulent matter contained  under it.  The
necrosis of the bone is then ascertained by introducing a
probe, which is found to pass on  a rough and naked sur-
face, if the affection of the bone really exist.
  " In a case of complete  necrosis of  a long bone,  the
limb swells at the part affected,  and a  hard tumour is
formed on it.   Abscesses form  at various points, they
burst, and their  openings degenerate into fistulae.  The
discharge  from these in the commencement is white and
inodorous, but becomes serous and fetid in a short time.
This matter is sometimes absorbed in such  quantity  as
to produce marasmus, hectic  fever, &c.   lu cases of ne-
crosis, in  which the whole bone  is  affected, the perios-
teum separates from the portion of diseased bone, its ves-
sels seem  to take on a new action, a calcareous phosphate
is deposited in its texture,  it acquires hardness, and in
time forms a cylinder,  in which the dead part of the bone
is included.  This new bone, which is in fact the peri-
osteum ossified, is rough on its  surface, and has but a
distant resemblance to that which it replaces.  Various
holes are observed in it, through  which  the purulent
matter and mouldering portions of bone escape, the fistu-
lous openings  in  the soft  parts being continuations  of
these holes, and the muscles of  the limbs are  inserted
into it.
  " The dead part, completely separated from the sound,
and enclosed by the indurated periosteum, is called the se-
questrum : this separation is perfectly analogous to that of
mortified soft parts.
  " The  promptitude with which gangrened soft  parts
are separated, is much greater than that with which a
dead portion of bone is detached ;  but  this difference is
to be entirely attributed to the state of the vital energy of 
                 elements of surgery.             419
the parts,  which is much more considerable in the  one
case than in the other."
  The causes of necrosis are various accidents by which
the texture of  a bone is destroyed, as blows,  pressure,
&c. and also certain diseases, as syphilis, scrofula,  &c.
indeed it is  difficult to  distinguish,  when  caries,  and
when necrosis have resulted from these constitutional af-
fections ; and it is unnecessary  to add to what has been
said of their effects in the last chapter.
  Some  of the most  interesting operations  of the  ani-
mal economy are called forth by necrosis.  The manner
in which new  bone is formed to supply that which has
been lost,  has  of late years excited great attention, and
appears at  present to be well understood.
  It frequently happens that the firmness of a limb re-
mains during the whole  of the process by which the new
bone is formed  ; it would appear from the observations of
Mr. Russell, that the old bone serves as a mould upon
which the new bone is formed, and the new bone not
only  begins to  grow, but actually acquires  solidity and
firmness before the dead bone is absorbed and removed ; I
have before me at this  time a very curious  specimen of
new  bone,  investing completely in  a hollow  cylinder
a portion of carious tibia, an aperture remaining in  front
nearly large enough to permit the  extraction  of the old
bone. And a case is recorded in which seven inches of the
thigh bone was pulled away from within a similar bony
production in a boy  thirteen years  old.  In some cases
a complete new clavicle has been formed,  the old one
being separated,  and large- portions of the lower jaw
bone have been regenerated  after being destroyed by
necrosis.
   If the new  bone  were not formed previously to the
separation of the old, the limb would become flexible at
the diseased part. 
 4£Q            ELEMENTS OF SURGERY.
   It has already been remarked that necrosis generally
 happens in the middle of the cylindrical bones, and that
 the articulating extremities remain sound.  From these
 extremities the formation of new bone progresses  upon
 the old, forming a case around it,  larger in diameter,
 of course,  than the old bone, but never exceeding it in
 length.  This bony involucrum  is at  first a soft pulpy
 mass, and Mr. Russell supposes it formed independently
 of the original bone, or its periosteum. Mr. Macartney op-
 poses this idea, and in a letter published by Mr. Crowther,
 remarks, " that the first and most important circumstance
 is the  change which takes place in  the  organization of
 the periosteum;  this membrane acquires  the highest de-
 gree of  vascularity, becomes  considerably  thickened,
 soft,  spongy, and  loosely  adherent to  the  bone.  The
 cellular substance, also, which is immediately connected
 with the periosteum, suffers a  similar alteration : it puts
 on the appearance of being inflamed, its vessels enlarge,
 lymph is  shed into its interstices, and  it  becomes conso-
 lidated with the  periosteum.  These changes are prepa-
 ratory to the absorption of the old bone,  and the secretion
 of new osseous matter, and even previous to the death of
 the bone,  which is to be removed.  In  one instance,  I
 found the periosteum vascular and pulpy, when the only
 affection was a small abscess of  the medulla, the bone
 still retaining its  connection with the  neighbouring parts,
 as it readily  received injection.   The  newly organized
periosteum, &c.  separates entirely from  the bone,  after
 which it begins to remove the latter by absorption;"  and,
while this is going on, its inner surface becomes covered
with  little eminences, resembling  granulations.   "In
proportion  as the old bone is removed,  new osseous  mat-
 ter is  dispersed in the  substance of the granulations,
whilst they continue to grow upon the old bone, until the
 whole, or a part of it, is completely absorbed,  accord- 
                ELEMENTS OF SURGERY.             421
ing to the circumstances of the case. What remains of
the investment, after the absorption of the old bone, and
the formation of the osseous tube, which is to replace it,
degenerates, loses  its vascularity, and.  appears like  a
lacerated membrane.  I have  never had  an opportunity
of examining a limb, a sufficient time after the termina-
tion of the disease,  to  ascertain, whether  the  invest-
ment be at last  totally  absorbed; but,  in  some  in-
stances,  I  have seen very little remaining.   During the
progress of the disease, the thickened cellular substance
which surrounded the original periosteum, becomes gra-
dually thinner, its vessels diminish, and it adheres strict-
ly to the new formed bone, to which it ultimately serves
as a periosteum."
   The symptoms of necrosis  have been well described
by Russell.  In an incipient state, it is characterized by
a  deep-seated excruciating pain, not at  first aggravated
by pressure, and which is soon followed by a rapid en-
largement  of the  parts along the course  of the bone.
Soon, however,  after the commencement of the  attack,
an external inflammation succeeds, which quickly ends
in the formation  of matter.   The  abscess,  at  length,
bursts by a small opening.  The extent of this  inflam-
mation is not  in general great.  Most commonly several
inflammations, of a circumscribed kind,  occur about the
same time, the abscesses burst by small openings, which
do not close, but continue discharging matter as fistulous
sores.  The apertures  are  generally situated over the
most superficial part of the affected bone.   The pus is
usually of good quality, and large in quantity,  issuing
from extensive cavities, into which the fistulae lead. .Such
abscesses,  being situated within the newly formed osseous
shell, cannot be  discharged  by  pressure, nor can any
fluctuation be felt.  A probe  can seldom be introduced
far into the fistulous openings, or discover any loose piece 
 422             ELEMENTS OF SURGERY.
 of bone. In this stage, the dead bone, technically called
 the sequestrum, can seldom be felt, though, in a few in-
 stances, small spiculae make their way outward, together
 with the discharge.  Fistulous openings may  be regard-
 ed  as  necessarily attendant  on all  cases  of necrosis;
 though so  mild a case may be conceived,  that the new
 bone may be generated without any outward ulcerations.
 No such instance, however, is on record."
  After the openings have  formed, the case  may take
 one of the two following courses. The ulcerations may in
 time heal up, the sequestrum never be seen, and no ves-
 tige of the  disease remain, except a permanent enlarge-
 ment and induration along the course of the bone,—this
 is the most favourable manner, in which a necrosis can
 terminate;  or secondly,  the sequestrum  may make its
 appearance externally, through the new bone and the in-
 teguments, attended with  degrees of pain, inflammation,
 and suppuration,  differing in  different  cases.   The
 sequestrum may  at first be moved by shaking it; but is
 too firmly wedged in the  surrounding parts to be com-
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 such 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- 
                ELEMENTS OF SURGERY.             423
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
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.  In 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 
 424)             ELEMENTS OF SURGERY.
 be completed in three months.  Mr. Russell has never
 known a necrosis of the  tibia get well  in  less than a
 year;  but, in general, nearly two years elapse first; some-
 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 referrable  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 saving his life.   This is the last crisis of imminent
danger; but, in general it is less perilous, than when the
inflammation comes  on in an incipient stage of necro-
sis." 
                 fci^MENTS OF SURGERY.             425
                      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
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 general
competent to the cure, but  in many cases art is required.
  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 pf these remarks.
  When any of the cylindrical bones are affected with
     Vol.  n.                3  i 
426              elements of surgery.
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.
  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  blood-vessels, or
other important parts.   It is best to remove completely

  ♦The necessity alluded to is the extreme exhaustion and hectic state of the
patient. 
                ELEMENTS OF SURGERY.            427
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-
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 inlaying 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. 
428             ELEMENTS OF SURGERY.
                  CHAPTER LX.

                Of Setons and Issues.

   A  seton is a wouud 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.
   Great attention should be paid  to  cleanliness, espe- 
                ELEMENTS OF SURGERY.             429
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 blood-vessel, 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.
   The use of caustic is however the best and most usual
method of forming issues.  The manner in which  I  have 
430            ELEMENTS OF SURGERY.
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 1 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.
  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- 
                ___IENTS OF SURGERY.             431
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 maybe 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 become
extremely offensive. 
43g             ELEMENTS OF SURGERY.
                 CHAPTER  LXI.

                 Of Mal-formations.

   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 HARE-LIP.

   Fissures in the upper lip of infants extending in many
 cases through the roof of the  mouth, affecting the bone
 as well as  the soft parts, have received from the resem-
 blance to the mouth of the hare,  the  appellation of hare-
lip..  In some cases  the fissure is  in the middle of  the
lip;  more generally it is on one side,  and occasionally
there is a  double hare-lip, a fissure existing  on each
side.
   Its extent varies considerably; sometimes it is confined
to the edge of the lip, at other times  it extends up to the
nose and even into the nostril; sometimes, the lip alone
is affected, in other cases the gum, and superior maxil-
lary  bone are divided,  and the fissure  extends  even
through the roof of the mouth completely to the soft  pa-
late,  the nostril  and  mouth forming one cavity.  The
velum pendulum palati is sometimes divided.
   The deformity, if no  other  inconvenience  existed^ 
                ELEMENTS OF SURGERY.              433
would be a sufficient motive for  the performance of any
operation necessary to effect its removal, but in addition
to this, the child sucks and swallows with great difficul-
ty, and  if a cure be not effected will remain unable to
articulate distinctly.
   It is the custom to postpone the operation for hare-lip
till the infant advances to the age of two years and up-
wards, under  an idea that convulsions  will result from
it—this caution  is I believe superfluous, and the earlier
the operation  is performed,  the  more complete  will be
its  beneficial  consequences  especially  in those cases
where the bones are affected, because in very early life
the vacuity will be more perfectly filled up.
   The operation for the cure of hare-lip consists in  par-
ing off the epithelium and skin of the lip,  on each  side
of the fissure, and keeping the cut surfaces in contact by
means of the twisted  suture.  We  are directed in the
more modern surgical authors,  to perform  the operation
with a sharp scalpel, from a fear that the contused wound
occasioned by scissors will not unite  by the first inten-
tion,  this caution, proceeding from  an unnecessary re-
finement upon the doctrines of adhesion is totally  use-
less, the operation may with great facility  be performed
by scissors, and the wound heals  in every instance by
the first intention, provided  the  suture is  properly ap*
plied.
   It is  of great consequence whether the  knife or  scis-
sors be employed, to cut out the upper angle of the fis-
sure, that the piece removed shall  form the letter V> if
this  be not attended  to, the whole of the  surfaces  will
not unite.
   When the skin of  the lip  is removed, the wound re-
sembles  any other incision through the same  part,  and
the mode of treatment must  be similar to that employed
   vol, n.               3 K 
434            ELEMENTS OF SURGERY.
in wounds through the lip.  Two silver pins with move-
able steel points are to be passed into the lip half an inch
from the wound, these pins are to be pushed through the
substance of the lip in such a manner as to  pass through
the wound; they should not extend deeper  than two-
thirds through the substance of the lip, the  points are to
be brought out half an inch from the wound on the op-
posite side, and then removed; a firm ligature of  waxed
thread is now to be  passed round and round these pins
in the form of the figure 8, in such a manner as to con-
fine the sides of the wound in contact, (see plate I.)  In this
manner the  twisted suture is  formed, and it certainly is
more convenient and effectual than the interrupted suture
in this particular instance, although the latter is preferred
by some surgeons, and no doubt answers tolerably well.
   When the operation for hare-lip is deferred until the
teeth have grown, we often find the large  incisors pro-
jecting on the edges of the fissure in the upper maxillary
bone,  they  should be  removed  in such cases before the
operation is performed.
   In double hare-lip  the same method of removing the
skin is to be performed on both sides, but the number of
pins need not be increased in this case, they must pass
through the insulated central portion of the lip, and great
care is necessary in the  accurate  co-aptation  of  the
wounded surfaces.  The pins should in general be taken
out at the end of the fourth day from the operation.
   When the  lower  lip  is totally or  partially affected
with cancer, its removal becomes necessary; in these cases
an incision  is  to be made on each  side of  the  diseas-
ed part with a  bistoury or  scalpel, and the lip  dissected
loose from  the lower  jaw;  if  practicable the incisions
should meet in a point  at the chin,  or on one side of it,
and then the sides of the wound can  be closed by  the 
                ELEMENTS OF SURGERY.             435
twisted suture, the pins being introduced and the liga-
ture applied,  just as incases  of  hare-lip,  if even the
whole lip is extirpated the  deformity is by  no means
very  great.   The bleeding, in operations both on the
upper and under lip, is generally profuse  at first, but
soon ceases.   Cancer of the upper lip is  to be extirpated
and treated when practicable in the same manner.
f 
486             ELEMENTS OF SURGERY.
                 CHAPTER LXII.

                    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 complaints
it is in these,  because the cure  consists in mechanical
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 nature
and degree, and consequently require very different treat-
ment.  The most usual form of the complaint, however,
consists  in a turning inward  and upward of the sole of
the foot, in the manner represented  in the  opposite out-
lines ;  when a person with such a foot begins to walk,
he walks on the outer edge of the foot, and the deformity
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 ma-
terially to augment the deformity, and consequently the
longer they are suffered to act, the greater this  deformity
will be. 
('tub  Foot.
H
)
./.v Ikwv dU i '<»//' 
/ 
                ELEMENTS OF SURGERY.             43<y
  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
natural posture of the foot, and this is to be attempted by
splints and bandages accommodated  to the particular na-
ture 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 susceptible
of any change in  shape which circumstances may direct.
The muscles have not yet acted sufficiently to  augment
the  original derangement. We are not, however, to be de-
terred from endeavours  to relieve  the complaint even
when years have elapsed before surgical aid is request-
ed,  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 separate
those parts where bony  matter is deficient, and to force
together those in  which it isvredundant; this will 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 
438             ELEMENTS OF SURGERY.
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 near-
ly approaching to the natural one, as the pre-existing de-
formity will admit.  This compression  of the cartilages
will, by condensing their substance, prevent the arteries
from shooting so freely into it,  in an improper direction,
as they would have done  but  for this impediment, and
thus stop the progress of ossification in an improper di-
rection, while that process  will go on in the natural way,
in every other part, till the  patient has arrived at ma-
turity, 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 imped-
ed, 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 is not in-
creased ;   and by  perseverance in this process it is cer-
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 modified,
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-
^le joint, and another in the foot, which is the case in  a 
                ELEMENTS OF SURGERY.             439
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 de-
formity by a contrivance which is represented in the an-
nexed 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 in 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. 
440
ELEMENTS OF SURGERY.
              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.  It 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.
 h. h.  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. 
Plate xxwi
) 
/ 
ELEMENTS OF SURGERY.            441
                CHAPTER LXin.

                  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-
logous 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 congenital defi-
ciency 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 Uh|
pid colourless serum, but sometimes it has been founcT
turbid and tinged with'blood. In examining spina bifida,
a fluctuation can always be felt, and in general the defi-
cient of bone can be discovered by the finger; this defi-
cienty is usually between two  of the  spinous processes,
thotfgh  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 £te
compl||pt, 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  sin-
gle instance been cured.  The tumour has been opened
by caustic and by incision, always with  a fatal  result.
   vol.  n.                   3 L 
  442             ELEMENTS OF SURGERY.
    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 pro-
  priety,  if this should fail, of puncturing the tumour with
  a finely cutting instrument, the wound to be immediately
  after closed with sticking plaster, and healed :  the reac-
  cumulation  of the fluid he proposes to prevent by local
  pressure. In one case Mr. Abernethy punctured a spina
  bifida every fourth day for six weeks, during  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 ulcerated;  the opening
  could not be healed, and death ensued: the discharge
  being previously changed from serum to a purulent fluid.
    Mr. Benjamin Bell proposed to tie  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
^^11 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 flaj||ned
  troqjiar 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 oBe, for
  the  whole  brain was compressed in  such a way as to
  fcujm a lining for the dura mater scarce half an inoh thick,
  its blood-vessels were very small, and the puncdWs 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." 
                 ELEMENTS OF SURGERY.             443
   Mr. Astley Cooper has published* some cases which I
*hall here insert as proofs, that this disease is no longer
to be considered as utterly beyond the reach of surgery.
   " James Applebee, Baldwin Street, Old Street, was
born on the 19th of May, 1807, and his mother, imme-
diately after his birth, observed a round and  transparent
tumour on the loins, of the size of a large walnut
   "Mr. Deering,  who  was her accoucheur, requested
Dr. Petch to  see the child with him, who informed the
mother of the dangerous nature of the complaint, and of
the probability of its fatal termination.
   " On the 22d of June, 1807, the child was brought to
my house, and I found, that although it had spina bifida,
the head was not unusually large; that  the motions of
its legs were perfect; and its stools and urine were dis-
charged naturally.
   " I applied a roller around the  child's  waist, so as to
compress the tumour, being induced to do so from consi-
dering it as a species of hernia, and that the deficiency of
the spine might be compensated for by external pressur^
   " The pressure, made by the roller, had no unpleasanx
influence on its  voluntary powers; its stools and urine
continued  to  be properly  discharged, but  the  mother
 thought, that the child was occasionally convulsed.
    " At the end of a week, a piece of plaster of paris,
 somewhat hollowed, and that hollow partly filled with a
 piece of lint, was placed upon the surface of  the tumour:
 a  strajp of adhesive plaster was  applied to prevent its
 changing its  situation,  and a roller was  carried around
 the waist,  to  bind the plaster of  paris firmly upon the
 back,^nd  to compress the  tumour as much as the child
 could near.
  •  "This  treatment was  continued until the month of
 October, during which time, the tumour was  examined
• 
444             ELEMENTS OF SURGERY. '
about three times a week, and the mother reported, that
the child was occasionally convulsed.
   " When the child was five months old, a truss was ap-
plied, similar inform to that, which I sometimes use for
umbilical hernia in children, and this has been continued
ever since.
   " At the age of fifteen months, it began to make use of
its limbs;  it could crawl along a  passage, and  up  two
pair of stairs.
   " At  eighteen months,  by some accident, the truss
slipped from the tumour, which had become of the size
of a small orange, and the mother observed, when it was
reduced, that the child  appeared in some  degree dull;
and this was always the case, if the truss was left off for
a few minutes, and then re-applied.
   " At fifteen months, he began to talk ; and at two years
of age, he could walk alone.
   " He now goes to school, runs, jumps, and plays about,
as other children.  His powers of mind do not appear to
  «ffer from those of other children.  His memory is reten-
  ^e, and he learns with facility.  He had the measles and
small-pox  in  the  first year, and the hooping cough at
three years. His head,  previously and subsequently to
the bones closing, has preserved a proper proportion to  j£
the other parts of the body.
   "The tumour is kept by the truss entirely within  the
channel of the spine ; but, when the truss is removed, it
soon becomes of the size of half a small orange./ It is
therefore necessary, that the use of the truss should be
continued.  When the truss is removed, the finger can be
readily pressed  through  the tumour into the channel of
the spine."  (Medico Chirurgical Transactions^rol. 2.
p. 323, $c.)
   The next case, also published by Mr. Astley Cooper, 
                ELEMENTS OF SURGERY.            445
will prove, that spina bifida may sometimes be treated
on another plan, so as to accomplish a permanent cure.
  "January 21st, 1809,  Mrs. Little, of No. 27, Lime-
house Causeway, brought to my house her son, aged ten
weeks, who was the subject of spina bifida.
  " The tumour was situated on the loins;  it was soft,
elastic, and transparent;  and its size about as large as a
billiard-ball when cut in half; his legs were perfectly.
sensible, and his urine and feces  were under the power
of the will, &c.
  " Having endeavoured to push the water, contained in
the tumour, into the channel of the spine, and finding
that if the whole was returned, the pressure would be too
great upon the brain ; I thought it  a fair opportunity of
trying what would be the effect  of evacuating the swell-
ing by means  of a  very fine pointed instrument, and  by
subsequent pressure  to bring it into the state of the spina
bifida in Applebee's  child.
   " I therefore immediately punctured the tumour with a
needle,  and drew oft* about two ounces of water.
   " On the 25th of January, finding the tumour as large
as before it had been punctured, I opened it again, and in
the same manner,  and discharged about  four ounces of
fluid. The child cried when the fluid was  evacuated, but
not whilst it was passing off.
   " On January 28th, the tumour was as large as at first,
I opened it again, and discharged the fluid. A roller was
applied over the tumour, and around the abdomen.
   "February 1st, it was again pricked, and two ounces
of fluid discharged.
   " On the 4th, three ounces of fluid were discharged.
   " 6n February  9th,  the same  quantity of fluid was
evacuated as on the 4th; but, instead of its being perfect-
ly  clear, as at first, it was now sanious, and it had been
gradually becoming so in the three former operations. 
446             ELEMENTS OF SURGERY.
  "On the 13th, the same quantity of fluid  was takes
away; a flannel roller was applied over the tumour and
around the abdomen;  a piece of pasteboard  was placed
upon the flannel roller over the tumour, and another roller
over the pasteboard to  confine it.
  " On the 17th, three ounces of fluid, of a more limpid
kind,  were discharged; the  pasteboard  was again  ap-
plied.
  " On the 27th, the  surface of the tumour inflamed;
the  nuid, not more  than  half its  former  quantity,  wa9
mixed with coagulable  lymph, and  the child, suffering
considerable constitutional irritation, was ordered calo-
mel and scammony, and the rollers were  discontinued.
  " February  26th, the  tumour was not more than a
quarter of its former size; it felt solid; the integuments
were thickened, and it had all the appearance of having
undergone the  adhesive inflammation.
  "On the 28th, it was still more reduced in size, and
felt solid.
  " On March 4th, it was in the same state as on the
28th of February.
  " March 8th, the swelling  was very much lessened;
the  skin over it thickened and wrinkled; a roller was
again had recourse to; a card was  put over the tumour;
and a second roller was applied.
  " March 11th, the tumour was much reduced; the skin
covering it was a  little ulcerated. On the 15th, it was
flat, but still a little ulcerated.
  " On the 27th, the effused  coagulable lymph was con-
siderably reduced  in  quantity,  and of a very firm con-
sistence.
  " On the 2d  of May, nothing more than a  loose pen-
dulous bag of skin remained, and the child appearing
to be perfectly well, the bandage was soon left off. 
              ELEMENTS OF SURGERY.              447
  " On December 18th, it was attacked with the small-
pox, and went well through the disease.
  " The skin now bangs flaccid from the basis of the sa-
crum ;  its centre is drawn to the  spine, to  which it is
united, and thus the appearance of a navel is produced
in the tumour by retraction of the skin.
  " The pricks of the needles are very obvious on each
of the punctured parts of the tumour, forming slight in-
dentations."   (See Medico-Chirurgical  Transactions,
Vol. 2. p. 326—329.) 
448
ELEMENTS OF SURGERY.
                CHAPTER LXIV.

                Of Imperforate Anus.

  Mr. Benjamin  Bell has  published in his system of
surgery a very good account of this subject;  from that
work 1 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 disco-
vered, 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 further 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
to make  an opening  sufficient for  evacuating them j  but 
                ELEMENTS OF SURGERY.            440
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 direction
the vagina or bladder, or perhaps both,  might be brought
to suffer; but backwards a^ng 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 pushed
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, after all> the faeces
are  not  evacuated,  as death must undoubtedly ensue if
something further be not attempted, a long trochar should
be pushed forward upon the finger, in" such  a direction as
the operator thinks will most probably 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 purpose suffi-
 ciently.  But in each of these  a great deal of  difficulty
 was experienced in preserving the passage sufficiently
 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 conside-
 rable time reuderedthe evacuation of the faeces extremely
 difficult. Sponge tent, gentian root, and other substances
    vol. n.                3 m 
450             ELEMENTS OF SURGERY.
which sWell by moisture, were at different times employ-
ed; but these  were uniformly found to produce so much
pain and irritation as rendered their continuance altogether
inadmissible :  applications of this kind are frequently, in-
deed  recommended in such cases; but any person who
has ever used  them in parts so exquisitely sensible as the
rectum always is,  will readily acknowledge the  impro-
priety 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 I was ever concerned in afforded  so
much trouble  and perplexity as was experienced  from
each of those  I have mentioned; 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
procured, that much nicety and  attention on the  part of 
                 ELEMENTS OF SURGERY.             451
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 recommended
should be undoubtedly practised: for, in the former case,
as all the faeoes must be emptied into the bladder, much
risk must occur of such accumulations being formed as
may put a total stop to the discharge by the urethra; and
in the latter, where the rectum terminates in the vagina,
much inconvenience and distress must be incurred; 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 in-
conveniences produced by the gut terminating in the blad-
der 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 practice.
   "When it unfortunately happens that no passage is ob-
tained for the  faeces by any of the means we have pointed
out, might not we attempt an opening above the pubes,
or perhaps ou  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 allowing
the attempt to succeed in the  most complete 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 situation, to  die  in much
pain, must prove so highly distressing, both to the friends
and the operator, as would at any time rather incline one 
452             ELEMENTS OF SURGERY.
to have recourse even to the doubtful and desperate re-
medy we have mentioned."  (B. Bell.)

  A very interesting case of imperforate anus is related
by my friend Dr. J. A. Smith, in the second volume of
the New York  Medical and Philosophical Journal; in
that  case the rectum communicated with  the  urethra,
through which  canal its contents were evacuated.  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 permitted, 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.
453
                CHAPTER LXV.

             . Of Imperforate Vagina.

  It is by no means unusual to find in new born girlsj
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 vt
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 flow, 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 becomes  necessary when in-
stead  of a mere  membrane to be divided,  the  surgeon
finds an obliteration of the vagina,  or a concretion of its
sides.  In this case he must proceed by slow and cau-
tious dissection, guarding w ith extreme care the bladder, 
 404             ELEMENTS OF SURGERY.
 on the one side and the rectum on the other.   De Haeu
 relates a case  in which 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. 
ELEMENTS OF SURGERY
455
                CHAPTER LXVI.

             Of the Ccesarian 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 dur-
ing 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  chRd 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^t^is  question shall simply state
that there are some case* 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,
 it is impossible for it to be delivered in the usual manner.
 In these cases I believe  the best practice is to wait until 
456             ELEMENTS OF SURGERY.
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. Vaughan, 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 uuder hectic fever and diahrTicea, 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 and a half
above  to the same distance below the umbilicus.   At
three strokes of the knife I got into the sac, and intro-
ducing my finger dilated  upwards and downwards as far
as could be clone 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
at first was easily done, but  after removing two or three 
                E1JEMENTS OF SURGERY.            457
it became more and more difficult, and at last I found it
absolutely impracticable to get aw ay 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 hap-
pened 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 justified  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 recover-
ed, 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 Caesarian
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
 pains, flooding, convulsions, &c.
   The operation being  determined upon  in  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, and her thighs  somewhat
 raised, in order to relax the muscles of the abdomen; an
                              3 N
vol. n. 
458             ELEMENTS OF SURGERY.
incision is then to be made six inches long through the
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 Edin-
burgh 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 which 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 and intestines protruded
from the wound but were reduced readily, and the wound 
                 ELEMENTS OF SURGERY.            459
was dressed by sutures and adhesive plaster.   The wo-
man,  however, died on the fourth day afterwards.
  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 Caesarian  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 Czesarian section has generally proved fatal.
  f Cours Uicorique et pratique tPaecouchemens, par J. Capuron. A Paris,
1811. 
460
ELEMENTS OF SURGERY.
                CHAPTER LXVII.

        On the division of the symphysis pubis.

   Another operation, the consideration of which pro-
perly belongs to midwifery, is described in several sys-
tems of surgery,  the division- of the symphysis pubis for
the purpose of enlarging the diameter of the pelvis, in
cases of difficult labours.   Mr.  Sigault, a French ac-
coucheur, contrived this operation as a substitute for the
Caesarian section, than which it is certainly less danger-
ous and severe; it was adopted by a majority of the French
physicians, who  proclaimed it one of the most important
improvements  of the healing art.  The British generally
rejected 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 table
of convenient height; " the pelvis should be elevated 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  div ision 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
no means hard,  it is easily done.  Both the teguments 
                 ELEMENTS OF SURGERY.            461
 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 de-dred  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.
   u The child is now  to be delivered  in the usual way
 by  the vagina, and this being effected, 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 effect au'altera-
tion in the situation of the bones, till nine or ten weeks
have elapsed." 
462              ELEMENTS OF SURGERY.
  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 Ossiura Pubis Synchondrotomia. Parisiis, 1811. 
ELEMENTS OF SURGERY.
463
                CHAPTER LXVIII.

                 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
fouud 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, iu which  the os tincae is si-
tuated ; 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 amount-
ing to severe pain, are however very distressing, and are
greatly augmented  by exercise.  Rest in  a horizontal
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
flowing over it,  and the friction occasioned by exercise,
often produce great pain and distress. 
464             ELEMENTS OF SURGERY.

                     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 conse-
quently preclude the ready return of the uterus : to over-
come  this  obstacle,  it is necessary to confine the patient
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 re-
main.  By the  use  of these remedies, and the  assist
ance  of the surgeon's fingers, the  uterus may be gene-
rally  replaced.  It is unnecessary to wait until all inflam-
mation ceases, because as long as it remains in  its unna-
tural  situation, exposed to the external irritations which
have  been mentioned,  it will  continue  somewhat  in-
flamed ; at the same time it would be highly improper to
make any effort at reduction, until the remedies just di-
rected have had the effect of considerably reducing the
inflammatory appearance 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 ma-
terials, adapted to the shape  of the vagina; these are,
however, at present  laid  aside, and a variety of substi-
tutes have been invented.
   A pessary ought to be formed of materials'sufficiently
firm to support the uterus, and so light as not to descend 
                   ELEMENTS OF SURGERY.              465
    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 import-
    ance.  Dr. Denman directs them to be made globular;
    Dr. Clarke prefers a flat oval form, with a perforation in
 't   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 pessa-
    ries 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 instruments are
    perfect, they all become exceedingly foetid after remain-
    ing a very  short time in the vagina.  Dr. Physick has had
    pessaries constructed of silver, very thickly gilt.  He pre-
    fers the globular  form  in most cases, and in order to
    have the instrument light, it  is made hollow ;  two very
[   thin hemispheres  of silver are soldered together, highly
    polished on the outside, and  then coated with gold. The
 ♦   silversmiths  very easily fabricate such  an  instrument,
    and it possesses several  advantages. The gold is not af-
 [   fected 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 reuder the pessary too heavy;  it is also
  '  more expensive.  The  use  of astringent 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-VERr
    sion of the uterus.
       vol. n.                  3  Q 
466             ELEMENTS OF SURGERY.
                CHAPTER LXIX.

                    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 opportu-
nities of acquiring dexterity in this  important  branch
surgery are so little sought after by medical students
this country.
  Bandages are 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  pre-
vents it from slipping, properties  which are combined in
no substance to so  great a degree as in muslin—flannel in
some  cases answers very well, but  it retains in general
too much heat.   The muslin  used  for banda
coarser kind, and it should be washed before
The  selvage or stiff margin  at  the edge of
should be torn off before the bandage is made.
ral  it  is best to have bandages free from seams.
a long roller is wanted, it should  be torn  from  a  piece of
muslin of the requisite length.
  The mode of applying  a bandage must depend en-
u-

in   \
 
                 ELEMENTS OF SURGERY.             467
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.  Inflammation
and grangrene have often resulted from negligence in  this4
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 in 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. 
468             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 suffi-
ciently 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 by 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 unskilfillness 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.  Th: 
                ELEMENTS OF SURGERY.             469
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. 
470
ELEMENTS OF SURGERY.
                 CHAPTER LXX.

              Of Opening Head 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
 diagnostic 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.
   Another introductory remark I beg leave to offer, which
 is, that to ascertain the  effects of disease on the animal 
                   ELEMENTS OF SURGERY.             471
    structure, it is essential that its healthy condition 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
    investigations.  To illustrate this, it may not be impro-
I   per to men-ion one or two very  common mistakes to
>   which the unpracticed dissector is liable. He confounds
    coagula 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
    adhesion; the glands of Pacchioni are sometimes consi-
    dered 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 symptomatic
    of malignant fever.  A young gentleman once supposed he
;    had discovered a symptom of yellow  fever which had es-
    caped the notice of all the writers on the subject, a gan-
    grene of the scrotum!   His discovery like many other
    discoveries depended on his ignorance of common  ap-
/   pearances. 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
    much caution cannot be urged upon  him.
       Very distressing accidents  having  sometimes arisen
 v  from wounds or punctures of the fingers in dissections,
    the surgeon should be careful to avoid such injuries.
 f      The instruments necessary in the  examination of dead
 t  bodies are scalpels, a saw, and strong elevator or chisel. 
 472             ELEMENTS OF SURGERY.
 needles, ligatures, and sponges.  Care should be taken
 to avoid soiling the shroud and coverings of the subject,
 and the utmost decency should mark the whole operation,
 every unnecessary exposure being carefully avoided.      t
    It is proper to make the external incision in such situ-
 ations  as not to  disfigure the corpse—of course in parts
 concealed from view.

                  OP 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   v
 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 reverted
 forward and backward so as to expose the cranium ; the
 temporal muscle is to be divided where it covers the tem-
 poral 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 frontal sinuses, and
 continued  horizontally around the  cranium;   the  dura
 mater should be avoided as carefully as possible, but it is
 scarcely practicable to prevent its being 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  j
 divided in a line corresponding with that by which the  v
 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
 and its ventricles are best exposed  by horizontal sec- 4
 tions,  and if necessary,  the falx  can afterwards be cut \
 loose, and the whole contents of  the cranium inspected. J 
                ELEMENTS OF SURGERY.            473
  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 ABDOMEN.

  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-
nium 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 manner
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 wdien the in-
testines  are distended  with flatus they are very apt to be
opened  unnecessarily by a hasty or careless incision;
when the peritoneum  is punctured at one place, two fin-
ders should be introduced into the aperture, and the in-

  • The crucial incision usually made, occasions more exposure than is neces-
sary and therefore should be laid aside.
   VOL. 11.                   3 P 
474             EL
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 dissection.
THE  END. 
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