•&:•;,'•■■; ■■..'rl ■t ■■m-'-v I: . Vt.-i ~,~. y.'/^-^t: ,TI* .■■•£-^-0:>^' '■.'''-"-'Itv!'^""'" ■••**.,"U*'"J-•'"■"' ^J§*& ,fe'i'" 'WlS?': *i,'^I^VU, ' i , , is-'-'"l.Hh" -,.>;^B «',,T.V' > ■ ■ ' '■•. IxtS-'-i'S-'rfr^. - ■•■ - • *.. .Kfe:^' i-.'-:'V, : 1 'g1*"" ill It'fV NEW ELEMENTS OPERATIVE SURGERY: ALF. A. L. M. VELPEAU, ♦ f. » Professor oif Surgical Clinique of the Faculty of Medicine of Tins Surgeon of the Hospital of La Charit*. Member of the Royal Academy of Medidine, of the Institute, &c. CAREFULLY REVISED, ENTIRELY REMODELLED, AND AUGMENTED WITH A TREATISE ON MINOR SURGERY, ILLUSTRATED BY OVER 200 ENGRAVINGS, INCORPORATED WITH THE TEXT: ACCOMPANIED WITH AN ATLAS IN QUARTO OF TWENTY-TWO PLATES, REPRESENTING THE PRINCIPAL OPERATIVE PROCESSES, SURGICAL INSTRUMENTS, &C. FIRST AMERICAN, FROM THE LAST PARIS EDITION. TRANSLATED BY P. S. TOWNSEND, M.D. Late Thysician to the Seamen's Retreat, Staten Island, New York. AUGMENTED BY THE ADDITION 0? SEVERAL HUNDRED PAGES OF ENTIRELY NEW MATTER, COMr-RIBlNG ALL THK LATEST IMPROVEMENTS AND DISCOVERIES IN SURGEIIY, IN AMERICA AND EUROrE, UP TO THE PRESENT TIME. UNDER THE SUPERVISION OF, AND WITH NOTES AND OBSERVATIONS BY VALENTINE MOTT, M.D. Professor of the Operations of Surgery with Surgical and Pathological Anatomy, in the 1 'nivcrsity of New York; Foreign Associate of the Acadomie Royale de Medecine ot Tuns, of that of Berlin, Brussels, Athens, &c. t IN THREE VOLUMES. &/'? \ VOL. II. ""/£ NEW YORK: SAMUEL S. & WILLIAM WOOD, No. 261 PEARL STREET 1847. Wo I til t PREFACE BY P. S. TOWNSEND, M.D. The Second Volume of this First American Edition of Velpeau's Operative Sur- gery, (from the last Paris Edition, 1839,) as translated, and with notes, by Dr. Mott and myself, has at length been completed, and is now offered to the Profes- sion ; one volume (the 3d) only remaining, which will be put to press on July 1st, ensuing, forming thus a work of 3000 large octavo pages, or an average of 1000 pages to each volume, including therein, with the Quarto Atlas, which will accompany the work, some 400 to 450 engravings of instruments, processes of mi- nor surgery, and special operations. The entire new matter prepared for this edi- tion, and 500 pages of which will be found in this second volume, will make, altogether, in the body of the work, some 1200 to 1500 pages, comprising in the same, as will be seen in this present volume, a distinct chapter of 100 pages, on the subject of Aneurisms, Ligatures upon Arteries, &c, from the pen of Pro- fessor Mott, together with all his capital operations, viz.: for Aneurisms, Am- putations, Exsections, &c, accompanied with plates ; this new matter embracing also all the latest improvements and discoveries in Operative and Pathological Surgery, brought down to the present year, the whole under the immediate su- pervision of Dr. Mott. It would be superfluous to dwell on the extreme, not to say often intense labor, required for the proper performance of this task by those who have undertaken it. It is gratifying to know, however, that in the midst of numerous and often press- ing professional and other personal engagements, the book is now, at least, two- thirds completed. Notwithstanding the unavoidable and unanticipated obstacles which have necessarily and naturally at times interposed to retard the consumma- tion of a labor of such magnitude, we, as well as the public, have now sufficient encouragement, derived from the favorable reception the first volume has already met with, the elegant and correct typographical execution which it has received from the co-operation of the publishers, printers, and engravers, and finally, the satisfaction which its outward costume, as well as intrinsic merits, have given to those who have translated, prepared and supervised its text; to consider, and to offer its progress so far, as a guarantee of its ultimate completion, and general adoption, and as the principal Elementary Text Book on Surgery, for all students and practitioners, at least, in America, if not in other parts of the world. We confess that it is with pride we present this work to the Profession; not so much, perhaps, from any pretensions we might make, in respect to the exact- ness and fidelity of the translation, or the composition and substance of the vast amount of new matter superadded, as from the conscious conviction we feel that there can be found nowhere, in any language, a surgical work so thoroughly com- plete, and so judiciously classified in (as has already been said in the Prefaces to the First Volume) the abundant and highly interesting and invaluable details which it comprehends, of surgical processes and discoveries, and surgical anato- my and relations, traced down with astonishing erudition and acute discrimina- tion, by the learned author, Professor Velpeau, from the earliest epochs to the present day. Though our labor has been one of a mechanical kind, demanding untiring assi- duity and industry, rather than any originality of mind or invention, we must be permitted to say, that, with the contributions which have been engrafted upon IV PREFACE. this American Edition, and Translation, and which have been furnished as well by Professor Velpeau himself, (See Vol. 1.,) as by Dr. Mott and the writer of this Preface; the student, especially, cannot fail to find herein an inexhaustible arse- nal or armory, systematically arranged in every department, for almost every- thing he may desire, that is truly valuable or worthy of preservation, in the great and controlling domain (now monopolizing almost the entire healing art) of Prac- tical, Operative, and Pathological and Anatomical Surgery. I would, further- more remark, that however little of originality or genius, (speaking in reference to myself,) may be accorded by the world to my own opinions or views expressed in this work, credit at least will be given to the new facts which I have added, and which have been obtained at the cost of much time, and severe researches in- to and a close analysis of all that has been published in different parts of the earth, on matters appertaining directly to Surgery itself, strictly so called, or indirectly to this noble art, through the discoveries and investigations of sciences immedi- ately collateral to it. I do not wish nor intend to dwell upon my own part in this performance, as I make no special pretensions to Surgery, however much I may admire the com- manding solidity of its structure, over that of any other branch of Medicine, or however ready I may have been to avail myself of all the occasions which have presented themselves in my professional career, of indulging in a practical appli- cation of its principles, at least, to many of its minor operations and elementary processes. My professional labors have, it is true, been for the greater part of my life con- fined more to the practice of Medicine itself, strictly so called, and especially di- rected to the investigation of febrile diseases, as personally examined and inves- tigated by me under all their varied aspects of climate and topography, and the influences of the latter on the human organization.* I shall, however, never cease to reflect with pleasure, hard as the task has been, in the thought that in what concerns the great department of Practical Surgery, I shall have left some testimonials, (lasting I trust) of my industry at least, and of my zeal to promote the advancement of an art whose high utility all the world, especially since its brilliant progress within 30 and even 10 years past, now concede to be open to palpable and actual demonstration, and as indisputably entitled to be ranked as an exact science, and as far beyond the reach and assaults of empiricism as ma- thematics itself. Another source of extreme satisfaction to me will be in the reflection that the profession in after times, perhaps, may not be unwilling to bestow their commen- dation upon these efforts. But a still higher source of gratification I frankly confess, is that of the conviction, that in my attachment to a long-cherished, per- sonal, and honored friend, preceptor and kinsman, and one whose eminent skill justly fills so large a space in Surgical history, (Dr. Mott,) I may have been, as I pledged myself I would be, (see Vol. I.,) instrumental both for him, and for his country, in rescuing the details of all his great and master operations, and discoveries, and improvements in surgical processes and principles, from that indistinctness into which they were necessarily passing, by his neglect, (culpa- ble, it would be, but from his repugnance to self-laudation,) to gather them toge- ther as I now have done in these volumes, from the scattered Medical and Surgi- cal periodicals and fugitive works, in which they had been briefly registered, successively as they emanated from his great practical mind, or were created in- to existence by his incomparable genius and consummate skill. * I will refer here, to some of my principal writings on those subjects : 1. My Report on the Fever which prevailed in Bancker Street, New-York, in the Summer and Autumn of 1820. 2. Account of the Yellow-Fever of New-York, in 1822. 3. Account of the Weather, Tonography, and Diseases of the Bahama Islands, West In- dies, 1823-4-6, published at New-York, 1826. 4. Account of the Black Vomit, or Yellow-Fever, at Havana, Island of Cuba, West Indies, 1830. 5. Sundry Essays in various Medical Periodicals, &c. 6. My Report on the Yellow Fever, imported from the West Indies into Rondout, Ulster County, State of New-York, on the Hudson River, 100 miles North of New-York city, in the summer of 1843. PREFACE. V These master operations have been now, as will be seen, in Dr. Mott's own special chapter on Aneurisms, also that of Exsections, &c, completely arranged and revised under his own inspection, in chronological order, so that hereafter there may be an orthodox work, to which reference may constantly be made for the authentic evidence of what he lays claim to as a Surgeon, and which, thus now, for the first time published to the world, in their ensemble, and under his sanction, together with his last, and latest opinions on these matters, present, in our view, we must confess, a precious treasure, for the student for all future time. It will, we feel assured, prove to be a great organum in Practical Surgery which the practitioner, as well as student, may never cease to peruse, and to re-peruse, as embracing some of the most important general axioms both in the minute ma- nipulations and in the higher order of Surgical operations, and which will long continue to be received from so exalted a source, as among the surest and most practical land marks to guide those who aspire to eminence in this science, in their onward march to success and honor. I feel constrained also to add, that the accomplishment of this part of my labor, is one to which considerations of love of country add in my mind no slight de- gree of value. For young as our country is in history, and filled as its annals are with great names, both in the heroic period of its settlement, and in its sub- sequent ages of military renown, national emancipation, and diffusion of the arts, there is in my humble judgment no name that adorns those annals either in the battlefield, or in the councils of government, or in its diplomacy, that has added more sterling reputation, and abiding lustre to the intrinsic glory and future fame of America than that of Valentine Mott, unaided and ungilded though that name may be by the insignia of office or of power. For one who in his duties as a christian and a man of science, has done so much personally in the active field of benevolence, and struck out such noble discove- ries and new paths to enable us more effectually to alleviate the miseries of our fellow creatures, there will be a balm as we believe, that will rest upon his me- mory in after time, less dazzling perhaps, but certainly full as enduring, and far more endearing to future generations, than any that the most ardent homage of patriotism could feel inspired with, for the glare of the most brilliant civic or military exploits. Thus much I have deemed it my duty here to record personally, at least of the views entertained by myself of the appreciation due to the accomplished Sur- geon with whom I have had the honor to be associated in these labors. And with these remarks I will not detain the reader longer than to say, that in this Volume will be found treated all the great and master, or capital opera- tions in the highest branches of Surgical Science, and which once constituted almost its only domain, to wit, Diseases and Operations upon the Arteries, Veins, and Nerves, with Amputations, Dislocations, and Fractures, and the important and comparatively new department of Exsections. In the course of which, it will be perceived that I have (as in our first volume also,) taken espe- cial care in this, to do impartial justice not only to European Surgeons, but also to those of my own country, who occupy an honorable rank in the Science, and have, therefore, in most instances, recorded at full length, the master operations the latter have performed, or the more important additions that have been contributed by them since M. Velpeau published his last edition. Thus have I given the labors of Barton, Ruschenberger, Buck, Carnochan, &c, a deservedly conspicuous place in these pages. I shall therefore, now proceed at once to the details of the Supplemental Appendix which follows this Pre- face, and which it has been found necessary to prepare, in order to embrace a brief notice at least of some of the more important points in Surgical pro- cesses and improvements, and Surgical Pathology and Anatomy, which have not been made public, or which were not accessible until after this volume had been put to press, or had advanced too far towards its completion, to allow of their being incorporated in their proper place in the body of the text, as they will be, and as will be also those of the first volume, in the next edition of this work. P. S. T. New-York, January 12th, 1846. TABLE OF CONTENTS OF THE SECOND VOLUME Page. Preface,.................................. iii Table of Contents,...................... vii Supplemental Appendix,................... six Section Fourth.—O P|E R A TI O N S WHICH ARE PERFORMED UPON THEARTER1ES,.................. 1 CHAPTER FIRST.—Anatomical Remarks, ib. $ I.—The middle coat of the Arteries,...... ib. $ II.— " Internal " " .. 2 §111.— " External " " ...... ib. § IV.— Their Common Sheath,..... 3 $V.— " Nerves.................... ib. CHAPTER SECOND.—Spontaneous Termi- nations of Lesions of the Arte- rial System,...................... 4 Art. I.—Aneurisms.—General Remarks,.... ib. Art. n.—Traumatic Hemorrhages,...... 8 $ I.—The Heart.........................lib. $ U.— " Aorta,......................... 9 CHAPTER THIRD.—Treatment of Arte- i rial Lesions,...................... 11 Art. I.—Medical Treatment,................ ib. $ I.—Method of Valsalva,............... ib. $ H.—Refrigerants and Styptics,........ 14 Art. n.—Surgical Treatment,........... 15 $ I.—Compression,.................... ib. A. Compression in cases of Neuralgias, Congestions and Inflammations,.. ib. I. Arteries of the Head,............ 18 II. " " Neck,............ 19 III. " " Thoracic Extrem- ity.......................... 20 IV. Arteries of the Lower Limb,.... 22 V. " " Abdomen,....... 25 B. Compression of the Arteries in the case of Wounds,............. 27 I. Temporary Provisional Compres- sion, ......................... ib. II. Curative Compression,.......... 28 A. Direct Compression,.......... 29 B. Indirect " .......... ib. [Note.—Traumatic Lesions of large Ar- terial Trunks, Direct Compression, Ligature, fcc, by Dr. MOTT,........... 30 [Note.—Wounds of the Arteries of the Foot, by Dr. MOTT,.................... 32 [Note.—Alveolar Hemorrhage,........... ib. C. Compression in the Treatment of Aneurisms................... 33 Page. $ I.—Indirect Compression,.............. 33 a. On the Tumor or diseased part, 34 [Note.—Tubular Aneurism.— New Nomencla- ture for Aneurisms,..................... ib. Remarks on do.,...................... 35 b. On the whole extent of the limb,...................... 39 c. Below the Tumor,.......... ib. d. Above " .......... 40 e. Appreciation,............... 41 [Note.—The newlt improved method of curing Aneurisms, by pressure above the Tumor, as practised by the Dublin Sur- geons, ................................... 43 § II.—Direct Compression,............... 59 a. Plugging or Tamponing,...... ib, b. The Artery Presser,.......... 60 Various means,.................... 61 A. Cauterization,.............. ib. B. The Suture................. ib. C. Torsion..................... 62 D. Crushing,.................. ib. E. Amputation,................ 63 The Ligature,..................... 66 A. Nature and Forms of the Ligature, • • ib. I. Scarpa's mode................. ib. II. Jones's " ............... 67 III. M. Roux's mode,............ ib. IV. Jameson's " ............ 68 V. Threads of animal matter,...... ib. VI. Metallic substances,.......... 70 VII. Recapitulation,.............. ib. B. The Permanent Ligature,............ 72 C. Precautionary Ligatures,............ ib. D. Temporary Ligatures,.............. 73 I. Sudden obliteration by Ligature,. • ib. II. Gradual obliteration by Ligature, ib. a. Process of Deschamps,........ 76 b. Assalini's Rundlet.............. ib. e. New Process,................. 77 d. Process of Dubois,............ ib. E. The Double Ligature with the section of the Artery between,.......... 78 F. Ligature through the Artery......... 79 G. Indirect Ligature,.................. 80 H. The Direct (immediate) Ligature,.... 81 I. The Double Ligature,................ 82 [Note.—Ligatures, Compression, and Tor- sion on Arteries, &c,.......... ib. $ IV.—Operative Process,............. 86 A. ByjElius.......................... ib. B. By Paul of Egina,.................. ib. C. By Guy de Chauliac,.............. ib. D. By Guillemeau,.................... 87 E. By Keysleyre,...................... ib. F. By Mollinelli, Guattani, &c,........ ib. G. By Anel,.......................... ib. Method of Brasdor.................... 89 Relative Value of the Principal Methods,.. 92 VU1 TABLE OF CONTENTS. Page. A. The Ancient Method,.............. 92 B. The Method of Anel,............... 93 C. The Method of Brasdor,............. P5 Turn Operative Process or Manual,. .. 97 A. The Ancient Method,.............. ib. I. Instruments..................... ib. II. Position of the Patient and Assist- ants............................. ib. The Operation,.................... 98 B. The Method of Anel,............... ib. I. The place of Choice,............ ib. II. The Incision................... 99 III. Isolation of the Artery,........ ib. IV. To apply the Ligature........... 100 V. To tighten the Ligature,........ 101 VI. Dressing....................... 10-2 C. Method of Brasdor,................. ib. D. Subsequent Treatment,.............. ib. VU. Consequences and Accidents of the Operation,............ 104 A. Sensation of Cold,.............. ib. B. Gangrene,...................... ib. C. Intense Fever,........••••...... ib. . T). Nervous Symptoms,............. 105 E. Shrinking of the Tumor.......... ib. F. Inflammation and Abscess of do., ib. G. Erysipelas, Phlebitis, &c,.......106 H. Exhaustion,..................... ib. I. Hemorrhage,.................... ib. [Note.—Hemorrhagic Diathesis, &c,...... 107 VIU. Changes effected in the Vessels of the Limb after the obliteration of an Artery,..................... 108 A. Collateral Arteries,.............. ib. B. New Arteries................... 109 C. Remote Capillaries,............. 110 [Note.—Pathology of Aneurisms.......... Ill [Note.—Rupture of the Heart,...........112 {Note.—Case of Rupture of the Heart, by Dr. Mott,......................... ib. Section Fifth.-ARTERIES IN PAR- TICULAR, ........................... 118 CHAPTER FIRST.—Arteries of the Ab- dominal Limb,........................ ib. Art. I.— The Dorsalis Pedis,................ ib. S I.—Anatomy,.......................... ib. 6 II.—Indications........................ 119 $ III. Operative Process,................. ib. Art. 11.—Anterior Tibial Artery,............ 120 § I.—Anatomy,......................... ib. E>II.—Indications, ...................... 121 $ ni.—Operative Process,................ 122 A. Process of Lisfranc,............»>•• ib. B. The Ordinary Process,.............. ib. Art. UL— Posterior Tibial Artery,........... 123 t> I.—Anatomy,.......................... ib. A. In the Tibio-Calcanean Groove...... 124 B. Between the Malleolus and the termi- nation of the Calf,................. ib. C. At the Calf,....................... ib. D. Anomalies,........................ ib. E) II.—Indications......................... ib. | III.—Operative Process................. 125 A. Behind the Malleolus,.............. 126 a. Process of the Author,........... ib. b. Process of M. Robert,............ ib. B. Below the Calf,.................... ib. C. In the thick part of the Leg,........ 127 a. Process of M. Guthrie,........... ib. b. That of most Authors,........... ib. c. BytheAuthor,.................. ib. Art. IV.—The Fibu'ar Artery, Operative Process,....... Art. V.—The Popliteal Artery, $ I.—Anatomy,........... <5 II-—Mechanism,......... «j III.—Circulation,......... § IV.—Treatment Page, .. 127 .. 128 ........ lb. ........ ib. ........ 129 ........130- ........131 A. The Depleting Regimen,............. ib. B. Cold Applications,................... «>• C. Indirect Compression,................ "j- D. Spontaneous Cure,.................. 132 E. Ligature............................ -b- I) V.—Operative Process,................. ".JJ A. Ordinary Process,................... ib. I. To reach the Artery in the Leg...... ib. II. Above the Condyles,.............. ib- B. Process of Jobert and Ashmead,...... ib. C. Process of Marchal,................. ib. D. Consequences of the Operation,......134 Art. VI.—Femoral Artery,.................. 135 III.—Operative Process,................206 A. Ancient Method in the hollow of the Axilla,........................ ib. B. New Method in the front of the Ax- illa...........................207 I Process of Desault,................ |b. U. Process of Keate................. ib. IU. Process of Chamberlaine, or Pelle- tan,........................... 208 IV. Process of Hodgson.............. ib. V. Ordinary Process,................ ib. o. First Stage,.................... ib. b. Second Stage,.................. >b. c. ThirdStage,.................... 209 [Note.—Ligature on the Axillary Artery or Axillary portion of the Subclavian,..... ib. [Note.—Do. do. below the clavicle,.......... ib. Art. VI.—The Subclavian Artery,..........210 & I.—Anatomy,......................... !£• A. Within the Scaleni Muscles,........ ib. [Note on Ditto,............................. 211 B. On the First Rib,................... ?J»- C. Outside the Scaleni,................ 1D- D. Anomalies, ....................... *•* § II.—Indications,....................... "•»■ A. Spontaneous Cure................. '»• B. Method of Brasdor.................*M C. Method of Anel,.................. »• $ in.—Operative Process,................ *}* A. Within the Scaleni,................ '^ I. Process of Colles.................. *• II. Process of the Author,........... »b. B. Between the Scaleni,............... lb. I. Process of Dupuytren,............215 C. Outside the Scaleni,................ ib. I. Process of Ramsdcn,.............. ib. II. Another Process,................ ib. III. The Process to be followed,.....216 A. First Stage........................ ib. B. SecondStage,...................... "b. C. Third Stage,..................... ">. IV. Section of theOmo-hyoideus mus- cle and external border of the ster- no-mastoid useless,............. ib. D. Method of Brasdor................. 217 E. Consequences of the Operation,..... ib. F. History and Appreciation............ ib. List of those who have performed the operation, 218 X TABLE OF CONTENTS. Page. CHAPTER THIRD.—Arteries of the Head, 219 Art. I.—Arteries of the Exterior,............ ib. [Note.—On False Circumscribed Aneurisms of the Temporal Artery,..... 220 Art. U. —Arteries of the Interior,...........221 [Note.—Aneurism of the Basilar Artery, ib. Art. III.—Indications,...................... 222 Art. IV.—Operative Process,................ 223 <) I. Temporal Artery,................... ib. t) II.—Occipital " ................... ib. <} III.-Facial " ................... ib CHAPTER FOURTH.—Arteries of the Neck............................... 224 Art. I.—External Maxillary Artery,........ ib. Art. II.—Lingual Artery,.................. ib. $ I.—Process the same as for the Maxillary, 225 5 II.—Process of the Author,............. ib. 6 HI.—Process of Blandin,............... ib. § IV.—Process of Mirault,............... ib. Art. UL—Thyroid Arteries,................ 227 $ I.—Superior Thyroid,................. ib. 5 II.—Inferior Thyroid,.................. ib. Art. IV.— The Vertebral Artery............. 228 6 I.—Anatomy,......................... ib. § II.—Indications,....................... ib. $ III.—Operative Process,............... 229 A. Process of Ippolito,................. ib. B. Process that should be adopted,...... ib. Carotid Tubercle of Chassaignac,.... ib. Art. \.—The Pharyngeal Artery,...........230 Art. VI.— The Secondary Carotid Arteries,.. 231 $ Operative Processes,................... ib. Do. do....................... 232 Do. do....................... 233 Art. VII.— The Primitive Carotid,.......... ib. $ I.—Anatomy,......................... ib. Anomalies,....................... 234 $ II.—Indications,....................... ib. List of those who have tied the Primitive Ca- rotid............................ 237 $ HI.—Operative Process,................ 241 A. Ordinary Process,................... ib. I.—First Stage,...................... ib, II.—Second Stage,.................. ib. III.—Third Stage,................... ib. B. Remarks........................... 242 C. Process of Sedillot,................. ib. D. Consequences of the Operation,..... ib. Art. IV.—Ligature upon the Trunk of the Carotid, according to the nature of the Disease,.................. 244 y1.—Wou nds, Hemorrhages, &c.......... ib. § II.—Aneurisms,....................... ib. § III.—Varicose Aneurisms,............. ib. § IV— Erectile Tumors,................. 245 | V.—Various Tumors,................. ib. § VI.—Operations on the Face or Neck,.. ib. $ VII.—Neuralgin,...................... 246 $ VIII.—Methods of Brasdor,............ ib. [Note.—Ligature on the Primitive Ca- rotid, near the Innominata, for carotid aneurism,.............................. 247 Also, for Aneurism of a secondary branch of the External Carotid,....................... 251 Wounds of the Carotid, causing Aneurismal Varix, and Varicose Aneurism,.......... 252 Page. Art. IX.—The Trunk of the Innominata,— 252 « L—Method of Brasdor.................253 § ii.—The Ligature upon the Brachio-ce- phalic Trunk itself,................25* A. Anatomy,......................... "k Anomaly,......................... •*>* B. Indications......................... «•• C. Appreciation.......................255 § III.—Operative Processes,..............256 A. Process of Mott,.................... ib. B. M. Graefe follows this,.............257 C. Some propose trephining the sternum, ib. D. Combined Process of the Author,--- ib. I. First Stage......................... ib. II. Second Stage,................... ib. III. Third Stage,.................... ib. IV. What M.Velpeau considers the best, 258 V. Consequences of the Operation,... ib. VI. Where the ligature on the Bra- chiocephalic Trunk is justifiable in the opinion of M. Velpeau....... ib. [Note.—On Aneurisms of the Large Trunks near the Heart,..................... ib. Difficulty of Diagnosis in Sub-stemal Aneurism, 260 Diagnosis of Aneurisms,...................... ib. Aneurism of the Pulmonary Artery...........261 Diagnosis of deep-seated Aneurismal Tumors,. 262 M. Guetteton Aneurism of the Innominata,... 263 M. Diday's Views on Aneurism of the Innomi- nata, and History of the Operations,...... 265 His Table of the operators, (amended.)........ 272 Distal Operations for Aneurism of the Innomi- nata................................... 274 Remarks.................................... 278 Simultaneous Ligature on the Subclavian and Carotid,................................ 280 Art. X.—Arteries of the third or fourth Order, which may also require the aid of Surgery,........................ ib. C\ I —The Arteries of the Shoulder,....... ib. $ II.—The Intercostal Arteries,...........281 § III —The Internal Mammary,.......... ib. § IV.—The Arteries of the Penis.......... 282 § V.—The Epigastric,................... ib. [Note.—Anomalous Deviations of Arte- ries, .................................. ib. [Note.—Re marks on Aneurisms, by V. Mott, M.D...................................... 283 Why the Ligature on the Right. Subclavian within the Scaleni is attended with an un- certain result.............................284 Extremt Difficulty of Diagnosis in Sub-sternal Aneurism, and why......................285 Where the Subclavian and Primitive Carotid are both to be tied, and the Subclavian only is foundpervious, that alone ia to be tied, and always without and never within the Scaleni, 286 The Arteria Innominata.—Dr. Mott's views and reflections upon the Ligature on this Artery, 287 Do. do.....................................288 Ligature on the Subclavian Artery within the Scaleni................................... ib. Ligature on the Subclavian Artery, on its mid- dle, or Scalenus portion,..................289 Ligature on the Subclavian Artery, without the Scaleni,.................................. ib. Ligature on the Left Subclavian Artery within the Scaleni Muscles,...................... ib. Ligature on the Primitive Carotid,.............290 The Anti-Cardial, Distal,or Brasdoreal Oper- ations.................................... ib. Arteries of the Superior Extremity,...........291 The Axillary Artery,........................ ib. The Brachial, or Humeral,..................292 Its wounds in Venesection,.................. jb. Howtobe treated,............................ ib. TABLE OF CONTENTS. xi Page.' The General Law laid down by Dr. Mott, in these cases,..............................293 True Aneurism of the Ulnar Artery,........ ib. Aneurisms of the Radial and Ulnar Arteries in the fore-arm, how to be treated,........ ib. Value of Pressed Sponge in tamponing arterial wounds.................................. 294 The Abdominal Artery—Aneurisms there,.... ib. Proposed Process suggested by Dr. Mott, for curing such Aneurisms,...................295 R emarks on the cases wherein the Abdominal Aorta has been tied,...................... 296 Ligature on the Internal Iliac............... 297 Aneurism in the Gluteal Region,............. 298 Dr. Mott doubts if Aneurisms of the Gluteal or Ischiatic Arteries can ever be treated on the Cardiac principle,........................ ib. He prefers a Ligature on their Primitive Trunk, ib. Ligature on the External Iliac,.............. ib. Dr. Mott approves the process of Sir A. Cooper, for this Artery,.......................... 299 His mode of employing it, and reasons for so doing ib. Ligature on the Femoral Artery,............. 300 Lower part of the Upper Third to be preferred, ib. Practicabli also above the Profunda,......... 301 Ligature on the Popliteal..................... ib. " " Anterior and Posterior Tibial Arteries,................... ib. " " Plantar Arteries,............. ib. On the Method of Tying Arteries, and on Ligatures, and Dressings, &c,— ib. How to cut down upon Arteries,............... ib. A General Rule laid down by Dr. Mott on this subject,.................................. ib. The kind of Ligatures to be preferred,.......... 302 Dr. Mott's mode of Dressing the Wound, after tying Uie Femoral Artery,................. ib. His description of Sir A. Cooper's attempt to tie the Left Subclavian,...................... 303 Dr. Mott's Cases of Ligatures on Arte- ries, {with Plates,)...................... 306 No. I. On the Arteria Innominata,............ ib. No. U. Right Carotid for a Tumor in the Neck, 327 No. III. The Primitive Iliac,................ 337 No. IV. The Primitive Carotid tied by the me- thod of Brasdor, for an Aneurism of the Arteria Innominata,..............*,..... 342 No. V. Ligature on the Primitive Carotid fur an Anastomosing Aneurism in a Child......... 347 No. VI. The Femoral Artery tied in several Places for Hemorrhage after Amputation of the Thigh,............................... ib. No. VII. The Subclavian Artery tied for Axil- lary Aneurism,.......................... 349 No. VIII. The External Iliac tied for Diffused Femoral Aneurism,...................... 351 No. IX. Right Subclavian tied within the Sca- leni, for Aneurism of the same Artery,..... 354 No. X. Right Internal Iliac tied for Aneurism of the Ischiatic or Gluteal,................359 No. XI. Ligature on the Subclavian above the Clavicle, for enormous diffused false Aneu- rism of' the whole upper extremity, from gun- shot wound in the Axilla,................. 360 Appendix by Dr. Mott, to his preceding chapter on Aneurisms.................. 365 His Remarks on the Recent, and only known case of a Ligature on the Left Subclavian Artery, by Dr. Jno. K. Rodgers, of N. York, ib. Supplemental Note on Aneurisms, by P. S. T. ib. The Ligature on the Primitive Iliac..... 367 The number of times performed, and by whom, ib' Page Remarkable case of Aneurism of the Basilar Artery, communicated by Dr. Ruschenber- ger, one of the Fleet Surgeons of the 0. S. Navy,.................................. 373 Dr. Ruschenberger's remarks on the importance of Matico, as a hemostatic resource, (commu- nicated by that gentleman,)................ 375 Farther Remarks on the cur* of Aneurism by Compression,............................ 377 Recent Successful Ligature upon both Carotids, at an interval of four and a-half days,___ ib. Section Sixth.—VENOUS SYSTEM,.. 381 Wounds,.................................... ib. CHAPTER FIRST.—Operations required for Varices,............................382 Art. I.—Varices in General,................ ib. § I.—Ancient Method,.................... ib. A. Acupuncture,....................... ib. B. Cauterization,...................... ib. C. Excision,........................... 383 D. The Ligature,...................... ib. E. Incision,........................... 384 F. Section on a single point............. 385 G. M. Brodie's Method,................ ib. H. Exsection,......................... 386 I. Appreciation,....................... ib. §11.—New Methods,.................... 388 Art. II.—Varices in Particular,............. 389 § I.—Varices of the Lower Limbs,....... 390 A. Ancient Processes,................. 391 I. Compression,..................... ib. II. Excision......................... ib. III. Transverse Section,.............392 B. New Processes,.................... ib. I. Acupuncture,..................... ib. a. Process of M. Fricke,........... 393 b. Process of M. Davat,............ 394 II. Compression,..................... ib. a. Process of M. Sanson,........... ib. b. " the Author............ 395 I. First Stage,................... ib. II. Second, " ................... ib. III. Third, "................... ib. IV. Fourth," ................. 396 V. Fifth, " ................... ib. VI. Other Precautions............ ib. c. Process of M. Reynaud,......... 398 [Note.—On Varicose Veins. § II.—Varicocele,....................... 399 A. Ancient Methods,.................. ib. B. New Processes,.................... 401 I. Process of M. Fricke,.............. ib. II. " " Davat,.............. 402 HI. " " Breschet,........... ib. IV. " " Sanson,.............403 V. " " Reynaud,...........404 VI. " " The Author,........ ib. a. Position of the Patient,.......... ib. *». First Stage,....................405 e. Second, " ..................... ib. d. Third, " ..................... ib. e. Fourth, " ....................... 406 [Note.—Varicocele, Obliteration, Ulcer- ation and Wounds of Veins........... 407 History of Varicocele, by M. J. Helot,........ ib. Process of Rolling vp the Veins, by M. Vidal de Cassis............................... 409 M. Velpeau's opinion thereon,................ 410 Mr. Curling's Proposed Process,........... ib. Excision of all the Lower Parts of the Scro- tum, as proposed by M. Velpeau,........ ib. Xll TABLE OF CONTENTS. A Pathological Diagnosis to be deduced from Varicose Veins,........................ 4U Wounds of Veins,.......................... 412 The Lateral Sinus of the Brain Ulcerated,.... ib. Obliteration of Large Venous Trunks as the VenaCasa,&-c.......................... ib, Remarks,.................................. 413 Rupture of the Right Internal .Jugular into an Abscess,................................ jb. Remarks,.................................. 415 Scrofulous Abscess with Perforation of the Jugular Vein,.......................... ib. Ossification and Obliteration of the Vena Porta, ib. On Cicatrices of Arterial and Venous Wounds, by M. Amussat,........................ 416 A Curious Fact as to the Lining Membrane of the Arteries,........... ..............__ 418 M. Velpeaus Claims to Priority in the Treat- ment of Varices,........................ ib. Section Seventh.—THE LYMPHATIC SYSTEM,............................ 419 Section Eighth. —THE NERVOUS SYSTEif,........................... 420 CHAPTER FIRST.—Nerves of the Head and Neck,........................... 421 Art. I.—Nerves of the Cranium.............. ib. ART. II.—Nerves of the Face,................ ib. 41.—The Frontal Nerve,................ ib. §11.—The Infra Orbitar Nerve,.......... 423 A. Excision of the Infra Orbitar Nerve by the Mouth,...................... ib. B. Excision ol the Infra Orbitar Nerve by the Face,...................... ib. I. Operative Process................. ib. $ III.—Section of the Superior Dental Nerve,......................... 424 *j> IV.—Section of the Inferior Dental Nerve, ib. $ V.—Section of the Facial Nerve,....... 425 A. Section of its Temporo-facial Branch, ib. B. Section of its Cervico-facial Branch, 426 C. Section of its Trunk,............. ib. Art. III.—Nerves of the Neck,..............427 [Note.—Division of the Par Vagum on one side, by an American Surgeon, without causing death,.......................... ib. CHAPTER SECOND. — Nerves of the Limbs................................ 428 Art. I.—Nerves of the Thoracic Extremities, ib. $ L—The Fore-arm,................... ib. ill.—The Elbow,.....................429 § HI.-The Ulnar Nerve................. 430 Art. II.— The Nerves of the Lower Extremi- ties, .............................. ib. •J I.—Nerves of the Leg,................ ib. A. The Internal Saphena,............. ib. B. The External Saphena,............. 431 C. The Anterior Tibial,............... ib. D. The Posterior Tibial,............... 432 «J II.—Nerves of the Thigh,.............. ib. A. Femoral Nerve,.................... 433 B. Sciatic Nerve,...................... ib. Page- Art. III.—Excision of the Extremity of the Nervous Trunks, at the bottom of Ancient Wounds or Cicatrices,.....434 [Note.—Exsection of the Median Nerve, by Dr. Mott,............................ ib. Dr. Darling's Description of the Process to be followed,................................ ib. Electro-puncture in Neuralgia,.............. 435 Inutility of Exsection for A'cura/gia,......... ib. Amputation of the Fingers and Arm for Neu- ralgia, ................................. ib. Remarkable Ganglionic Transformation of Serves, as described by M. Serresof Mont- pelher,.................................436 Nervous Substitutions,...................... 437 Influence of the Sympathetic—its Functions, ire, 438 Section Ninth. —AMPUTATION OF THE LIMBS,........................ 439 PART FIRST—Amputation in General, ib> CHAPTER FIRST.—Indications,.......... 441 Art. I.—JAmbs almost Entirely Divided,.... ib. Art. II—Gangrene.,........................ 442 § I.—Inflammation...................... 443 § II.—Hospital Gangrene................. ib. III.—External Violence,............... 444 IV.—Spontaneous Gangrene,........... 445 V.—Congelation, [or Freezing,].........446 VI.—Deep Burns,...................... 447 VII.—Traumatic Lesion,............... ib. VIII.—Aneurisms...................... ib. Art. III.—Fractures and Luxations,........ 448 $1.— Compound Fractures,.............. ib. External to the Articulations,........ ib. $ II.—Luxations, (or Dislocations.)....... 450 § III.—Wounds from Fire Arms,......... 452 Art. IV.— Various Affections,............... 455 § I—Necrosis and Caries,................ ib. § II.—Cancerous Affections,............. ib. § III.—Exostosis and Fibrous Tumors,___ 453 § IV.—White Swellings,................. ib. § V.—Suppuratioi........................ ib. § VI.—Corroding Ulcers, Lupus, &c,.....457 § VII.—Tetanus......................... ib. [Note.—Amputation tor Tetanus,......... 458 $ VIH.—Bite of Rabid Animals,.......... 459 Art. V.—Amputations out of Complaisance,.. 460 § I.—Anchylosis, Deformities, &.c,....... ib. § II.—Anchylosed Fingers,............... 462 § III.—Supernumerary Fingers,.......... ib. § IV.—Toes raised up or angulated,....... ib, § V.—Anchylosis of the Large Joints,..... ib. § VI.—Ulcers with Loss of Substance..... 463 CHAPTER SECOND.-Preliminary Cau- tions, ............................... ib. Art. I.—Counter-Indications,................ ib. & I.—Cancerous affections,............... ib. $ II.—Pulmonary Phthisis, Caries of the Spine, &c,........................ 464 6 III.—Scrofula,........................ ib. $ IV.—Points to Discriminate,............ 4fi5 5 V.—Debility not always a Counter-Indi- cation,............................ ib. $ VI.—Recent Traumatic Lesions,....... ib. Art. II.— The Period when to Amputate...... 46t> TABLE OF CONTENTS. xiii Page. [Note.—When to Amputate—Sir J. Ballin gall's Views,............................ 470 Art. III.— The Place where Amputation should be Performed,..................... 471 Art. IV.—Preparations,.................... 473 $ I.—The Hour of the Day,.............. ib. 6 II.—Dressings,........................ ib. § III.—Position of the Patient,............ 475 % IV.—Assistants........................ ib. % V.—To Suspend the Course of the Blood, ib. CHAPTER THIRD.—Operative Method,.. 476 Art. I.—Amputations in the Continuity,...... ib. §1.—The Circular Method,.............. ib. A. Division of the Skin,............... ib. B. Division of the Muscles,.............478 D. Section of the Bone,................482 § II.—The Flap Operation............... ib. & HI.—The Ovalar Method,..............486 Art. II.—Amputation in the Contiguity......487 Art. III.— The Dressing,...................490 § I.—Hemostatic Means.................. ib. § II.—Disposition of the Wound,.........492 Art. IV.—Consecutive Treatment,...........493 § I.—Position of the Stump,.............. ib. § H.—Immediate Medication,............. ib. & III.—Regimen,........................494 § IV.—First Dressing,................... ib. § V.—The Ligatures,....................49G ART. V.—Accidents,......................... ib. t> I.—During the Operation,............... ib. A. Hemorrhage,....................... ib. B. Syncopes, &c ,.....................497 C. Spasms,........................... ib. $11.—After the Operation,...............498 A. Hemorrhage,....................... ib. B. Conicity of the Stump..............500 C. Protrusion of the Bone,..............501 I. Spontaneous Separation, —....... ib. II. Exfoliation.......................502 HI. Exsection of the Bones and of the Slump..........................503 D. Hospital Gangrene,.................504 [Note.—Gangrene, Hospital Gangrene, &c. ib. Amputation during non limited Trau- matic Gangrene,.................505 Venesection in Mortification,.........ib. E. The Inflammatory Enlargement of the Slump,........................... ib. F. Purulent Infection,..................506 G. Cystitis,............................507 Art. VI.—Organic Changes Produced by Am- putation,......................... ib. I) I.—In the Stump....................... ib. (j II.—In the rest of the System,..........508 Art. VII.—Prognosis of Amputations,........ib. PART SECOND — AMPUTATIONS IN PARTICULAR, .................510 CHAPTER FIRST.—The Upper Extremi- ties,............................. ib. Page. Art. I.—Partial Amputation of the Fingers,.... 510 <> I.—Anatomy,......................... ib. $ II.—Amputation,......................512 A. In the Continuity...................ib. I. Circular Method,.................. jb. H.Flap » .................. ib. B. In the Contiguity,..................513 I. Circular Method,.................. ib H-Flap ....................ib. a. Process of Garengeot............ ib. b. " Le Dran,.............. jb. c. " Laroche,..............jb. d. " Lisfranc,.............. jb! t. " Walther...............514 /. The Usual Process,............. jb. g. Process of Rust,................ jb. C. Dressing and Subsequent Treatment, 515 D. Accidents,......................... jb. <) III.—Amputation of a Whole Finger..... ib. A. Circular Method,...................517 B. Flap " .................... ib. I. Process of Sharp,................. ib. If. " Garengeot,.............. ib. III. " J. L. Petit,.............. ib. IV. By Puncture..................... jb. V. Process of Le Dran,..............ib. C. The Oval Method,..................519 Process of M. Scoutetten,............ ib. k IV.—Amputation of the Four Last Fin- gers at one Operation,............520 Accidents,............................521 Art. H.—Amputation of the Metacarpus,.....522 $ I.—In the Continuity,.................. ib. A. Anatomy,......................... ib. B. Operative Process,.................523 I. Partial Amputation,............... ib. a. Ancient Process,................ ib. *. New " ................524 § H.—Amputation in Mass,..............525 a. Method of Louis,................... ib. b. A Single Palmar Flap,............... ib. $ III.—In the Contiguity,................ib. A. Partial Amputation,...............ib. I. Metacarpal Bone of the Thumb,.... ib. a. Anatomy,......................526 b. Operative Process,.............. ib. I. Ancient " .............. ib. TI. Another " ..............527 III. Process of the Author,....... ib. IV. New Process,............... ib. V. Ovalar Method,..............528 II. The Fifth Metacarpal Bone,.......ib. HI. The Middle " " .......529 A. Flap Method,...................... ib. I. Metacarpal Bone of the Fore- finger, .................... ib. II. Metacarpal Bone of the Middle Finger,.................... ib. III. Metacarpal Bone of the Fourth Finger,...................530 B. The Ovalar Method,................ ib. C. Simultaneous Amputation,..........ib. I. Anatomy,........................532 II. Operative Process.................533 a. Process of the Author...........ib. b. Process of M. Maingault.........534 ART. Ill— The Wrist,......................535 i) I.—Anatomy,......................... ib. -c. (Communicated by the Author.) 869 [Note.—DR. MOTT'S CASES OF EXSEC- TIONS OF THE UPPER AND LOWER JAW, CLAVICLE, &c.................882 [Note.—Claims of Dr. Mott as the Author and Projector of the Operation of Exsection of the Lower Jaw for Osteo-Sarcoma,....... ib. [Note No. I.—Dr. Mott's First Case of Exsec- tion of the Lower Jaw for Osteo-Sarcoma, Nov.l7th and 18th, 1S.I1, (with plates,)... 883 [Note No. II.—Dr. Mott's Second Case, viz., Ex- section and Disarticulation of the Lower Jaw for Osteo-Sarcoma, May 15th, 1823, (with plate,) ...*........................891 [Note No. HI.—Dr. Mott's Exseclion of the Cla- vjcle for Osteo-Sarcoma, June 17,1828,... 894 [Note.—Extract from a Report of a Medical Com- mittee, (Dr. D. L. Rodgers, chairman,) on this subject,.............................902 [Note No. IV.—Dr. Mott's Exsection of the Up- per Jaw, &c, for Tumor, July 8,1841,(with plates,).................................904 XV111 TABLE OF CONTENTS. Page. [Note No. V.—Dr. Mott's Exsection and Disar- ticulation of ihe Entire Half of the Lower Jaw, Nov. 23. 1814. (Drawn up by P. S. Townsend, M. D.;.......................908 [Note.—Letter from Prof. Mott to Dr. Liston of London, i,i relation to the chiitns of priority of the first mentioned surgeon to exsection of the inferior m;ixilla for osteo-sarcoma,...................... 915 Section Eleventh.—TREPHINING OR OPERATION WITH THE TRE- PHINE,............................ 918 CHAPTER FIRST.—The Head,............ ib. Art. I.—The Cranium,..................... ib. 5 I —Indications,....................... 919 A. Fractures,........................ ib. B. Effusions,......................... ib. C. Toe Collections are sometimes ab soibed spontaneously,..............920 $ II.—The parts of the Cranium which ad- mit of the application of the Trephine 921 § III.—Dressing......................... 922 § IV.—Operative Process,...............92:1 A. First Stage........................ ib. B. Second Slage,..................... 9J4 C. Third Sta»e,....................... 9_>5 D. Fourth St ge,...................... 92end, .M.D..]............990 Singular Erectile Tumors of the toes and Fingers....................... 991 SUPPLEMENTAL APPENDIX TO THIS AMERICAN EDITION, VOL. II. Plan to remove certain serious Objections to the Dextrine Band- age.— It is well known, from the melancholy results which attended the application of the dextrine bandage to the fractured arm in the case of Professor Dubovitsky of St. Petersburgh, (vid. supra, Vol. I., text,) and from a still more disastrous result in a case of fracture in the practice of one of our most respected and eminent surgeons in the Southern States, and wherein gangrene followed to such ex- tent as to require amputation of the leg, that the great danger of the immediate application of this unyielding (and, as to its solidity, metallic)encasement to fractnres,dislocations,&c,is the confinement of the part, and therefore total resistance, to, and aggravation of, the consecutive inflammation and tumefaction which must necessarily follow all such injuries. It is now proposed, in order to obviate the severe contractions, or even gangrene and destruction of parts, which the dextrine bandages injudiciously applied may and do sometimes produce, that the bandage, as soon as it has become dry, should be slit down along the whole of its length, in (for example, cases of fracture of the leg) the space between the tibia and fibula. This will allow of some degree of expansion of the limb ; and if the sides of the opening are held aside, its condition can be examined. (See Mr. Hey, jun., in Transactions of the Provincial Medical fy Surg. Assoc, Loud., 1844. Vol. XII., p. 171, 112; also Dublin Journ, of Med. Science, Nov., 1842.) It is to be remarked, however, that this suggestion is by no means new, as it is entirely in accordance with the precautions recommended in this work by Prof. Velpeau, who is one of the most ardent admirers of this kind of dressing. Anaplasty, Tenotomy, Retraction of the Muscles, &c. Division of the Entire Masseter.—Having, on the authority of Dr. J. W. Schmidt, of this city, stated in our 1st volume, that he was the first person who first divided the entire masseter, I felt bound in justice to present before the public the counter-testimony of another surgeon, (Dr. Carnochan,) of this city, as addressed by him to me in the way of reclamation ; which I accordingly hasten to incorporate inio this Vol. II., from the New York Journal of Medicine, (January, 1846, Vol. VI., No. 16, p. 59-62,) where it recently appeared. This memoir will be found exceedingly interesting in many other points of view than that of the mere matter of priority of the total section of the masseter. XX new elements op operative surgery. Art. V.—Remarks on the Subject of Priority in the Division of the Entire Masseter Muscle; proposed Simultaneous Division of the same and of the Temporal Muscles of one or both sides, and the formation of an Artificial Joint on the Inferior Maxillary, either by a Simple Division of the Bone, or by the Exsection of a portion of it; as a Remedy for Immobility of the Jaw. By John Mur- ray Carnochan, M. D., of New York. To Charles A. Lee,M. D., &c. Editor of the New York Journal of Medicine. New York, Dec. 8, 1845. Dear Sir,—My friend, Dr. Carnochan, being in Europe at the time of the publication of the first volume of the American edition of " Velpeau's Operative Surgery," translated, and with Notes by Professor Mott and myself, it was out of my power to obtain from Dr. C. the details of a remarkable operation which I had understood he had performed some years since in this city, to remedy the " im- mobility of the lower jaw." I hasten, therefore, as an act of justice to Dr. Carnochan, to transmit to you the following highly interesting and instructive communication from him, and addressed to me in relation to that subject. I am, very respectfully, yours, P. S. TOWNSEND, M.D. To P. S. Townsend, Esq., M.D., &c. Sir :—In your translation of the " Medecine Operatoire " of Vel- peau, I observe that you insert, in addition to the original article on Tenotomy and Myotomy, a note, in which the credit is given to a gentleman now practising medicine in this city, for having first divided the masseter muscle for that affection which has been term- ed " Immobility of the Lower Jaw." I should feel inclined to allow this statement, and the mere mat- ter of priority, to pass unnoticed, although I am in fact entitled, contrary to your statement, to the claim of having been the first to divide that muscle in this affection, five years ago, were it not that the interest and importance of the case I then operated on, ap- pear to merit a detailed account of the treatment adopted by me on that occasion. In the year 1840, I was consulted by the mother of a girl about 13 years of age, whom, upon examination, I found to be affected' with a destruction of the left cheek, extending from the commissure of the lips, to within a line or two of the ascending branch of the lower jaw, and the anterior margin of the masseter muscle. Ac- companying this extensive loss of substance of the cheek, was a complete immobility of the lower jaw, by which the upper and lower jaws were kept in close contact; mastication, and even the intro- duction of solid alimentary materials, being thus prevented, and articulation rendered exceedingly imperfect. This condition of things having existed for several years, the girl was emaciated to a supplemental appendix. xxi very great degree, owing to defective nutrition, resulting from the scanty and crude nature of the aliments, which alone could be in- troduced into the stomach. As both she and her parent seemed ready to submit to any operation which would tend to alleviate her distressing condition, and remove the deformity, I proposed, in the first place, to remedy the immobility of the jaw ; and secondly, to repair the loss of substance, by a Taliacotian operation, or by the Indian method of taking a flap from the adjoining healthy parts, and transplanting it to the almost destroyed cheek. It is in relation to the operation for remedying the immobility of the lower jaw, that I at present wish to call your attention ; and although the case under consideration, from its difficulties, and the total ossification upon one side of the temporo-maxillary articula- tion, resulted only in amelioration, yet I claim, in the operation I then performed, to have generalized certain surgical principles, and to have been the first, in this or any other country, to divide en- tirely the masseter muscle for that affection *, as well as to have suggested the formation of an artificial joint, on the anchylosed side, as a justifiable procedure, when the temporo-maxillary articulation remained in its normal state on the other side. After having divided the ligamentous, and almost cartilaginous, bridles and adhesions, binding the jaw immovably closed, and ap- plying the screw-lever inserted between the jaws ; after the removal of some teeth, the parts not yielding, I passed a narrow tenotome between the masseter muscle and the ramus of the jaw, and divided sub-cutaneously, from within outwards, that muscle, hoping that the division of its fibres would facilitate the liberation of the joint. I now applied the screw-lever again with considerable power, but the jaw still remained immovable. It became almost evident to me now, that the joint, on the side where the ulceration had origi- nally existed, between the glenoid cavity of the temporal bone, and the condyle of the jaw, was anchylosed, or soldered by osseous matter, and that nothing short of fracture or section of the bone would allow the articulation of the other side to play. The hope- less and desperate condition of my young patient induced me to persevere, and before resorting to the division of the temporal mus- cle, towards its insertion at the coronoid process, as a dernier ressort, as was my intention, I again applied the lever, and the jaw gave way opposite a groove on the inner side of the bone, which the original ulceration had produced. This having been done, the ar- ticulation of the right side being perfect, the mouth could be opened an inch and a half, and the patient was so pleased at the novel sensation of putting her tongue out, and with the idea of having a sight of it, of which she had no previous recollection, that she called for a looking-glass. This result, in appearance, was very well, but a fracture unites like an incision of the soft parts, and for the mo- ment the re-union of the jaws in their fixed position, passed in my mind as the probable result. By the action of the masseter, tem- poral, and pterygoid muscles of the sound side, and their antago- nists, the patient could now move thejaw,and even immediately after XXU NEW ELEMENTS OF OPERATIVE SURGERY. the operation had power enough to masticate. I therefore gave. her an anodyne, and applied a loose bandage, and left her to study and reflect upon this somewhat complicated case. Before my next visit, the following morning, the successful attempt of the formation of an artificial joint on the femur, where the coxo-femoral articula- tion had become anchylosed, first performed by Dr. Barton, of Philadelphia, occurred to me, and I made up my mind to apply this principle to the lower jaw. After the first inflammatory symptoms- had subsided, I ordered a wedged-shaped piece of wood to be kept several hours at a time between the jaws, to prevent them from closing, and requested the patient to put into action the muscles of the sound side during the intervals of its removal, and to masticate biscuit, or other solid substances, which she could very well do. The patient was not old enough, however, to understand the im- portance of the motion being kept up, to bring about the end I had in view, that of an artificial joint, and from relaxing her efforts, after being able to masticate and move the jaw for about three weeks, it became evident that the efforts of the healing process were beginning to produce ossific union. To have maintained the mouth in a fixed and open position would have been more inconvenient than to have had the jaws permanently approximated; the indica- tions then became, either to exsect a portion of the lower jaw en- tirely, so as to insure by loss of substance an artificial joint, or to adjust the jaws in such a way as to prevent further deformity, after the formation of the callus, and at the same time, if possible, to leave an increased space between the alveolar margins for the more easy introduction of food. The condition of the patient not justifying at that time another operation, which, from its nature, would have been tedious and bloody, I determined upon fulfilling the latter indication, and to wait for the improved health and more mature age of the patient, before attempting the formation of an artificial joint by exsection. With these views I allowed the callus to form undisturbedly, and in about six weeks the jaw became im- movable in the approximated position, with the amelioration, as a result of the operation, of a slightly increased space having been gained for the introduction of food. This, then, is the statement of a case, which, from the frequency of the " immobility of the lower jaw " in this country, generally originating from the too free mercurial treatment of the febrile dis- eases, endemic in the Western and Southern States, may not be devoid of interest, and may afford some guidance in the operative procedures, that may be attempted in cases somewhat analogous. In regard to the train of circumstances which suggested the thera- peutic means above resorted to, I shall add a few words. Many years ago, while a pupil of the celebrated Mott, I had seen in his practice, and assisted him in many of these cases of immobility of the jaw, in which he always succeeded so as to restore both the func- tions of articulation and mastication. In one case, however, which occurred in his practice in 1832, that of a young lady from Louisi- ana, after putting into play the full power of the screw-lever, and SUPPLEMENTAL APPENDIX. xxiii rack-and-pinion-lover, himself and an assistant using simultaneously the two instruments applied between the jaws, the operation had to be abandoned without the least success. Alter Strohmeyer had given the impetus to tenotomy, and proved its utility, in reflecting upon this case last mentioned, it occurred to me that in those in- stances where a free division of the adventitious fibres and ligamen- tous bands, had proved insufficient to bring about the liberation of the articulation, the next indication would be, provided there was not an osseous anchylosis at the temporo-maxillary articulation, to divide at a place of eli-ction the masseter and temporal muscles of one, or even of l>oth sides; and I had made up my mind to put these operations into practice, if Mich a case happened to present itself to me. In my course of lectures on Surgical Anatomy and Operative Surgery, delivered in the winter of 1840,1 publicly men- tioned these views, and made a dissection of the parts of the lateral regions of the head and face, for the express purpose of demon- strating the practicability and rationality of the section of the mas- seter and temporal muscles, in this affection of immobility of the lower jaw, under certain circumstances. In the same year, the case I have detailed, occurred in my practice, and in the presence of Mr. Eleazar Parmly, Dr. Francis, and other practitioners, now in this city, I made the sub-cutaneous section of the masseter in the manner I have above stated. I-was, therefore, as far as I know, the FIRST TO SUGGEST THE DIVISION OF THE MASSETER AND temporal muscles, in the treatment for immobility of the lower jaw, in those cases in which the division of the other abnormal ad- hesions had proved insufficient, and where there was not a true anchylosis at the temporo-maxillary articulation, or a doubtful diagnosis existed on that point: as well as the first to put into prac- tice the division of the masseter muscle, and to suggest, and en- deavor to bring about the formation of an artificial joint, where perfect anchylosis existed on one side, and where the joint of the other side remained natural, and the corresponding muscles retained their normal functions. The inference to be drawn from the results of this case, which has induced me to mention to you these particulars, and the expe- riments performed in relation to the re-union of the shafts of the long bones, would lead us to believe, that mere fracture, or section of the inferior maxilla, even accompanied by repeated and free motion, would be insufficient to produce an artificial joint; and that to fulfil this indication, the entire exsection of a portion of that bone, either towards the angle, or at some other locality which the nature of the individual case might suggest, would be necessary. The latest, and one of the most distinguished French writers upon Ope- rative Surgery, in speaking on this subject, says, where this affec- tion " est due a une veritable ankylose, alors, I'art ne peut autre chose que pratiquer une voie aux aliments, par l'extraction d'une ou plusieurs dents." So far, then, as authors have heretofore writ- ten, therapeutic means have been abandoned where there was an XXIV NEW ELEMENTS OF OPERATIVE SURGERY. anchylosis, on one or both sides, at the temporo-maxillary articu- lation. As I have already mentioned, the mere fact of priority would not have induced me to touch, at this time, upon this subject; yet I consider the details themselves of the above case, from its com- plexity, and the surgical principles brought into play during its treatment of some interest, and as likely to have a bearing upon analogous cases, which, from the frequent occurrence in the coun- try of "Immobility of the Lower Jaw," are not unlikely to be offered to the attention of the surgeon. I have the honor to be, Sir, Your obedient servant, New York, Dec. 6th, 1845. John Murray Carnochan. The body of the lower jaw has very recently been successfully exsected by an American surgeon, Dr. Simms of Alabama. The case is one of such value in itself, and augurs so encouragingly of the advance of surgical science in the South, that we annex the particulars, (See Amer. Journ. of the Med. Sciences, No. XXI., Jan., 1846, Art. XIII., p. 128, &c.) Art. XIII.—Osteo-Sarcoma of the Lower Jaw.—Resection [i. e., Exsection] of the body of the Bone.—Cure. By J. Marion Simms, M.D., Montgomery, Alabama. The subject of this case was a negro man about 26 years of age. The disease involved the body of the bone, extending from the third molar tooth on the left to its fellow on the right side. From the left lateral incisor to the third molar on the right, the teeth had all been removed and their places were occupied by a large granu- lated, fungo-fleshy looking mass, constantly discharging a fetid sa- nious secretion. On the left the teeth were firm, but somewhat displaced, being pushed upwards, their crowns inclining slightly inwards. The protuberance on each side of the bicuspids was very elastic to the touch. The whole under surface of the jaw was of a boney hardness, the right of the symphysis being larger than the left, and projecting a little lower. The following account of the history of the case is from the mas- ter of the boy, R. R. Moseley, Esq. :— " Some five years ago Sam had syphilis, and was some time under the influence of medicine before a cure could be effected. About a year after he got well, a rising commenced on the inside of the jaw, on the right side,, resembling a gum boil; but it con- tinued so long that I began to think it was the effect of the medi- cines he had taken to cure the disease. I got a Doctor to look at it, who pronounced it a gum boil, and as such opened it, but it did not go away. Some considerable time afterwards, I got the Doc- tor to examine it again. He found all his teeth on that side loose, entirely out of their sockets, and just sticking in the gums. The Doctor then cut down to the jaw-bone and found it diseased, and SUPPLEMENTAL APPENDIX. XXV matter on it similar to brains. That was fifteen or eighteen months ago. Sam has been taking some kind of medicine for it ever since. This is a short and imperfect account of his case, but about the best I can recollect at present." The tumor was never painful, but had put on such a frightful appearance, that it warned his master of the necessity of having something done for his relief. He accordingly sent him to one of the most distinguished surgeons of the whole country, who imme- diately took steps for the performance of an operation. The pa- tient was seated ; an incision about an inch long was made on the left side of the jaw, when he resisted the efforts of the surgeon, by springing suddenly from his seat, and refusing to submit to the cut- ting :—nor could any entreaty induce him to do so. He persisted so obstinately in his foolish determination, that the surgeon was com- pelled to send him home, trusting that time and a little reflection might bring him to a sense of his danger and show him that his only safety consisted in the extirpation of the disease. Soon after his return home, his master sent him to Montgomery, hoping that he might yet be induced to undergo an operation. I was not long in ascertaining that it would never be done with his consent; his only objection being that" it would hurt too bad." Having made up my mind to give him the only chance for his life, and having determined not to be foiled in the attempt, I con- trived the following method of securing him:— Everything being ready, the operation was performed on Thurs- day, 15th May, 1845, at 11 A. M. The apparatus consisted of a barber's chair, on which was placed a plank about twelve inches wide and five feet long, the other end of it resting on a common bench or stool, of the same height as the chair. Persuading him to sit down on the chair with his legs extended out on the plank, he was secured tightly to it by means of straps made of surcingle webbing, which were passed successively over the thighs, knees, and ankles. A strap around the abdomen, or rather pelvis, fastened behind, and another across the upper part of the thorax and points of the shoulders, running downwards and backwards, held him so firmly that it was impossible for him to move his body forwards. Some bands made of the same substance, (surcingle webbing,) fit- ting accurately each wrist, (after the manner of " handcuffs,") were buckled together with a strong leather strap, and this made fast to the band that passed over his knees, thus keeping his arms ex- tended. His elbows were pinioned to his sides by a strap buckling behind. His legs, body, and hands being now immovable, it only remained to fix his head, which was done by a band passing around it, and having attached, at the occiput, a strong leather strap. By laying hold of this, and pulling directly downwards in the course of the spine, his head was so far controlled that an as- sistant could hold it in any position that I wanted. He appeared to be very much alarmed. Dr. Baldwin counted his pulse, and found it varying from 122 to 128 beats in a minute. Taking my position on his right, an incision was commenced on XXVI NEW ELEMENTS OF OPERATIVE SURGERY. the left side, a little more than half an inch anterior to the angle of the jaw and continued along the base of this bone to the symphy- sis. At this cut he made a most furious effort to get loose, which proved that I had not put myself to any unnecessary trouble in securing him. The facial artery being secured, each end requiring a ligature,. the incision was continued from the chin, along the right side of the jaw, to a point corresponding with its commencement on the left. The divided ends of the right facial artery, (like the left,) each required a ligature. The upper flap was dissected rapidly from the tumor and held up in the usual way by an assistant. The lower flap was in like manner dissected off and turned down. This was somewhat tedi- ous in consequence of the thinness of the skin and its close adher- ence to the diseased mass. The posterior fang of the second molar on the left (its crown being decayed) was extracted to make room for the saw. I attempted to cut the bone with a small, long, nar- row saw, but made such slow progress that I laid it aside and picked up a very strong pair of Liston's bone forceps, with which I was equally unsuccessful. I then resorted to the chain-saw, pass- ing it around the bone in the manner usually directed, by which it was severed in a few seconds. Its application on the right side was quite as successful, dividing the maxillary just anterior to the third molar tooth. A strong double ligature was now passed through the fraenum linguae to prevent the spasmodic retraction of the tongue, and the operation was completed by dissecting the lin- gual muscles from their attachments to the bone. The retraction of the tongue was pretty strong at the moment of separation; though easily controlled by the ligature, which proved the safety and utility of this precautionary measure. There was a good deal of hemorrhage from the nutrient vessels of the diseased part: but no ligature was needed. The operation lasted forty minutes. From his constrained position and loss of blood the patient was quite ex- hausted. He was loosed from his fetters, laid on a bed, and took some brandy and water; which, by the bye, had been given to him occasionally during the operation. The wound was not adjusted, till reaction had been fully established and the oozing of blood en- tirely checked. The ligatures of the facial arteries were left hang- ing from their respective places. The ligature of the fraenum and those of the ranular arteries were drawn through the opening at its central point; the wound was closed by some six or eight inter- rupted sutures, and a water dressing applied. He had taken sixty drops of laudanum previous to the operation, which did not appear to produce any effect till it was over, when he seemed almost nar- cotized, sleeping profoundly the whole afternoon and all night. Mr. Norris, one of my students, sat by his bed-side the whole night, watching his tongue and keeping the dressings constantly moistened with cold water. The frssnum linguae ligature was cut loose and drawn out on the second day; but the dressing was not disturbed till the fourth, SUPPLEMENTAL APPENDIX. xxvii when I found the wound healed through its entire extent by the "first intention," except just at the points where the ligaturesnung out. They came away in due time, and their points ol exit at the chin and on the right side granulated directly; but on the left there remained a fungous growth sprouting up above the level of the surrounding skin, about the size of a pea, which did not get well till an exfoliation of bone was ihrown off through this opening. On the right there was a like exfoliation, but it was discharged by an opening on the inside of the mouth. For several days I observed that when he would lie on one side, the large, flabby, skinny chin would gravitate to that side; and when he would lie on his back, its own weight, assisted by the inspiratory act, would cause it to cave in, as it had no support on the interior. Sam left Montgomery on the 12th July, perfectly well. Previous to the operation, he was never known to laugh or even to speak to any of the other patients in the Infirmary; hut now, his mouth is almost always on the broad grin, and he is continually cracking jokes and playing pranks on his companions. I have rarely ever seen a patient exhibit more real heart-felt gratitude than he docs. His mastication is very good, having the third molar tooth left on each side; but the action of the pterygoid muscles has a ten- dency to draw the ends of the bones inwards, and thus mastication is performed, not with the crown, hut rather with the outer edge of the tooth. This, I fear, will, by and by, cause them to become dis- placed, loose, and useless. The operation was performed in the presence of a large number of medical gentlemen,* and I am under especial obligations to Drs. Boling, Baldwin, Blakey, Bellangee and Vickers for their valuable aid. A review of this case presents to my mind the following points of interest. 1st. It adds another to the long list of successful operations for this disease. 2d. It proves the practicability of the operation, whether the pa- tient is willing or not. 3d. The chain-saw is to be preferred for the division of the bone, when it is of a healthy hardness. It is a labor, time, and pain-sav- ing instrument. 4th. There is safety in the framum linguae ligature. 5th. The water dressing is preferable to every other. 6th. If any apology were necessary for the length of time (rortjr minutes) taken in the performance of the operation, it might readily be found in the constrained posture of the patient, and consequently the increased urgency for rest, which, according to my experience, is all important in any capital operation. If I had to do this operation again, I would not bring a single ligature through the wound, but I would leave them long, bring* * Ten medical students and fifteen doctors. XXV111 NEW ELEMENTS OF OPERATIVE SURGERY. them out at the angles of the mouth and fasten them to the cheeks with adhesive plaster, thus allowing the wound to heal up entirely by the first intention, and avoiding the deformity of a cicatrix from granulation. Keratoplasty, or transplantation of a new cornea, which, though touched upon by our author,(vid. text, Vol. I.) is deemed of anexperi- mental character too hazardous and empirical almost to be spoken of, otherwise than as an operation to be absolutely proscribed, we per- ceive, nevertheless, continues to engage the attention of some prac- titioners in France as well as in Germany. M. Desmarres, (Archiv. Gen. de Med.,4e ser., Paris, Nov., 1843, t. III., p. 363,) at the sit- ting of the Paris Academy of Sciences, Oct. 2, 1843, states that he has ascertained that the cornea of a rabbit may with much facility (assez facile) be engrafted upon that of another animal of the same species; but that the transparency of the new graft (lambeau) is generally deficient, (ordinairement nulle,) at least in the greater part of its extent. The new cornea first swells, then becomes gradually flattened, and contracts so as to become diminished in all its diameters to two-thirds of its primitive dimensions, though preserving the exact form of its original periphery. In its retrac- tion, it draws to it concentrically the border of the former cornea, which latter, singular as it may appear, becomes elongated some- times to six times the breadth of what was pared oft*. Hence if, in transplanting, we take care to remove a flap of the iris, the widen- ing of the remains of the old cornea gives free passage through it, and through the aperture in the iris to the retina, whereby vision is established, but not through the transplanted cornea. The application of anaplasty for the cure of ranula, by M. Jo- bert of Paris, which we have alluded to in our Concluding Appen- dix, Vol. I., but could not at the time find the details of, consists in the adaptation of this remedy to this disease upon the same principles upon which it is used for the cure of contractions of natural orifices. In the first stage, the surgeon carefully dissects off from the tumor, without penetrating the latter, its mucous mem- brane or external envelope, the dissection being made to an extent proportionable to the volume of the ranula. He then excises a flap, so as to obtain a bleeding surface of a certain extent. The second stage consists in opening and evacuating the pouch, (or sac,) by incising the internal membrane which remains. Finally, he re- verses this internal membrane on each of the lips of the incision, and doubles it upon itself so as to fill up the bleeding surface, and keeps it in this position by means of a point of suture acting as a hem, (en ourlet.) (Vid. Dieffenbach's Ingenious Process for Atre- sia or Contraction of the Mouth: text, Vol. I.) M. Jobert pro- poses thus to create a permanent opening, as in the processes of Dupuytren, Boyer, &c.; the obliteration, however, here being, in his mode of operating, less to fear, because the borders of the orifice are, by the very fact of the operation, made to consist of non-bleed- ing (non-saignantes) surfaces, which can neither approximate nor SUPPLEMENTAL APPENDIX. XXIX unite, (Annales de la Chirurg. Franc, et Etrang., Juin, 1843; also Arch. Gen. de Med., Paris, 4e ser., Sept., 1843, p. 100,101.) M. Jobert proposes to extend this process to imperforate passages or cavities, as the vulva, mouth, &c., by first laying them open, and then bring- ing out the mucous membrane and hemming it by pin sutures to the cutaneous border of the external wound, (Archiv. Gen. de Med., 4e ser., t. II., Juin, 1843, p. 238.) At the sitting of the Academy Royal of Medicine of Paris, Au- gust 1,1843, we notice a second report of our author, M. Velpeau, on a memoir of M. Debrou, which latter, in cases of hare-lip, with a considerable projection of the inter-maxillary bone, proposes, after the manner of M. Vallet, to exsect a triangular portion at the lower part of the septum, so that the projecting bone, deprived of its pedicle, may be more easily crowded back, and allow the reunion of the two portions of the lip with the median tubercle. M. Vel- peau, in referring to a similar operation by M. Blandin, (vid. also text and Appendix of Vol. I.,) considers that of M. Vallet ante- rior to his. He also expresses an opinion that the process might be modified and simplified by means of a vertical section of the septum, (cloison,) which would allow of the pushing back of the inter-maxillary bone. M. Blandin, it appears, claimed priority over M. Vallet, (Arch. Gen. de Med., Paris, 4e ser., t. III., Sept., 1843, p. 108.) This, we should judge, was in fact nothing more than a new application of the wedge-shaped exsections of bones, as first practised by J. R. Barton, of Philadelphia, (vid. text of this work, Vol. I.) M. Blandin, in the January number of the Journal de Chi- rurgie, 1843, preceding the above, gives, in detail, the steps of the operation which he claims. M. Blandin advises the base of the ex- sected wedge to face downwards, and its apex to reach to near the bridge of the nose, (dos du nez,) which would make it a sharp tri- angle. The only difficulty is, some hemorrhage from the arteries of the septum. To arrest this, he uses torsion ; and, for greater se- curity, does not proceed to unite the fissures in the lips till two or three days after the above operation. (Vid. Archiv. Gen. de M6d., 4e serie, t. I., Mars, 1843, p. 365 ; also Dr. Mott's Process, Supp. Append, of M. Velpeau, Vol. I.) Contractions of the limbs, in cases of cerebral hemorrhage and other lesions of the brain, are, as noticed in our Concluding Ap- pendix, Vol. I., attracting of late a good deal of observation among English as well as French surgeons. In a very interesting paper on this subject, by M. le Docteur Max. Durand-Fardel, (Arch. Gen. de Med., Paris, 4e ser., t. II., Juillet, 1843, p. 300, et seq.,) he main- tains the almost constant presence of these contractions, either in the paralysed or non-paralysed limbs of hemiplegic cases, from cerebral effusion into the pulpy substance of the brain ; and states the singular fact, that these contractions have escaped the notice of most investigators. Thus it was merely alluded to by M. Rochoux, (Recherches sur VApoplexie, 2e edit., p. 142,) but is not even men- tioned in the works of Portal, MM. Moulin, Abercrombie, and An- dral; while M. Lallemand appears to think, on the other hand, XXX NEW ELEMENTS OF OPERATIVE SURGERY. that flaccidity of the limbs is constant in hemorrhage, (Lallemand, Lettres sur 1' Encrp hale, let. 2, p. 259,) and M. Gendrin is still more positive in this opinion, (Traite Pi.ilos. de Med. Prat ,t. I., p. 583.) M. E. Boudet was the first to make this subject clear, {Mem. sur VHemorrhagic des Meninges, 1839.) He states, in his work, that contraction will not be found where inflammation does not extend into the cerebral pulp, beyond the walls of the effusion, (f »yer;) but where the lesion of the cerebral pulp is accompanied with rup- ture through the walls of the ventricles and effusion of blood into its cavities, or upon the surface of the brain, contraction super- venes. In eighteen cases of ventricular hemorrhage, M. Durand- Fardel found that thirteen had contraction of the paralysed limb, two contraction on the non-paralysed side only, and three were of simple resolution without contraction. In eight cases of hemor- rhage on the exterior of the brain, there were six cases of contrac- tion of the paralysed limbs, one of contraction of the non-paralysed limb, one of simple resolution. He thinks that, in certain cases, the march of the effusion dur- ing life may be measured by the contraction. This surgeon con- cludes as follows:— " That, in cerebral hemorrhage, the contraction of either the paralysed or non-paralysed limbs, almost constantly accompanies the rupture of the bloody sac (foyer) into the ventricles, or into the meningeal coverings. That the contraction shows itself but very rarely, as a conse- quence of hemorrhages limited to the substance (epaisseur) of the hemispheres. A most important point, certainly, in relation to tenotomy and myotomy, is to diagnose correctly between such contractions as are the result of almost irremediable and hopeless lesions, like the above, and those which, whether from primary cerebral or spinal lesions or not, terminate in such permanent alterations and de- formities of the tendinous, muscular, and osseous parts, as to require the use of the tenotome. In noticing Professor Mutter's late work on Cases of Deformities from Burns, (Philadelphia, 1843,) the editor of the London British and Foreign Medical Review, (Oct. 184t,) speaks of a case which fell uncer his own observation, and in which a plastic operation having been attempted for a loss of teguments involving the axilla, upper arm and side, the efforts of the patient to resist the contrac- tion of the cicatrix, though an apparatus was also used to support the side and arm, were so great as to produce a commencing curva- ture of the spine. At the sitting of the Academy of Sciences, Feb. 19, 1S44, (Gaz. Med., t. XII., p. 125-6,) a memoir, transmitted from M. Maunoir, of Geneva, was read, on the muscularity of the iris, which he pro- poses to demonstrate on the strength of a long series of experiments. The iris, he says, is composed of an epiderm, or rather an epithe- lium, mucous substance, (corps muqueux,) two muscles, viz., a dilator and sphincter, cellular membrane, pigmentum nigrum, and SUPPLEMENTAL APPENDIX. XXXI a cellular membrane enveloping and reciprocally limiting all those parts. In man the two muscles seem one, the external or radiat- ing, which originates from an aponeurosis, called the ciliary liga- ment, which is found at the periphery of the transparent cornea, at its junction with the sclerotica. The fibres of this muscle fall per- pendicularly upon the great circumference of the orbicularis or sphincter muscle; the little circumference of this latter forms the pupil. The radiating or dilator muscle occupies nearly three-fourths of the disc of the iris, and the sphincter one fourth. Galvanic experi- ments confirmed these researches of M. Maunoir. In his micro- scopic experiments on animals, he found the iris variable, but the muscular arrangement unchanged. Finally, he was enabled by accident to demonstrate conclusively the antagonism of the con- strictors and dilators of the pupil, by a case in which, from a wound in the cornea from the point of a knife, a small artificial triangular pupil was accidentally formed above the line of the cicatrix and near the normal pupil, which latter constantly contracted as the other dilated, and vice versa. A new application of tenotomy and myotomy, and which, in our opinion, promises to be one of great value, has been recently made by M. Fabrizi, an Italian surgeon, (Gaz. Med. de Paris, tome XII., 1S44, 17 Aoiit, p. 526, etseq.,) viz., to the division of muscles or ten- dons implicated in contractions in consequence of old suppurating wounds, in which the matter penetrating and burrowing, and form- ing sinuses in the midst of the deep-seated tissues, tediously pro- longs the cicatrization. M Fabrizi has operated in four cases of this kind; in the first of which the suppurating wound being in the arm, and involving at its bottom the tendon of the biceps, that tendon was divided near its insertion into the radius; in two others the burrowing wounds being in the calf, and causing in one in- stance a complete talipes-equinus, and in the other contraction of the gastrocnemii, (jumeaux,) the tendo Achillis below was divided ; and in the fourth, the wound being in the fore arm, and causing permanent flexion of the hand, he divided the tendon of the pal- maris longus, and the flexor carpi ulnaris, (cubital interne.) In every instance, the operation aided by the subsequent treat- ment of Massage, to relax the muscles, and suitable injections of iodine, &c, effected a perfect cicatrization and speedy cure. It is to be noted, in support of what we have said, (Preface, Vol I.,) that the division of the biceps cubiti on the seat of the wound, was an effective resource in promoting the cure by dilating the wound and its burrowing sinuses, and exposing them freely to the air, not by a sub-cutaneous operation and occlusion of the air; while the other three cases were rigidly sub-cutaneous, and the advantages they pro- cured in promoting cicatrization were, undoubtedly, as the author of this new application of tenotomy says, imputable to the relaxa- tion of the parts about the wound, the removal of the tension and bridles, &c, and therefore, though not directly performed on the seat of the disease itself, proved eminently serviceable as an aux- iliary sub-cutaneous resource. XXX11 NEW ELEMENTS OF OPERATIVE SURGERY. As the cases are rare in which the division of the tendons or muscles of the fore-arm is called for, it is well to note here that in a case in which a cicatrix on the fore part of the fore-arm had caused this part of the limb to be slightly flexed in strong supina- tion, the wrist to be drawn into abduction, and the thumb and other fingers to be contracted ; while the tendons of the extensor ossis metacarpi pollicis and the flexor brevis pollicis were strongly salient in front of the styloid process of the radius, M. Balassa, of Vienna, as early as Dec. 13, 1841, successfully divided with Watt- mann's tenotome, the tendons of the above two muscles in front of the styloid process of the radius, and immediately the forced abduc- tion of the hand ceased. He then completely separated the cicatrix from its attachments, and kept it thus isolated between the muscles and skin. The extension of the hand and fingers was now effect- ed without the least difficulty, (Gaz. Med., tome XL, 1843, Jan. 28, 1843, p. 62.) An interesting specimen, illustrative of the organic plastic pro- cess and intermediary deposite which take place in divided tendons, was exhibited by M. Berard, at the sitting of the Royal Academy of Medicine, of Paris, March 28, 1843. The patient was a female aged 24, upom whom M. Berard had divided the tendo Achillis on one side for a double pes equinus, and who died six months after- wards of a pleuro-pneumonia. The tendon operated upon was four centimeters longer than the other. The new material was found to be a fibrous substance whitish on its surface, and rose-colored in its centre, where vessels still existed. It was intimately adherent, and united in its extremities with the cut ends of the tendon. M. Rochoux contended that the intermediary substance and the nor- mal tendon, however analogous in appearance to the eye, were not in reality so, as had been ascertained by the microscope, (Gaz. Med. de Paris.) M. Sedillot, of Paris, going farther than ourselves against (See Preface, Vol. I., &c.,) giving too great a generalization or extension to sub-cutaneous surgery, says in fact, in his memoir, (to the Acade- my of Sciences of Paris, Jutfe 12, 1843, entitled De VlnnocuiU de la Tenotomie, &c, Vid. Gaz. Med., t. XI., 1843, 17 Juin, p. 382,) that" all the applications of the sub-cutaneous method made in other than (en dehors) fibro-tendinous and muscular sections, have proved failures," and he regards " as erroneous, the generalization of the sub-cutaneous method to all the operations which may be per- formed under the integuments ;" on which M. Jules Guerin, in a note, {Gaz. Med., lb.,) calls for proofs, and then adds, that he main- tains the opinion diametrically the reverse of M. Sedillot, and as- serts that in all the applications he had made of the sub-cutaneous method, outside of, or beyond, the limits of tenotomy, have, with- out a single exception, proved that all sub-cutaneous wounds with- out abnormal complications, be their seat what it may, enjoy the same immunity as the wounds of tendons. The Action of the Oblique Muscles of the Eye.—The subject of the action of the muscles of the eye, to which we have devoted SUPPLEMENTAL APPENDIX. XXX111 much space in our Vol. I., as connected with the important opera- tion for strabismus, is still, we are pleased to see, attracting the at- tention of surgeons. (See Ranking's Half-Yearly Abstract, &C, Amor, edit., New-York, 1S45, Vol. I., p. 270-271.) M. Bourgery, (Med. Gaz., Jan. 1845, p. 462,) finds that the mean weight of the encephalon, or central nervous mass being 20393*5 grains troy, the cerebral hemispheres stand for 1694046 grains of that quantity, the cerebellum for 2176-7 grains, the cephalic pro- longation of the cerebro-spinal axis for 1312 2 grains, of which the optic thalami and corpora striata take 879 9 grains ; the medulla oblongata, with the pons varolii, 432 2 grains, and the spinal cord 710*1 grains. Hence, in man, the cerebral hemispheres include a nervous mass which is four times that of all the rest of the cerebro- spinal mass, nine times that of the cerebellum, thirteen times that of the cephalic stem of the spinal cord, and twenty-four times that of the spinal cord itself. The Eye.—Action of the Oblique Muscles. Dr. George Johnson (Cyclopedia of Anatomy and Physiology, art. Orbit., p. 791) has performed some experiments to determine the action of the oblique muscles of the eye, and has obtained results similar to those arrived at by Volkman, (Muller's Archiv, 1840-1-2. See also the patho- logical evidence by Szokalski, and other confirmatory facts in Lon- get, Du Si/xteme Nerveux, tome II., p. 396,) and others, proving the truth of Hunter's opinion, that these muscles rotate the eye- ball on its antero-posterior axis, (Palmer's Edition of Hunter's Works, Vol IV., p. 274,) and so keep the eye steadily fixed on an object we are regarding, during certain movements of the head, as from shoulder to shoulder, (the effects of which are not corrected by the recti muscles, and thus enable the image of the object to be kept on the same point of the retina, and not to be allowed to move over its surface, which it would do, during these movements of the head, were there no oblique muscles to counteract this tendency. In Dr. Johnson's experiments, a dog was killed by the injection of air into a vein, and immediately the inferior oblique muscle was exposed by dissecting off the conjunctiva without in any way interfering with the surrounding parts ; by means of two fine wires, a slight elec- tric current was then directed through the muscle. The effect was a rapid rotation of the eye upon its antero-posterior axis, so that a piece of paper placed at the outer margin of the cornea passed downwards and then inwards towards the nose. The superior ob- lique was then exposed at the back of the orbit, and was treated in the same manner. The rotatory movement produced was pre- cisely the reverse of the former ; the paper at the outer margin of the cornea passed upwards, and then inwards towards the nose. In the case of the superior oblique the movement was less exten- sive, the irritability of the muscle being less, perhaps from the delay in exposing it, and from some slight injury inflicted on it in so do- ing. There could be no doubt as to the direction of the movement in both cases; there was not the slightest appearance of elevation, depression, abduction, or adduction of the cornea. The experiment c XXXiv NEW ELEMENTS OF OPERATIVE SURGERY. was subsequently repeated on another dog, with precisely the same result Diseases of the Heart, Aneurism, &c—Having expressed our- selves, under the high authority of Dr. Mott, rather doubtingly of the value of auscultation in sub-sternal and thoracic aneurisms, (See text,Vol. II.,) we deem it a matter of justice to make a slight refer- ence to those who entertain a contrary opinion, among whom we confess the names of such authorities asBellingham, Comgan, &c, to which we may add that of so profound an anatomist, skilful a surgeon,and accurate an observer as Dr. Jno. Murray Carnochan, of this city, (New-York,) are well calculated to arrest our judgment. We quote from Dr. Ranking's Half-Yearly Abstract of the Medical Sciences, American edit., New-York, 1845, Vol. I., p. 212-213, some remarks which are apposite to the subject:— Diseases of the Heart.—The contributions to the study of the diseases of the heart and great vessels during the preceding six months are principally those by Drs. Bellingham, Furnival, and Christison, and MM. Forget and Gendrin. The observations of Dr. Bellingham, which will be found at length in another part of this work, (19,) are valuable for the clearness with which the physical signs of valvular disease in particular are laid down. In common with the majority of auscultators, he considers regurgitant diseases of the mitral valve, to be indicated by a " bruit" with the first sound, most distinct under the left nipple. In regard to this point we may be allowed to state, that it has long been our opinion, founded upon careful clinical observation, that disease of the mitral valve does not give rise to any bruit whatever, and that in fact we have no means of diagnosing the lesion, excepting by reference to the pulse, which is in itself almost pathognomonic. In looking lately through a list of cases of mitral valve disease, we have been able, within certain limits, (not as extensive as might be wished, it must be allowed,) to gain a numerical confirmation of these views. Of 14 cases of mitral disease, as ascertained by post-mortem examina- tion, a bruit with the first sound existed in 8, and none in 6. This at first sight might appear to favor the common opinion; but we further find that out of these 8 cases, another cause capable of generating the " bruit," namely, obstructive disease of the aortic valve, exist- ed in 6. On the other hand, in the 6 cases of patulous mitral valve in which no bruit was perceptible, neither was there, with one ex- ception, any co-existent disease of the aortic orifice. The excep- tion alluded to, it may also be observed, is not in reality, one to which any value can be attached, for the aortic orifice was in that case reduced to a rigid narrow ring, a condition which is generally allowed to be incapable of generating a bruit. We conclude, there- fore, as far as so small a number of observations will warrant our coming to any deduction at all, that a patulous condition of the mi- tral valve does not give rise to a " bruit," but that the sound heard in such cases is due to a co-existing lesion of the aortic orifice. Dr. FurnivaPs work {Diagnosis, Prevention, and Treatment of Diseases of the Heart, &c., Svo., London, 1845) is a careful resume SUPPLEMENTAL APPENDIX. XXXV of the ordinarily received doctrines of the day, but adds little to our previous knowledge. He particularly insists upon the advantage of giving alkalies in the treatment of acute rheumatism,as a means of preventing cardiac complication. The formula preferred by him is :—Liq. potassae 3 ss ; Vin. colchici n\ xx; Infus. sennae, or Aqua? menthae § j three times a day. He likewise speaks highly of aco- nite as a sedative in heart disease, and considers it in all cases pre- ferable to digitalis. M. Forget (Memoir to the Acad, des Sciences Medicales; re- ported in Lancet, Nov. 1844) considers that too much value is at- tached to valvular sounds in the diagnosis of diseases of the heart. He thinks that, in order to arrive at a correct diagnosis, it is neces- sary to determine the relative frequency of the lesions of the differ- ent orifices, and the relations of those lesions to hypertrophy and dilatation of the parietes. The results of the analysis of several hundred cases have shown him, that the most conclusive sign of a contracted aortic orifice is dilatation, and generally also hypertrophy of the left ventricle. This is indicated by a bulging in the precordia, increased impulse, and bellows-sound along the track of the aorta. This state of the left ventricle implies also passive dilatation of the other three cavities, so that in diseases of the aortic orifice the whole heart is enlarged, giving rise to increased dull space in the precor- dial region. Contraction of the mitral orifice is followed by dila- tation of the three cavities behind it, but the left ventricle remains undilated. In this case there is neither precordial bulging, nor in- creased dulness on percussion. The practical deductions drawn by the author from these views arc,—that in aortic stricture, with hypertrophy and dilatation of the left ventricle, debilitants and sedatives may be used without fear; whereas, in cases of mitral stricture, these means must be used with caution, as the left ventricle not being thickened, requires all its energy. Pericarditis.—The occurrence of this disease, as a complication of scarlatina, has already been mentioned, (vide p. 3.) Mr. Sibson (Op. cit., p. 523) speaks of a mild form of pericardial inflammation, which he believes to occur some time or other in the life of almost every individual. He is induced to come to this conclusion, from finding a small quantity of fluid, and a delicate fibrinous deposit on the auricular appendages in the majority of post-mortem exami- nations in persons dying of lingering disease of the chest, injuries, &c. Aneurism.—The diagnosis of aneurisms of the aorta forms the subject of a comprehensive paper by M. Gendrin, for which we re- fer to our notes under arteries in this volume, and is also briefly alluded to by Dr. Furnival, (Op. cit., p. 176.) A peculiar form of dissecting aneurism of the aorta has been de- scribed by Dr. M-Donnell, (Med. Gaz., March 2, 1845,) in which the blood had taken a double course, one downwards behind the sigmoid valves, which eventually burst into the pericardium, the other upwards, separating the arterial tunics as far as the innoini- XXXV1 NEW ELEMENTS OF OPERATIVE SURGERY. nata and subclavian vessels. The symptoms of this lesion are well shown in a similar case which is recorded by Dr. Todd in the 27th volume of the Medico-Chirurgical Transactions. These appear when the disease occurs suddenly, to be in the first place, a state of syncope, which is evidently due to the sudden abstraction of a large quantity of blood from the general circulation, and its impul- sion into the new-formed channel. The tearing away of the cellular tissue connecting the coats of the artery before the column of blood, was in the above case announced by severe anomalous pain in the course of the arterial trunk. Lesions of the Large Arterial Trunks.—Fatal lesions of, and hemorrhage from, the aorta and other large neighboring trunks, as the carotid, subclavian, and pulmonary arteries, by foreign bodies arrested in the oesophagus, are not unfrequent occurrences. Dr. Duncan, one of the surgeons of the Royal Infirmary of Edinburgh, relates, during the year 1844, (Cormack's Lond. fy Edinb. Month. Journ. of Med. Science, Oct., 1844, p. 862, etc.,) the extraordinary case of a man aged twenty-two, a journeyman dentist, who, hav- ing been in the imprudent practice of wearing during sleep two artificial, superior anterior incisors, which he had adjusted in place for the two that had been lost, and which, for the sake of conceal- ment, were badly secured by springs, accidentally found, on awak- ing one morning, that they were missing, which induced him to believe that he had swallowed them, of which he was unhappily convinced by the difficulty and pain he experienced in attempting to swallow. Mr. Syme, to whom he applied for assistance, detect- ed, by means of the probang, a foreign body in the oesophagus, considerably below the cricoid cartilage, and much beyond the reach of the ordinary forceps used for extracting foreign bodies from the gullet. The swallowing having improved, it was thought the teeth had passed into the stomach ; but the pain continued, and some small quantities of blood were spit up. About nine days after the accident, he suddenly fainted and vomited a mouthful of blood. The attempt to introduce a forceps now brought on vomit- ing of blood in considerable quantities, viz., to eight or ten ounces, when the false teeth were brought up ; but this was immediately followed by several mouthfuls of bright arterial blood, when the lips became livid, the pulse ceased, and the patient expired in con- vulsive sobs. On careful examination of the parts, says the narrator, (Dr. Dun- can,) the oesophagus, stomach, and duodenum were found distended with eight or ten pounds of bright arterial blood. There was an ulcerated perforation of the anterior part of the oesophagus, about four and a half inches from the rima glottidis, about three-fourths of an inch in length, and three lines in breadth, passing obliquely upwards from the right to the left side. The edges of the perfora- tion were rounded, and there was considerable surrounding injec- tion of the mucous membrane. By this opening, the probe could be readily passed into the aorta, which vessel, after keeping the parts a day or two immersed in spirits, was found to contain a per- SUPPLEMENTAL APPENDIX. xxxvii foration about the size of a large crow-quill, about half an inch be- low the origin of the left subclavian. The opening was irregular, with the edges everted, and at the lower part there was a pretty firm adherent coagulum. There was little or no vascular injection around the opening. The artery was otherwise perfectly healthy, The gold plate of the teeth was large, with projections correspond- ing to the spaces between the adjoining teeth, the two last on both sides being large and pointed, with almost a cutting edge. A more dangerous instrument for lodgment near the aorta could not well be imagined, and it was owing to its curved form, Dr. Duncan thinks, that the probang passed freely by it, in the second attempt to introduce that instrument. This rare and instructive case incul- cates, he remarks, the necessity of removing foreign bodies from the oesophagus as early as possible. Such foreign bodies sometimes occasion suffocation immediately, or inflammation and suppuration, followed by ejection of the body by the mouth, or its descent into the stomach ; or the suppuration may be so extensive that it makes its way, as in the case recorded by Hofer, into the chest, and causes death in that manner. In the case of a soldier, and which occurred in India, as related to Dr. Duncan by Sir G. Ballingall, death followed extensive gan- grene of the parts, from a bone impacted in the gullet. Sometimes the body has escaped externally by suppuration; at other times the trachea has been perforated, and death thereby caused ; or it has formed a pouch and been afterwards ejected by vomiting, even after the lapse of fourteen or sixteen years. In the Dictionnaire de Medecine, (1840,) three similar cases to the above are related of fatal hemorrhage : one by Martin, of a soldier, who, swallowing coin for a wager, had one of the pieces lodged in the oesophagus, so that fifteen days after, it perforated the aorta nearly at the same point as the false teeth in Dr. Duncan's case,and caused vomiting of blood and death; the two other cases are by Wagret and Saucerotte. Dumoustier, in the same work, relates a similar case from a wound in the carotid ; also Begin, at the Val- de-Grace, gives the case of a soldier who swallowed a piece of bone, which, though getting out of the reach of the probang, con- tinued to produce pain, and several weeks after brought on vomit- ing of seven pounds of blood, ending in death. Two parallel ul- cerations were found in the upper third of the oesophagus—the one on the right side nine lines in breadth, and that on the left, twelve. Opposite the latter there was an adhesion between the oesophagus and the corresponding part of the carotid, in which latter there was a small erosion about a line in diameter, which was undoubtedly the outlet of the hemorrhage and the cause of death. Guthrie, in his work on the Arteries, relates a case of a soldier in whom both carotids were wounded by swallowing pins. Mr. Bell, of Barhead, (London Medical Gazette, Feb. 10, 1843,) gives a case in which the rightcarotid was perforated byaneedle accidentally swallowed. In a case related by M. Bernast, of the Toulon Hos- pital, communicated to M. Begin, the pulmonary artery was wound- XXXVI11 NEW ELEMENTS OF OPERATIVE SURGERY. ed, in a soldier, from swallowing a sharp piece of bone, which penetrated the vessel by a minute opening at its point of bifurca- tion, to be distributed to the lungs, causing intense lancinating pain, inflammation, and, on the 8th day, vomiting of some blood and effusion of a large quantitv of that fluid into the chest, causing death, (LondonMed. Gaz.,'Mi\y 11th, 1843.) The right subclavian has also been thus wounded in a case relat- ed by Mr. Kirby, (Dublin Hospital Reports, Vol. II.,) in which this vessel rose from the left side of the aorta, and passed to the right, behind the oesophagus, (Northern Journ. of Medicine, May, 1844.) Necessity of Opening Abscesses early.—Danger of Perforation of Large Arterial Trunks from Deep-seated Abscesses.—Professor James Miller, of the University of Edinburgh, in enforcing the ne- cessity of early evacuating acute abscesses, especially such as are occult or deep-seated, remarks of these latter, (see his Principles of Surgery, Edinburgh, 1844, p. 184-187,) that it is now conceded that if neglected, as in the neck for example, where the pus is bound down by the cervical fascia, they frequently make themselves an opening into the oesophagus or trachea; and that "recently ex- amples have not been wanting of still greater hazard, by periora- tion of either the. carotid or the internal jugular." In these views of speedy and also the necessity of free dilatation of abscesses, we fully concur with him, as contradistinguished from the now perhaps too fashionable tendency, founded on the growing popularity of sub cutaneous surgery, of favoring too much the doctrine of occlu- sion, of cavities, articulations, &c. Nevertheless, this author's new, peculiar, and unsustainable idea, that ulceration is not the result of absorbent action, but of inflammatory disintegration and softening, is one which we must dissent from, as having a very anomalous and questionable shape, in juxta-position as it is with the plain common sense maxims of his book. Anomalies in the Arteries of the Neck.—Dr. Darling, Demonstra- tor of Anatomy in the University of New York, mentions to me a singular anomaly which he has recently met with in the arteries of the neck on the right side, a very elegant specimen of which may be seen preserved in his museum at the university. The pleura of the right side ascends as high as the fourth cervical vertebra, and extends so far to the left side as to have pushed to the left side of the median line the arteria innominata, and the origins of the right carotid and right subclavian arteries. So great is this dis- placement, that the right carotid, which, with the right subclavian, lies on the upper and anterior part of the pleura, is obliged to make a curve of about two inches in length, with the convexity forwards, in order to reach its normal situation. The left carotid and left sub- clavian are normal. It may, he continues, (private communica- tion, Jan., 1846,) be interesting to state, that the appearance of the subject (a female aged about 50 years,) was very remarkable. Her neck was exceedingly short and thick ; her whole person very squatty and wonderfully corpulent, so much so that the upper part of the thigh measured nearly two feet in circumference. SUPPLEMENTAL APPENDIX. XXXIX In another case, of which the specimen is also preserved in the same museum, the right subclavian arises to the left of the left sub- clavian, from the posterior surface of the arch of the aorta, and passing behind the left subclavian and left carotid, and the trachea and oesophagus, reaches its ordinary situation. Hemostatic Means.—M. Morand, (Journal. deMedecine; see Lond. Lancet, Oct. 5, 1844, p. 34,) to arrest leech bites, applies with suc- cess a cake of oil and yellow wax over the orifices. Dr. Bordes (Jour, de Chirurg.,) found the introduction of a pin through the lips of each orifice, and the twisted suture as in veterinary prac- tice, perfectly effectual. The more simple and most efficacious mode is that which I have already described, (see vol. I.,) of pass- ing a fine needle of white silk through the lips of each bite, and securing it with a knot. In some cases, where the bite is large, I have found two of these sutures necessary. The arrest of the hemorrhage is instantaneous, and this resource is of infinite im- portance in loose tissues, where pressure cannot be made, i. e., where there is no point d'appui, as on the neck, abdomen, &c. Ligature on the External Iliac, by Mr. Liston of London, in the recent case of fatal duel.—As we have alluded to this important case, which we perceive has given rise in England to many dis- paraging remarks, we think it due to the eminent surgeon in ques- tion to give the following abrege of the Reports made upon the case, which are deemed most authentic by, we believe, Mr. Liston himself. They will be found in detail in various recent periodi- cals, viz.: The Lancet, Medical Times, &.C.; also in Ranking's Half-Yearly Abstract of the Medical Sciences, American Edition, New-York, 1846, Vol. IL, p. 118-119-120. Ligature of the Exteral Iliac Artery for a circumscribed false Aneurism from the division of a superficial branch of the femoral artery by a pistol shot; a suspicion being entertained that the femoral trunk was wounded. By Mr. Liston. (Condensed from the Reports and Commentaries in the Lancet, Medical Times, 6)'C By Dr. Potter and others 1845 On the evening of the 20th of May, Mr. Seton received a wound from a pistol ball, which, entering the upper part of the right thigh a little above and in front of the great trochanter, and crossing the abdomen, passed out about the middle of the fold of the left groin. No surgeon was present, but the non-medical witnesses of the event describe the hemorrhage which occurred as rapid, the blood being florid, in large quantity, and issuing per salturn from both wounds ; and as rising when uncontrolled in a jet to the height of two or three feet from the wound in the right hip. Attempts were made to arrest the hemorrhage by pressure over the wounds, but the patient fainted, and the hemorrhage ceased. When first seen by a surgeon, the patient appeared almost life- less, but was restored by proper measures. The following day the temperature of the surface became more natural, the pulse increas- Xl NEW ELEMENTS OF OPERATIVE SURGERY. ing in rapidity and somewhat in strength. The track of the ball was marked by an elevated ridge, from one opening to the other, and some ecchymosis of the skin extended from this line over the lower part of the abdomen and scrotum. The patient suffered great pain in the groin and right lower limb generally, with a sen- sation of numbness of the front of the thigh, and partial loss of power over the muscles of that part of the limb. Subsequently, the application of iced-water and bladders of ice to the right groin gave some relief. In the course of the next few days little change occurred, but on the seventh day after the receipt of the injury, (May 27th,) the swelling over the track of the ball appeared more evident in the right groin, and was here observed for the first time to pulsate with each stroke of the heart. During the next two days, the swelling increased, although not very rapidly, and the pulsation became stronger. On the evening of the tenth day, (May 30th,) Mr. Liston first saw the case. The patient's skin was blanched and waxy, and his pulse rather quick and feeble. He suffered at times severe pain in the limb, but there was no marked expression of anxiety in his countenance or manner ; he felt his strength improving, and was hopeful as to the final result. The wound on the right hip was circular, filled with a dry depressed slough, with a narrow faint blush of redness round its margin ; that in the left groin was a jagged line already partly closed by a thin cicatrix. There was extensive ecchymosis of the skin in both groins, and over the pubes, scrotum, and upper part of the right thigh. In the right groin there was a large, oval, visibly pulsating tumor, extending transversely from about an inch and a half on the inner side of the anterior superior spinous process, to about opposite the linea alba ; its lower margin projecting slightly over Poupart's liga- ment into the upper and inner part of the thigh. On handling, it appeared elastic but firm, very slightly tender, and not capable of any perceptible diminution in bulk by pressure. The pulsation was distinct in every part, and equally evident whether the fingers were pressed directly backwards, or whether they were placed at its upper and lower margins, and pressed towards the base of the tumor in a direction transversely to its long axis, the parts being for the time relaxed. The femoral artery was slightly covered by the swelling, and its pulsations were obscure in the upper third of the thigh. No pressure on this artery or on the abdominal aorta ar- rested the pulsation in the tumor, and pressure in the former situa- tion was attended with severe pain. It was inferred that the tumor was a circumscribed false aneurism. The question would now arise : Has the femoral artery been wounded ? If the wound from the pistol-ball had injured the femoral artery, so as to give rise to an instantaneous, rapid, and severe hemor- rhage, there is the highest probability that Mr. Seton would have- died on the field :— SUPPLEMENTAL APPENDIX. xli A pulsation being felt on the distal side of the tumor was against there being a wound of any consequence in the femoral artery :— For several days there had been no return of hemorrhage, and no tumor was visible, which could scarcely have been the case if the femoral or any important artery was wounded. If the wound throughout its whole length were sub-cutaneous, the femoral artery would in ail probability be uninjured. The reports do not state that this circumstance was made out during life, although it turned out to be the case, on post-mortem examination. The presumption was accordingly very strong, if indeed the cer- tainty was not established, that the injured artery could not be the femoral. But the following circumstances presented themselves to form a prognosis, from which it was inferred that the patient was in great if not imminent peril: The blood in the tumor appeared florid, the tumor pulsated very forcibly, the circulation was gradually being restored, and the effusion if left to itself would probably increase, as it had since its first appearance, although there was some doubt about this during the latter period;—" some thought it had been enlarged during the preceding night." An additional quantity of blood might be poured out at any moment. When the sloughs separated, renewed hemorrhage might occur, and the further loss of blood would in all probability prove fatal; or, the patient, weakened by its loss, would have to bear up against profuse sup- puration after the closure of the injured vessel by ligature or otherwise. On the question of treatment, pressure either with or without the application of cold, was looked upon as quite insufficient to arrest even the further increase of the effusion, inasmuch as the bleeding vessel could not be more directly pressed upon than any other part, and as from the very form of the swelling, the com- pressing force would tend to drive the blood already extravasated further under the fascia of the abdomen. The first indication, therefore, which presented itself was, to lay open the tumor, search for the wounded vessel, and tie it above and below the wounded point, but it was thought practicably to be unwarrantable; because— 1. Supposing the operator able to command the circulation on the proximal side, it must still be attended with a dangerous loss of blood. 2. As the supply of blood to the tumor could not, in this instance, be effectually interrupted by pressure on any large arterial trunk, the hemorrhage, in searching for the wounded vessel, would pro- bably be unusually great. ^ 3. Supposing that the common femoral artery should be found V wounded, or one of its branches divided close to the main trunk, so as to render it necessary to apply two ligatures to the common femoral itself, the chances of the recurrence of secondary hemor- rhage on the separation of the ligatures would be very great; con- Xlii NEW ELEMENTS OF OPERATIVE SURGERY. sidering the frequency with which this occurs in cases where the common femoral is secured by a single ligature, and in the most favorable position that the operator can select. It was now, therefore, a question whether the external iliac ar- tery should be tied. Against the performance of so formidable an operation the following reasons existed:—1. The patient's consti- tution : he was very fat, particularly considering his age ; had lived very freely, taken little exercise for years, was delicate and impres- sible, and when indisposed, was always observed to be easily low- ered by treatment. 2. The recent shock which the constitution had received ; two such shocks within nine days must almost inevita- bly prove fatal. 3. The character of the operation ; the extent of the wound would be a source of immense constitutional irritation in such a subject; the peritonitis which would supervene must be almost inevitably fatal,—the danger of mortification of the limb,— the unsuccessful result of large operations generally. On the other hand, it was supposed that mortification of the limb was less likely to occur from there being little pressure on the femoral vein, and that the chances of peritonitis and mortification taken together, were less unfavorable than the chances of imme- diate and secondary hemorrhage attaching to the other operation. It was accordingly determined to tie the external iliac. As to the time of performing the operation, the following circum- stances existed in favor of delay. The further effusion of blood might never take place ; if it did take place, it would not necessari- ly destroy life. No circumstance existed at the moment urgently demanding an operation. The delay would introduce no new ele- ment of danger, nature would either show a tendency to close the wound, or new symptoms would exhibit themselves; the patient might live a very considerable time without any interference, and an aneurism of this size and superficial situation might vanish without causing death. The surgeons in attendance agreed, on the other hand, that any increase in the quantity or superficial extent of the extravasation must add materially to the difficulties of operating. They had pre- viously agreed that an operation was necessary, and as the patient had rallied tolerably well, they considered that the sooner the sup- ply of blood to the tumor was cut off by ligature the better chance the patient would have of life. Operation by Mr. Liston the eleventh day after the injury, (May 31st, 9 A. M.) The patient having been placed on a table in a good light, an incision was made through the skin, commencing just above Poupart's ligament, rather nearer its outer than its inner termination, and continued upwards and a little outwards. A layer of from one and a half to two inches of sub-cutaneous fat, and the external oblique muscle, having been cut through by successive strokes of the scalpel, another thick layer of yellow lobular fat projected into the incision, hiding completely the internal oblique muscle, and looking at first somewhat like the omentum. This layer of fat, the internal oblique and the transversalis muscles, were then SUPPLEMENTAL APPENDIX. XliU cut through cautiously, and to a limited extent, until the thin trans- versalis fascia just appeared. This was readily torn through, and the finger being introduced beneath, it was lastly divided to the full extent of the external incision by means of a curved probe-ended bistoury carried along the finger as on a director. The sub-peri- toneal cellular membrane thus exposed, proved to be so loaded with adipose tissue, and consequently so firm and solid, that it was easily separated from the face of the fascia iliaca ; and for the same rea- son, the peritoneum and intestines were more readily and completely held aside than is usual in this operation. At the bottom of the deep wound thus formed was seen, first the iliacus muscle under the fascia, and then the psoas and the genito-crural nerve ; but at first nothing was visible of the external iliac artery, nor could it be felt in its usual situation, close against the margin of the psoas. The fact was, that the vessel, adhering more closely to the sub-perito- neal cellular-tissue than to the other parts, was drawn with it slightly out of its course ; and turning the ball of the finger inwards towards the cavity instead of towards the brim of the pelvis, its pulsations were felt distinctly. The external iliac was now a little more exposed, a common aneurism needle passed under it, and a strong twisted silk ligature carried round; but before this was tied, it was ascertained that when the vessel was pressed against the curve of the needle, the pulsation in the tumor was completely ar- rested. No return of pulsation took place in the tumor, but symp- toms of peritonitis rapidly set in, and the patient died about thirty- five hours after the operation. On post-mortem examination, it was found that the ball had passed altogether in the sub-cutaneous fat; that it did not pierce the fascia lata ; and that the only vessel wounded, and forming the false aneurism, was a superficial branch of the femoral artery, which was divided close under Poupart's ligament, and nearly an inch from the main trunk, its divided extremity being perfectly open. The blood effused, and forming the main tumor was coagu- lated (forty-three hours after death.) There were several pints of sero-purulent fluid in the cavity of the peritoneum, and several " patches of inflammation " on parts of that membrane covering the large and small intestines, and the parietes of the abdomen near the wound made for the application of the ligature. This wound had a sloughy appearance, and was filled with a thin purulent dis- charge. The artery had been tied about the middle of its course, and was but little separated from the surrounding parts. There was no coagulum in it, either above or below the ligature. The vein was sound and healthy. There was a small abscess in the left groin, and a collection of blood in the cavity of the tunica va- ginalis. The cord was not divided, but blood was extravasated in patches along its course. Ligature on the External Iliac Artery for Aneurism.—Although from the rapid advance of operative surgery this ligature is now become a common affair, difficulties still attend it, and death often xliv NEW ELEMENTS OF OPERATIVE SURGERY. ensues, as is seen in the above case of gun-shot wound by Mr. Liston. It is well to note that the artery has recently been tied successfully at the Royal Infirmary, Edinburgh, by Dr. Duncan, (Northern Journ. of Medicine, March, 1845,) and by the report at that time was doing well. The patient was a man thirty years of age, an American sailor, of a stout robust frame, and full habit of body. The disease com- menced in consequence of making a violent effort while reefing a sail, and was of some months' duration when he was admitted into the Royal Infirmary in Edinburgh, at which time the tumor was rapidly increasing in size. It measured six inches in length, and extended from about an inch above Poupart's ligament downwards. It was somewhat irregular in its surface, in consequence of some enlarged glands lying over it. It felt pretty resisting at all points except over its upper and an- terior parts, where it was more compressible and most prominent. It pulsated, when grasped, in all directions; but the pulsations were felt most distinctly over its upper and anterior part. Over the same part an indistinct bellows-murmur was heard, more particu- larly when the thigh was flexed on the abdomen. When the limb was extended so as to make the fascia tense, the tumor diminished somewhat in size; and a certain diminution could be effected by pressure, and likewise by compressing the abdominal aorta so as to suspend the pulsation in the swelling. The integuments over the tumor were free from discoloration, were perfectly lax, and could be moved freely over it. There was no osdema of the limbs, and no congestion of the superficial veins. After the requisite pre- liminary antiphlogistic treatment had been practised, the vessel was tied. The patient was laid resting rather on his left side, with the shoulders slightly elevated and the limb somewhat bent. An incision dividing the skin and superficial fascia was made, com- mencing about an inch above the middle of Poupart's ligament, and carried upwards for about three and a half inches, in such a direction as to be, when it passed the anterior superior spinous pro- cess, about an inch or more internal to it. It was slightly curved, the concavity being towards the mesial line. The aponeurotic ex- pansions of the external oblique, the internal oblique, and transver- salis were divided to the same extent. The fascia transversalis was next divided to the requisite extent, the peritoneum carried inwards, and the vessel exposed. The thin fascia covering the artery was divided to a very slight extent, and the needle carried around the artery, with its convexity towards the peritoneum, counter-pressure being made with the fore- finger of the left hand. As a small filament of a nerve lay over the needle along with the artery, another needle was passed from within outwards, the first being retained to serve as a guide. The vessel was then compressed over the needle, and immediately the pulsation in the tumor ceased. The ligature was secured, one end being cut close to the knot. The securing the ligature was fol- SUPPLEMENTAL APPENDIX. xlv lowed by immediate cessation of the pulsations, and collapse, to a certain extent of the tumor. The wound was brought together by several points of suture, and lint, wetted with cold water, applied. The patient was laid in bed, with the limb slightly bent, and sup- ported by pillows at the knee. The patient scarcely had a bad symptom afterwards, except that some excitement was caused by a crowd of students around his bed at the visit the day after the ope- ration, which was removed by an opiate antimonial draught. He was also bled from the arm the same evening. The ligature came away on the twenty-second day. A serious objection to a ligature upon any of the great arterial trunks, if it were well established, would be the so-called white ramol- lissement or softening of the brain, alleged to be an occasional con- sequence of a ligature upon the carotid. Dr. Todd (Medico-Chi- rurgical Transactions, Vol. XXVII.) gives in illustration a lesion of this kind from obliteration of the right carotid caused by a dis- secting aneurism of the aorta. He makes it appear that the lesion is quite analagous to that of senile gangrene. Paralysis of the left side was produced in the case of Dr. Todd, from, as he supposes, the obliteration mentioned. The entire right hemisphere of the brain was found anaemic or in the state of white softening. General Principles of Treatment in Aneurisms of the Aorta.— Though we cannot by any means subscribe even to the qualified approval given by Dr. Norman Chevers (See Ranking's Half- Yearly Abstract of the Medical Sciences, Vol. II., Ameri- can edition, New York, 1846, Langleys, Publishers, New York, p. 39—40; See also London Medical Gazette, Aug. 29, 1845) to Val- salva's treatment, we have had ample means of knowing that no- thing can be more true, rational and effective, than the following sound, and for the most part new, views as given by Dr. Chevers for the relief or even cure of aortal dilatations, where the structural disorganization from the continuance of the disease or age of the patient probably have not advanced too far, and where the disease may be deemed secondary, or symptomatic of irregular life, impro- per diet, &c. Dr. Chevers says, (Ranking, lb., p. 39 :) The natural process by which the cure of an aneurism is effected, is, by procuring obliteration of the sac by layers of firm coagula. In aneurisms of the extremities this alone appears to be sufficient, but in aneurisms of the aorta, a far more delicate process requires to be effected, as here the sudden formation of loose coagula will always be liable to occasion rupture of the walls of the sac. " It is necessary in aneurism of this artery," says the author, " to cause the obliteration of the sac, by layers of coagulum firm enough to resist infiltration of blood, and which shall present internally a smooth surface over which the blood may readily glide." Another object in the treatment, much insisted upon by the author, is that of removing visceral congestions, and avoiding all unnecessary irritation and excited action in the organs, at the same Xlvi NEW ELEMENTS OF OPERATIVE SURGERY. time endeavoring to keep up a natural discharge of their functions. The two organs which it is especially necessary thus to attend to, are the liver and kidneys. Many cases of disease of the heart and great vessels would be readily enough kept in abeyance, were they not aggravated by consentaneous inactivity or irritation of these two great emunctories. In aneurism, as in every other form of organic disease of the vas- cular centres, the prolongation of life generally, in a very great measure, depends upon the maintenance of that degree of rest which, while it prevents the capillary obstruction which is attendant upon muscular action, does not deprive the patient of the benefits of the air and gentle exercise. The reduction of the volume of the circulating fluids has always been considered a main point in the treatment of organic diseases of the heart and its appendages, but " unfortunately," observes the author, " depletion has been too often the course adopted, to effect this purpose." The desired effect, however, may be far more suc- cessfully produced by gradually diminishing the fluid ingesta, than by any system of active evacuation ; and the fact, that the palpita- tion, lividity of the surface, &c, mainly depend upon the admission of an undue quantity of material into the blood, becomes itself a suggestive that in such cases, all unnecessary articles of diet, solid as well as fluid, should be dispensed with. The author animadverts with severity upon the practice of ex- hibiting digitalis, and other medicines which have a depressing effect upon the power of the heart. The great error, he observes, is in regarding the palpitation, for which these medicines are gene- rally given, as though it were itself the disease, and not what it really is, the sole means by which an overloaded and obstructed heart is enabled to propel its contents. The rational mode of treat- ment is clearly to remove the causes of the obstruction from which the heart suffers, where these are not of a permanent nature; or if this be not possible, to diminish the load of fluid which embarrasses the heart when the palpitation being no longer requisite, will cease of itself. It is certainly unwise to administer a medicine which its advocates justly term a " direct sedative of the heart" in a class of diseases, where all the worst symptoms arise from the difficulty that organ experiences in propelling its contents. Whenever, as frequently happens, the patient appears to be gradually sinking from the violence of the paroxysms which attend the failure of the heart's powers, restoratives, or even powerful stimulants, become necessary. Venous Pulse.—In the larger venous trunks it is familiarly known in surgical operations about the neck, that a reflux pulsation is fre- quently communicated to them from the heart, but in the smaller veins we know of no other fact of venous pulsation, except the following, recently recorded. (See Ranking's Half-Yearly Abstract, &c, American edition, New-York, 1845, Vol. I., p. 256—7.) M. Martin Solon, in a memoir read before the Academy ofScien- SUPPLEMENTAL APPENDIX. xlvii ces, Paris. (Lancet, Jan. 4,1845, and Bulletin des Academies, Novem- bre, 1844, p. 24,) has given the details of two cases in which he ob- served pulsation of the dorsal veins of the hands. The patients had both been repeatedly bled, and taken tartar-emetic, for an attack of pleuro-pneumonia. The veins were prominent, rounded, of a blue- ish-red color, and presented a diastolic and systolic movement, easily appreciable by the eye, and synchronous with the pulse : it was evidently not communicated by any adjacent vessels. Upon pressing the fingers, the pulsation ceased; but when the wrists were pressed, they remained as before. When the brachial artery was pressed, the pulsations of the radial and ulnar arteries, and of the dorsal veins of the hand, all disappeared together. In both cases, the patients gradually recovered. In one the venous pulsa- tion appeared on the fifteenth day and remained seven days, the cardiac impulse being strong : in the other, the heart's impulse was feeble, and the venous pulsation remained for a shorter time. M. Solon explained the phenomenon of venous pulsation in these cases, by supposing that the abnormal fluidity of the blood facilitated its passage through the capillaries, and thus enabled it to retain the impulse communicated by the heart. He alluded to similar cases by Dr. Graves and Dr. Ward, (Lond. Med. Gaz., 1832, p. 376. Dr. Ward accounted for the phenomenon of venous pulsation in the way above suggested by M. Solon.) Pathologically, he thought the phenomenon important, as indicating a state of fluidity of the blood, which would render further bleeding inadvisable. Physio- logically, it was important, as proving that the entire circulation is under the influence of the heart. In a discussion which ensued after the reading of the memoir, M. Poiseuille agreed with M. So- lon in considering the phenomenon as another proof of the influ- ence of the heart over venous circulation, but could not attribute it to the greater fluidity of the blood, for the experiments of Ma- gendie and himself had proved that the more aqueous the blood became, the greater was the difficulty with which it passed through the capillaries, owing to imbibition. He thought it, therefore, more correct to explain the influence which loss of blood evidently had in producing venous pulsation, by considering the heart as having lost energy, whereby a smaller quantity of blood is thrown into the arteries, which being less dilated, contract with less force, and thus lose their power of converting the intermittent fluid into a continuous one, as is normally the case. Tetanus cured by Alcoholic Drinks, in inebriating Doses.—A treatment for tetanus, at war with the movement in favor of tee- totalism, is proposed by Mr. Stapleton, (London Lancet, March 22, 1845,) viz., ardent spirits in intoxicating doses, which in one case succeeded in entirely suspending the tetanic symptoms, but without saving the life of the patient. Another case was wholly cured of this too often fatal disease, (See paper by Dr. Wilson describing a case attended by Mr. Ilott, sitting of the Medico-Chirurgical Soci- ety of London, April 22, 1845,) by the exhibition of brandy in enormous doses, opium being at the same time studiously avoided. Xlvhi NEW ELEMENTS OF OPERATIVE SURGERY. During the space of eight days the patient took as much as two gal- lons of brandy, in addition to wine, &c. The acknowledged fact that most fatal cases from tetanus, (and most of them unfortunately are fatal,) die in a state of asthenia, ap- pears to justify this last-mentioned treatment. We have thought it proper to allude to the above subject, from tetanus being almost exclusively one of the consequences of surgi- cal operations, or of wounds requiring surgical treatment, (see text of this Vol.) We may also add in relation to the use of alcoholic drinks in a medicinal point of view, that in the ravages of Asiatic cholera, at London, Paris, and also in this country, the steady use of moderate potations of pure brandy at certain intervals of the 24 hours, and use of animal, and avoidance of most kinds of vegetable food, was deemed the surest preventive and protector against an attack of the disease. The same has been observed in our preva- lences of the West India pestilence to Northern men, known as yellow fever. Dr. Mott's last Case of Exsection of the Lower Jaw for Osteo-Sarcoma. Case of Exsection of Part of the Lower Jaw for Osteo-Sarcoma, at Newark, New-Jersey. By Dr. Mott, Thursday, Dec. 26, 1844. (Drawn up by P. S. Townsend, M. D.) The patient H----, was aged about 35. This was a genuine case of the malignant disease known as osteo-sarcoma, but confined almost exclusively to the alveolar processes on the left side of the lower jaw, which was the part exsected. The patient was of rather tall, slender make, pale and thin—with dark hair—and of nervo-bilious temperament. About two years or eighteen months before, during a quarrel, he had received a severe blow directly on this part of his jaw, from a man who knocked him down. About a year ago, the gums over this portion outside began to show a spongy livid appearance from the alveolar process, and its periosteum beneath having become previously in- flamed and swollen. The tumor pushed the cheek out in this part, and its size was that of a pigeon's egg. The warty bed of long fungoid shoots, or vegetations, on the side of the gum in front, had a very peculiar appearance, being generally about a third to a half an inch in length, and in some places loose with fissures, separat- ing them down to their roots, allowing of an opportunity when these roots were held apart, to notice the carious foetid portions of the alveoli, which were not yet wholly destroyed. Such however, had been the devastation within a year, that the three or four teeth which corresponded to this part were so loose that they could easily be moved with the finger, and of course as readily taken out. The surgeon, (Drs. Darcey, Pennington, Campfield, &c, of Newark, being also present,) commenced his curvilinear incision at his usual place in front of the meatus auditorius externus, and brought it SUPPLEMENTAL APPENDIX. xlix down outside and under the angle and base of the jaw close to the latter, till coming to near the symphysis of the chin, he terminated the division below the border of the lower lip. The upper border of the wound, and sufficient of the lower being dissected off to insu- late the jaw and its tumor and tissues, and two or three vessels tied in the course of this dissection, the chain-saw was passed by a sharp thick probe, first behind the front part of the jaw, and that portion sawed perpendicularly from below upwards—not however, without some difficulty from the saw becoming pinched in the bone. In a few minutes after the same saw was introduced in the same man- ner, a little behind the angle of the jaw, and that portion sawed obliquely upward and forward—the last cut of the saw reaching up to near the fungoid tumor—but evidently outside of the degenerate structure, as the fresh, wholesome surface of the sawed bone showed. The diseased portion was thus completely isolated and exsected, being about 3 inches in extent along the base of the jaw, and less above. After waiting a while for any bleeding from the small vessels to cease, and tying such of the vessels that required it—the flap was brought down, and the ligatures and straps applied in the usual manner. The patient showed much moral courage as well as physical force for one so thin, pale, and apparently delicate in frame, as he sat up in a common chair, his head only supported behind, during the whole operation. The hemorrhage for a temperament like this was considerable, but not important, and there was not the least syncope or collapse,—the pulse being almost unchanged by the operation. Feb. 26,1845.—Having read over on this date the above sketch to Dr. Mott, he said the patient had long since gone home quite re- covered. In alluding to the cauliflower appearance that the soft parts or gum in this patient exhibited, Dr. Mott said that it possessed some- what more of the fungoid character than most cases of osteo-sar- coma. Exsection of half the Lower Jaw for an Osteo-Sarcomatous Tumor —also Disarticulation of the Jaw and Previous Ligature on the Primitive Carotid Trunk, by John P. Batchelder of Utica, State of New York.—After all that has been done by American surgeons cotemporaneously with foreign practitioners, to exalt pari passu, the science of surgery, and after all that this science owes for many of its important results to the high standing generally of medical institutions and the medical profession in this country, there is much that some of our surgeons have culpably neglected to make public, which requires yet to be rescued from oblivion. We therefore make with pleasure the following summary from a private commu- nication just received from an estimable practical surgeon, Dr. Batchelder of Utica. The operation for the removal of an osteo-sarcomatous tumor in- volving the inferior maxillary bone, about two inches of which, with D 1 NEW ELEMENTS OF OPERATIVE SURGERY. the tumor, was excised, was performed on the 16th of June, 1825, at Deerfield, Mass., by Dr. J. P. Batchelder, now of the city of Utica, N. Y., the carotid artery on the affected side having been ligated the day previous. It is believed that this operation is the first of the kind ever performed in the New England Slates. Although the whole morbid mass appeared to have been extirpated, the dis- ease returned, and on the 19th of November following another ope- ration was instituted by which one-half of the lower jaw with the whole of the tumor constituting the disease, was removed by sawing through the former, at or near the symphysis, and disarticulating the condyloid process from the glenoid cavity in the temporal bone. The operation for the excision of one-half of the inferior maxilla for the cure of this most formidable disease, was performed in the first instance by our distinguished countryman, Prof. Mott, with whom it was original, and in the second by Dr. Batchelder as above stated. The patient, Mr. Spencer Hubbard of Deerfield, very soon recovered from the operation, and continued sound some six or seven years, when the disease returned and ultimately destroyed him. We avail ourselves of another interesting surgical fact, which would fall under Exsections in this work, and which has just been contributed to surgery by the practitioner above mentioned. We find it recorded [correctly as the surgeon himself has informed us] in the New York Medical and Surgical Reporter, edited by Clark- son T. Collins, M. D., &c, Vol. I., No. 7, Saturday, Jan. 10, 1846, p. 113—115. Removal of the Head of the Femur. This important operation was performed by J. P. Batchelder, M. D., Df Utica, N. Y., during the past summer, and we are indebted to a friend for the following particulars of the case, which, if incor- rect in any particular, we beg will be corrected when the operator shall, have seen this article. The subject of the operation was a young man, about twenty years of age,—he received an injury at the hip-joint, from the kick of a horse, some four or five years pre- viously, and had not been able to use the leg from that time, up to that of the operation. The limb had become somewhat atrophied, and was about two inches shorter than its fellow. There were two fistulous openings which kept up a continual discharge, and con- sequently his general health had become very materially impaired. The above alluded to, fistulous openings were situated between the trochanter major and the tuberosity of the ischium, one above the other, and about three inches apart. Upon introducing a probe at either of the sinous openings, a bone was felt, which was supposed to be the head of the femur necrosed; but whether it was detached or not could not be determined.—The dead bone which lay in the direction of the acetabulum was about three inches from the sur- face, owing to the tumefied condition of the soft parts. The sur- geon at first proposed to make an incision down to the bone, and SUPPLEMENTAL APPENDIX. li extract it, but owing to the patient's state of general health, it was concluded to adopt a slower and equally certain, and perhaps safer mode ; which was to introduce tents of compressed sponge, for the purpose of dilating the openings; the spongia praeparata being in- serted every night and morning, pro re nata, and gradually en- larging the quantity. In the course of ten days the openings were considerably enlarged, in consequence of which, by the use of the probe, it was fully ascertained that the head of the bone was de- tached. .The surgeon then introduced an eyed probe, very much curved, and armed with a ligature, attached to winch was a cord of about one-tenth of an inch in diameter; he succeeded in passing the curved probe in at the lower opening, and along the bone, until it could be felt at the bottom of the one uppermost, when it was seized with a strong dressing forceps, and after some trouble, but without much pain, drawn out through that aperture and the ligature tied with a slip-knot over the intervening flesh, so as to be tightened daily, which was continued for about a fortnight, when having com- pletely effected the object for which it was employed, it dropped off. On passing the finger deep into the chasm, the bone could be distinctly felt, and was ascertained to be slightly movable. A fur- ther and more particular exploration was now made, and the scoop end of a strong director hitched under one of its edges, by means of which it was slightly raised, which enabled the Doctor to grasp it with the forceps, and by turning it still more up, he finally suc- ceeded in bringing it out edgewise through the external wound. The bone taken away, proved to be the head of the femur. The wound was dressed by introducing a fold of lint between the lips of the wound, passing it to the bottom of the cavity, and over this a compress and bandage applied. In the course of a few weeks, the entire wound was healed, with the exception of a small opening, which appeared to be about half an inch deep, over which he ap- plied small blisters in succession, by means oi' which, and the use of R. Tr. canth. and tonics, it was soon completely healed. [Dr. Batch- elder informs me that he has always found the internal administra- tion of cantharides eminently serviceable in his surgical practice, in rapidly promoting granulations. Take this tonic effect in connec- tion with the tendency or metastasis to cystilitis, abscess of the liver, &c., after surgical operations, and the vicarious functions of the kid- neys and liver. See on this subject our note towards the conclu- sion of the volume. Dr. Batchelder gives the cantharides until slight strangury is produced. T.] His general health rapidly im- proved under a constitutional treatment, until he was discharged, completely cured. In three months after the removal of the bone, he laid aside his crutches, and by the help of a cork-soled shoe, walked short dis- tances quite easily, and somewhat gracefully. It may be said by some, that the knife would have been prefer- able to the slower means used, but it was adopted upon the golden rule, " do unto others as we would wish to be done by,"—a prin- ciple which should always govern us in surgery, as well as in Ill NEW ELEMENTS OF OPERATIVE SURGERY. morals. Dr. B. is a gentleman of experience in his profession, hav- ing occupied the chair of surgery in one of our Medical Colleges many years since, but latterly he has been engaged in private prac- tice only. We are informed that the Doctor has been in the habit of mak- ing great use of the sponge tent, and compressed sponge, in various affections of the bones, such as necrosis, and particularly caries, for more than thirty years past. By the tent, a passage may be made without pain to the parts, to which pieces of compressed sponge may be applied daily, until all the morbid parts are absorbed, when the practice should be dis- continued, and the sores, ulcers or fistulas, allowed to heal. Many other intractable morbid growths, even of a malignant nature, may be successfully treated in the same manner. What must have been the condition of the hip-joint from the time of the injury up to the time of the operation ? Was the neck of the bone fractured and dislocated at the same time, by the kick from the horse, some years previously ? Or was the neck of the bone merely fractured, and the head left remaining in the socket, and acting as an irritant, causing the cotyloid ligament to be absorbed, thus freeing itself from the acetabulum 1 Or could it be that there was morbus coxarius caused by the injury, and followed by necro- sis of the head of the bone ? Our informant has not given us enough of the early history of the case, in order to decide an important question. The operation for removing the superior extremity of the femur, for hip-disease, has been performed twice in England, which was unknown to Dr. Batchelder, at the time of his operation ; hence, the operation was original with him. The os coccygis has been recently extirpated by Dr. Nott, an American surgeon, (See Amer. Journ. of the Med. Sciences,) in a lady, aged 25, for severe neuralgia—a diagnosis of the condition of the spine indicating extreme tenderness over that bone. The incision was made down to the bone two inches in length vertically upwards from the point; the bone was then disarticulated at its second joint, the muscular and ligamentous attachments divided, and the two terminating bones dissected out without much difficulty. The last one was found carious, hollowed out to a mere shell, and the nerves exquisitely sensitive. The operation, though short, was attended with extreme suffering, and the pain afterwards violent for hours, coming on every ten or fifteen minutes, and accompanied with a sensation of bearing down like labor pains. At the end of a month, all medicaments proving of no avail, the pains subsided, the wound healed, and the general health was much improved. At the next catamenial period, she suffered severe pains and tender- ness in the vagina, which were ultimately effectually cured by citrate of iron in five-grain doses three times a day. Fracture of the Totality of the Spine of the Scapula by Muscular Action—Dr. Heylen (Anal, de la Soc. Med. d'Anvers, and Jour, de Chirurgie, Paris, Mai, 1845 ; see also Ranking's Half-Yearly Ab- SUPPLEMENTAL APPENDIX. liii stract, &c, Amer. ed., vol. II., New York, 1846, p. 8S-9) furnishes an interesting case where the whole body, as it may be called, of the spine of the scapula, is supposed to have been fractured at its base by the mere force of holding on with the arm to a cart which the horse had run away with. The diagnosis of distinct crepitation at the middle portion of the crest of the spine was made by holding the clavicle and the coracoid process firm, while the arm was being rotated. There was no ecchymosis, and none of the usual signs of fracture of the acromion. The fractured fragments seemed to have been held naturally in place by the muscles of the shoulder, and the head of the humerus in its cavity, there being no injury to these last. For a better diagnosis of fractures of the neck of the femur, M. Lionet proposes, (Gaz. des Hupitaux, Paris, June, 1845,; in order more distinctly to hear the crepitation, to let the patient stand his whole weight on the sound limb while the other hangs down free, and the ear or stethoscope is applied to the joint. M. Vidal justly approves of this as better than auscultation in the longitudinal posi- tion. On the Position to be maintained in the Treatment of Diseases of the Hip Joint in the Young.—In diseases of such growing import- ance in the increasing luxuriousness of the present age, as those of the hip-joint, and where, as we have seen in several recent instances, so much and even such diametric discordance among the highest known surgical authorities, as to their true diagnostic marks, and wherein a simple morbus coxarius according as it had been long supposed to be understood, differs from carious and other affections outside of the head of the femur and cotyloid border of the bone, it is advisable to record as soon as it can be procured, for the benefit of the profession, all'that can throw any new light upon these sub- jects. We are satisfied, therefore, that we should notice here im- mediately the latest opinions of so esteemed an authority in surgery as Mr. Aston Key, of London, from whose paper (see London Med. Gazette, Oct. 24, 1845 ; also Ranking's Half-Yearly Abstract, &c., Amer. ed., vol. II., 1S46, p. 111-13) recently laid before the Phy- sical Society of Guy's Hospital, London, we extract the following observations :— The insidious progress of strumous disease of the hip-joint, the division of the disease into its several stages, and its usual termina- tion in a greater or less degree of anchylosis of the joint, are, I pre- sume, so well known that I shall forbear to enter minutely into the pathology of the disease ; my object in these remarks is to point out the inconvenience of the deformity that is almost always found to attend convalescence, the causes which give rise to it, and the best mode of preventing it. The first change usually observed in the relative length of the two limbs, is the temporary elongation or shortening of the one affected, according to. the position which the patient mairtains in the act of progression in the early stage of the disease, when it is characterized rather by a sense of weakness than actual pain. In the commencement of the affection, the patient throws the weight llV NEW ELEMENTS OF OPERATIVE SURGERY. of the body instinctively upon the sound limb, and merely steadies or balances himself upon the unsound one. If the foot be carried forward and placed flat on the ground, the same side of the pelvis is carried forward and drops, giving a lengthened appearance to the limb. If, on the other hand, the unsound limb is not advanced much in progression, and the patient rests on his toes, the pelvis is carried upward on that side, and the limb appears to be shortened. Both these states are usually only temporary, and disappear if the patient is prevented from walking, and is made to lie down. To those who have had much experience of this affection it is almost needless to remark, how rarely it is seen in the early stage, at a period when properly applied remedies can restore the joint to its previously healthy state. The insidious nature of the attack disposes both medical men and parents, alike unsuspicious of its real nature, to regard the affection as one merely of weakness, un- til unequivocal symptoms evince the commencing disorganization of the articular cavity. The second stage of this disease is no longer, as the first has been, one of erythema of the synovial lining of the joint, but assumes a more active form of inflammation, extending to the more dense parts of the capsule and cartilage, and is attended with severe pain in rotation and abduction of the limb. Often, in the earliest part of the second stage, the limb will not admit of perfect extension, and by careful examination of the joint it may be discovered that the thigh is permanently flexed upon the pelvis. It is this state of the limb to which I wish to direct your attention, as fraught with the worst consequences to the patient. This state of flexion of the femur on the pelvis usually takes place slowly and imperceptibly, but sometimes it is rapidly induced by a sudden attack of inflammation in a joint which has previously exhibited signs of disease in its mildest form. This is the worst form of the disease, so far as deformity of the joint is concerned, for the in- tense pain which the patient experiences on the slightest movementof the limb, induces him to seek for ease in positions that add greatly to the distortion of the limb, by the obliquity given to the pelvis. The patient is seen lying usually on the sound side, with the affected limb drawn up to nearly a right angle with the pelvis; as the patient lies on his side, the affected limb appears to be three or four inches shorter than the other. When he is placed on the back—a position as- sumed with difficulty—and the bearings of the two patellae and the spinous processes of the ilia are noticed, the former are seen to dif- fer as much as from two to three inches, while only a difference of an inch is perceptible in the level of the latter. This would seem to show that the limb is actually shortened ; such, however, is not the case, but by examination of the pelvis it will be seen that the twist of the pelvis on the lumbar vertebrae, by carrying the affected joint backwards, is the cause of the great shortening of the limb. During the stage of inflammation it is impossible to use any means for counteracting this disordered condition of the pelvis; and by the time that the patient is able to bear extension, so as to re- SUPPLEMENTAL APPENDIX. lv store the pelvis to its natural bearings, and to diminish the angle which the femur makes with it, the parts have become so fixed in their new position as to render it difficult of alteration, and impossi- ble in the majority of cases to restore them to their natural bearings. The consequence is, that when the patient is convalescent with a somewhat stiffened joint, the foot cannot be brought down to the ground, and a shoe with a sole of two inches is required to enable him to walk with the foot flat on the ground. How is this state of things to be prevented ? The only remedy for the evil is, in every case of hip-joint disease, to maintain the straight position as soon as the nature of the affection is ascertained, which is a position applicable in all stages of the disease. In the early stage, characterized by only a slight limping in the gait, or by an occasional slight pain in the knee or thigh, it possesses the advantage of maintaining the joint in a state of complete re- pose. The articulation being at rest, the muscles do not act, but remain in a passive state. On the contrary, when the limb is kept bent,with a pillow placed under tile knee, a position usually resorted to in the early stage of the disease, the pelvis and thigh of a child are continually in motion ; little or no pain is felt by the patient, and injunctions to preserve rest are made in vain. In the bent position, therefore, rest one of the most important elements in treat- ing a diseased joint, is not maintained, and the disease therefore fails often to be arrested. By a long splint applied along the outer side of the limb and made to extend from the toe to the axilla, entire rest is given to the joint, and absolute inaction of the muscles pre- served. I believe from what I have seen of this stage of the affec- tion, that the arrest of the disease is greatly expedited by the entire tranquillity which is obtained by the straight position in conjunction with the mercurial treatment. The principal advantage of preserving the limb in a straight po- sition is seen in the second stage of the disease, when under the united effects of inflammation and ulceration of the cartilage of the joint, the tendency of the flexor muscles to contract induces such a degree of deformity in the lumbar vertebrae, pelvis and hip-joint, as when once allowed to take place, can never afterwards be wholly remedied. The position on the back is not irksome to the patient, nor painful, but is borne with cheerfulness and without complaint, because, in the movements which the body undergoes, the diseased joint is kept at rest. The course which abscess follows when suppuration takes place in the joint, seems to be in some degree modified by the straight position. When the limb is allowed to bend upon the pelvis, mat- ter is usually formed at the back part of the joint under the glutei muscles, or at the side of the joint on the anterior margin of the M. Seutin of this precious conquest, (!) so fruitful of successful re- sults, (!) and which may be considered as a plume which does honor to Belgic surgery ! It is proper to state that the Peruvian plant maiico, of the virtues of which as a hemostatic remedy we have given an interesting ac- count from Dr. Ruschenberger of the U. S. Navy, (see this Volume under Dr. Mott's chapter on Aneurisms,) who first introduced its employment in this country, has also been used by many practi- tioners of Great Britain in the form of decoction internally, and the under side of the leaf externally, viz., by Dr. Munro of Dundee, Dr. Jeffreys of Liverpool, (for vaginal hemorrhage,) Dr. Lane of Lancaster, &c, (see Braithwaile's Retrospect, Vol. VIII., 1843, p. 48, &c.) Ligatures on Important Arterial Trunks.—Dr. Mott has on 1XX1V NEW ELEMENTS OF OPERATIVE SURGERY. several occasions established it as a principle in all his operations on osteo-sarcoma of the jaws, and tumors, &c, of the neck, to be prepared to place a ligature on the carotid trunk or its divisions, whenever required, either as a preliminary step, or contingently during the course of the operation. As examples in anticipation of two cases of his which we shall give under their appropriate head of tumors, we may mention that of his ligature on the exter- nal carotid in extirpating the parotid glayid, July 13th, 1831, (see Amer. Journ. of the Med. Sciences, Philadelphia, 1832, Vol. X., p. 17—20,) and. his ligature on both the external and primitive carotid, during his extirpation of an enormous tuberculated sarcoma from the neck, in February, 1832, (see Amer. Journ. of the Medical Sciences, Philadelphia, 1833, Vol. XII., p.'121-122.) * In this last case, it may be well to remark, in relation to the effect of the growth of vast tumors upon the superincumbent muscles, that the sterno-mastoid (as in the case of Dr. Mott, of which I have given a short description in the notes at the end of this volume) was here also found expanded in its whole course over the tumor, and so attenuated as to be reduced to the laminar character of the platysma myoides, (lb.) Another triumphant case for conservative surgery, and for the cure of aneurisms by comnression, as now established by the Sur- geons of Dublin, is recorded in the London Medical Times, (Feb. 1, 1845,) wherein a soldier of the Coldstream Guards, aged 27, with popliteal aneurism filling up the whole of that space, was radically cured in the space of one day, it may be said, by the employment of an Italian tourniquet, the patient himself during the space of twenty-four hours, changing the pad to a position higher up on the femoral artery, so that, incredible as it may seem, the tumor in the short space of time mentioned, (i. e., in twenty-four hours, or from July 8th to July 9th, 1844,) was found perfectly solid, and no pul- sation or hollow sound afterwards perceived. The compression was continued for nine days longer, and when the instrument was removed, the femoral artery was distinctly felt to pulsate down to its entrance into the tendinous canal, and two arteries of the size of crow-quills could be traced over the surface of the now hard and solid tumor. From that date the swelling gradually diminished, and the patient began to walk Aug. 9th, and returned to duty Dec. 12th, which he had efficiently performed up to the time of the record of the case, Feb. 1, 1845. I add here, with regret, that this important plan of the cure of aneurisms has not been received at our public institutions with the ingenuousness which ought to distinguish a profession like that of ours. Some imperfect attempts have been made without due atten- tion to the proper mode of employing two or more clamps, (like those of carpenters,) as enjoined by Dr. Bellingham, (see our note under Arteries,) by which carelessness the process so important in behalf of humanity, has been prematurely condemned, and the favorite severe surgical operations on the femoral, or amputation, resorted to. The process of the Dublin surgeons has found a warm SUPPLEMENTAL APPENDIX. lxxv advocate in M. Giraldes, of France, (Journal de Chirurgie, Mars, 1845.) A remarkable case of dissecting^aneurism is related by Dr. Mc Donnel, (Dublin Journal, January, 1S45,) in a woman aged 50, who, dying very suddenly, presented the following appearances :■— The semilunar valves were perforated in different places, and especi- ally near their free borders by round and oval apertures. The aorta was sound at the place of insertion of the valves, but about one inch above this point was a transverse laceration as smooth as if divided by a bistoury, through the internal and middle coats with- out implicating the external. It was If of an inch in length, and a sound could be passed through this opening freely between the external and middle coat as far as to a point corresponding with the upper border of the semilunar valves, but not behind the sinus of Morgagni. A pale fibrinous clot was found over this laceration. The dissection of the coats was traced to the bifurcation of the in- nominata on the right, and as high on the left as half an inch upon the origins of the carotid and subclavian, without, however, any intermediary clot. There was a solid, large, dark homogeneous coagulum at the apex of the pericardium near the origin of the large trunks. This clot was covered by a transparent membrane. The aperture in the external coat through which the blood escaped, was an inch in length, and situated at the point where the aorta and pulmonary artery approximate. The lungs and liver were engorged. The peculiarity of this case consists in this, that, the blood, after dissecting the tunics, instead of effusing itself into neighboring cavities, insinuated itself into the cellular tissue which unites the external tunic to the detached serous coat of the pericardium be- tween the aorta and pulmonary artery, forming there a solid clot. The aorta, except at the place of laceration, was greatly degener- ated, being filled with osseous plates and etheromatous deposites. We regret to find that notwithstanding the broad, palpable and perfectly satisfactory evidence now before the professional world, in proof of the unfailing success and radical cure of popliteal aneu- rism, in every case, (now fourteen or fifteen,) in which the per- fected Dublin mode of compression upon the femoral trunk, by means of simple clamps resembling those of carpenters, and which can be regulated with ease by the patient himself, (see notes under Arteries in this volume, on the results of this mode of the surgeons of Dub- lin, &c.,) has been tried, still surgeons persist both in London and in this country, in adhering to the ancient favorite anti-conserva- tive practice of a ligature on the femoral. Thus Mr. Hancock, of Charing-Cross Hospital, (London Lancet,Part XIX., October, 1845, p. 377,) so late as Sept. 6th, performed this operation on the femo- ral for a popliteal aneurism, in a case where, from the apparent good constitution of the patient, and the ascertained non-existence of any aneurismal diathesis in his system, there is every reason to believe a radical cure could have been effected by compression as above mentioned. The patient, as usual in tying the femoral in such cases, had a narrow escape from sloughing of the wound, and lxxvi NEW ELEMENTS OF OPERATIVE SURGERY. the pulsations in the tumor persisted, notwithstanding the opera- tion, for a considerable length of time, i. e., for ten days or more after it had been performed. One of our most skilful surgeons in the navy, Dr. Foltz, while with the American squadron in the Mediterranean, and in charge of our naval hospital established at Port Mahon, Minorca, in 1839, '40 and'41, made many interesting observations, which he pub- lished in the New-York Journal of Medicine, 1843. His remarks on Aneurisms, including n&vi materni, are worthy of record:— Aneurism.—This is a very common disease; and as its nature and treatment are here but little understood, it generally proves fatal. As we attribute this affection to a diseased nutrition, we may be prepared to meet many cases of it at Mahon. Those of the large arteries, near the heart, are most frequent, and seldom are they confined to a single tumor; they are rapid in their progress, and speedily prove fatal. We made a post-mortem examination, in which five large aneurismal tumors were found upon the aorta and the subclavian arteries ; and in this case, the only treatment that had been pursued was Morrison's pills, and at intervals large doses of quinine. Our introduction to our medical confreres of Mahon, and into practice among the natives, was owing to a case of aneurism. Very soon after our arrival, we were invited by Dr. Regal to be present at an operation for securing the femoral artery in a case of pop- liteal aneurism; and as this operation had not been attempted here for years, most of the faculty had assembled on the occasion. Our first impressions, we must acknowledge, left but little desire to cul- tivate a further acquaintance. There are, however, among them several gentlemen of liberal education, and well qualified to take a higher stand than they are destined to hold in this community. The patient, a Spanish sailor, set. 30, had a large aneurismal tu- mor in the left popliteal region, with strong pulsations in every part of it; the size of the tumor was so great, that the limb from the knee down was osdematous,and pulsations could not be perceived in the arteries below the tumor; the individual was much emaciated, and in an unfavorable condition to undergo the operation. In di- viding the superficial layers, much time was unnecessarily consum- ed, and unfortunately, the vein was opened, which produced a pro- fuse hemorrhage. After much delay, sponging, and tearing, the surgeon was unable to secure the artery. At this stage of the pro- ceedings, our assistance was requested ; and from the unfavorable condition of the case, we recommended immediate amputation. This, however, would not for a moment be listened to, either by the medical attendants or the patient. We, therefore, proceeded to make a fresh incision two inches higher, and passed a ligature around the artery, which, as soon as secured, arrested the hemor- rhage and pulsations in the tumor. The patient was now placed in bed, directed to be kept quiet, and one drachm of infusion of digitalis ordered every four hours. Notwithstanding the unfavor- able prognosis, the case continued to do well until the twelfth day, SUPPLEMENTAL APPENDIX. lxxvii when violent pain set in, which terminated in mortification of the foot. Tne ligature came away on the eighteenth day after the operation, and soon after, the line of demarcation distinctly formed in the middle of the leg; and, after months of suffering, the mor- tified parts were completely detached, leaving a very clever stump. The unpleasant duty here devolves upon us to record the death of one of the most affluent and useful citizens of Mahon, in con- sequence of the officious interference of an ignorant, surgeon, in a case of popliteal aneurism. M. Vidal, aged fifty, had enjoyed un- interrupted health for many years, devoting his time to the manage- ment of his estates and the enjoyment of domestic comforts. Dis- covering a small tumor under the knee, which gave him no uneasi- ness, as it was unaccompanied by pain, he, nevertheless, as it con- tinued to increase, sent for his medical attendant, who pronounced it an imposthume, declaring that he distinctly felt the fluctuation within. Promising to call again and open it, which he assured his too credulous patient would at once relieve him, he accordingly did so in the evening ; and boldly plunging a lancet into the sup- posed imposthume, he opened the cavity of an aneurismal sac which was, of course, immediately followed by a copious hemorrhage. By means of compress and bandage, he succeeded in arresting the bleeding for a time; and now leaving the patient in bed, he as- sured him that all was just as he had anticipated. The exhausted patient soon fell into a profound sleep, the hemorrhage recurred, and during the night he awoke and found himself weltering in his blood. Scarcely able to articulate, time was only allowed to ad- minister the last rites of the Roman church, when the unfortunate patient expired. In several cases of aneurism, in which we were consulted, we had the gratification, by a rigid perseverance in the antiphlogistic regimen, venesection, perfect rest, and digitalis, as recommended by Valsalva, of seeing the most happy results follow. In the case of a watchmaker, the individual was enabled, after some time, to resume his usual avocations, and contribute to the support of his family. Aneurism by Anastomosis.—A few cases of congenital aneurism came under our care; but they are not more frequent here than elsewhere. In their removal we rarely had recourse to the knife, as we found the natives invariably recovered slowly from opera- tions ; and, as regards union by the first intention, we do not re- member having ever witnessed it, however small the lesion may have been. When these cases of naevi materni occurred in chil- dren, little difficulty was experienced in destroying them by repeated applications of the caustic potassa. We always took especial care to insert it well within the enlarged blood-vessels, and then waited until the parts had completely cicatrized before a second applica- tion was made. The time required for treatment by this method may be urged as an objection; but with the conscientious sur- geon, such an objection, when he comes to calculate the advantages of this mode of treatment, will have but little weight; and he will lxXVifi NEW ELEMENTS OF OPERATIVE SURGERY. perhaps be quite agreeably surprised, as we were, on seeing the very small cicatrix left after the use of the caustic; and this, in cases in which the affection is seated in the face, is a matter of no small importance. In another instance, a large aneurismal tumor, extending from the ear to the angle of the inferior maxillary bone, was much re- duced in size by means of pressure with a piece of wood, carved to adapt itself over the surface, to which it was bound. Thus was a hazardous and painful operation avoided ; and, in addition to the important blood-vessels involved, the individual was subject to an erysipelatous affection of the head which interposed new obstacles to an operation. [We would barely note in reference to the above, that we cannot well understand how the depleting, reducing, not to say, exhaust- ing method of Valsalva, could succeed in the cure, where the author in the beginning (above) acknowledges that aneurismal disease at Minorca is, in his opinion, imputable to diseased (i. e., defective or impoverished) nutrition. T.] The fatal blunder of an aneurism for an abscess, and the division of the femoral vein in the attempt to place a ligature on the femoral artery, furnish corroborative evidence of the low state of surgical science in the Spanish kingdom. The author still insists on the treatment of Valsalva and digi- talis, (now justly, as we think, proscribed,) as will be seen by the following case of one of our fleet, also occurring at Minorca. Case of Aneurism.—The case of aneurism was in the person of an aged quarter-gunner, who, from his long and useful services, had strong claims upon our careful attentions, but who proved a most ungovernable and unmanageable patient. He was fifty-five years of age, and for twelve months previous to his admission, had suffered much from violent palpitations of the heart, and recently, a tumor had made its appearance beneath the left clavicle, which pulsated strongly. In the umbilical region, there was also a very perceptible enlargement, which not only pulsated strongly when pressed upon in a line with the artery, but communicated the same throbbing sensation when elevated from the spine by lateral pres- sure, which, as the patient was much emaciated, could be easily effected; and it was from this abdominal tumor that he suffered most inconvenience. His only complaint was from the " thumping amidship," as he expressed it. Having witnessed the most happy results from the strict enforcement of the treatment of Valsalva among the native Minorcans, we were desirous of pursuing the same course in this case ; and for many days, and even weeks, when closely watched, he confined himself to his bed, taking no other food than the most mild and unirritating diet, while Wither- ing's infusion of digitalis was administered to the fullest extent that his system would allow. Under this course he was much improved, which promised at least to prolong his life, and pass it compara- tively without pain ; but, in the midst of this nursing, he would at midnight leave his bed, scale the walls, and without his clothing SUPPLEMENTAL APPENDIX. lxxix rush to the first grog-shop. Here he would drink, quarrel and fight, as long as he was able to stand; and when overcome by his exertions, he would be brought back to the hospital, to undergo another course of arrow-root and digitalis. When intoxicated, his exertions were powerful, and it was frequently necessary to resort to the use of the straight-jacket, during his furor; and at these times, the action of the heart and throbbing in the aneurismal tumors were so violent, as to occasion great apprehension of an immediate rupture. In this situation, it was necessary to bleed him freely; and such was the condition of his fluids, that the blood contained but little coloring matter, and from the scarification, after the use of cups, serum would continue to flow until arrested by a compress. This course continued for many months, until his final return to the United States. We were equally astonished at the greath strength manifested by him when under the influence of liquor, and that the case did not prove fatal during some one of his excesses. After each debauch, when perhaps scarcely able to raise his head, he would say that he felt much better; and if we would only give him a little more rum, he would be sure to get well. Had our patient joined the " tee-totallers," it would have been of more service to him than ail our medicine and advice. In our notes in the text of this volume, we have under the cure of aneurism by compression, (see Arteries,) indulged the hope that electro-puncture, which was first suggested by M. PraVaz, (see Dic- tionnaire des Sciences, Paris, 1835, t. XI.,) might, notwithstanding some contradictory testimony that might be adduced, one day achieve a real triumph for conservative surgery, by effecting a radical cure of aneurismal tumor by means of consolidating the contained blood. It is gratifying, therefore, that this immediate consolidation and cure were for the first time most satisfactorily accomplished on living man, September 10th, 1845, and that, in the space of a few minutes, before numerous practitioners and students, at the Hotel Dieu of Lyon, by the distinguished surgeon, M. Petrequin, (see his communication to the Academy of Sciences, of Paris, at their sitting, October 27th, 1845, in Gaz. Med. de Paris, No. 44, t. XIII., 1845, November 1st, p. 704-705.) The patient, Dasniard, a black- smith of Lyon, aged 19, was brought into the hospital, August 4th, 1845, insensible from contusion on the left eye, and fracture of the lower jaw, caused by a fall from the second story. He was seized with small-pox towards the end of the treatment, and went regularly through that disease. On Sept. 9th, M. Petrequin no- ticed a small pulsating aneurism on the left temporal artery, of the size of an almond, evidently the result of traumatic lesion or con- tusion of the artery. Its pulsations were visible to the eye, iso- chronous with those of the wrist, and the artery could be distinctly traced up to the tumor. Strong pressure below the tumor upon the artery suspended the pulsations in it, and reappearad as the pressure was removed. On the 10th September, M. Petrequin publicly applied the electro- 1XXX NEW ELEMENTS OF OPERATIVE SURGERY. galvano-puncture to the tumor, by introducing two fine sharp nee- dles into it, to the depth of about two centimeters, giving them a direction at right angles to each other. He then made their heads communicate with the poles of a pile. At the first contact, there was an electric shock and acute pain, which symptoms went on increasing in proportion as he augmented the dose of galvanism. At the fifteenth these symptoms were extremely intense, and the surgeon then ceased. The duration of the operation of the trans- mission of the fluid was not, however, ten to twelve minutes, dur- ing which he changed the direction of the galvanic currents three times. While operating, the surgeon himself perceived that the pulsations were diminishing, as was confirmed also by Drs. Girin and Rambaud, who assisted at the experiment. What was the delight of M. Petrequin, when he found they had entirely ceased at the end of the sitting. " The aneurism with isochronous pulsations, says the surgeon, was replaced by a solid and indurated tumor. The problem was solved. I removed the pins, and the dressing consisted of compresses wet with fresh water, and sustained by some turns of bandage." The patient returned to his bed himself; two hours after suffered no more, and in the afternoon ate his usual meal. M. Baumers (interne) has drawn up a minute description of the case. On Sept. 12th, the tumor was found to have disappeared ; not the slightest pulsation existed; the temporal artery, immediately above it, [the word is en-dessous—a mistake, undoubtedly, for en- dessus. T.] was obliterated, as no pulsations were observable, whereas they were very evident in the course of the vessel below. On the 20th of Sept., the nodule (noyau) which had succeeded to the tumor was nearly absorbed, no longer rose above the skin, and was destitute of all pulsation or pain. M. Bouchacourt also confirmed these facts. Eight days after, the cure remained com- plete. The surgeon insists on this experiment on man being more conclusive than those from vivisection. In two other experiments on aneurisms, one on the ophthalmic, the other on the brachial artery, the results however were incom- plete. M. Petrequin will give new details, and the rules and method he deems the best, in his proposed new work Melanges de Chirurgie. As it is, it is a wonderful triumph for electro-puncture. The more and more as observations are gathered upon the important, subject of thoracic and sub-sternal aneurisms, the more do we find the rage which has existed for some years for ausculta- tions of the heart, and the aorta and its trunks, receding and retro- grading before the truths which this very ardor of investigation has disclosed. The more arguments also do we thus obtain for falling back for the honest truth in these matters upon such great practical observers and surgeons as Dr. Mott himself, whose illus- tration of the fallacy of the fashionable (not always unprofitable) modes of diagnosis, as seen in his valuable chapter on the subject of Aneurisms, &c, in this volume, is another striking proof of the necessity of relying for the evidences of commencing aneurisms in SUPPLEMENTAL APPENDIX. lxxxi the great trunks in the thorax, (and which is the only period when medical aid can avail) upon such broad, clear, and "common-sense manifestations as are to be derived from a thorough knowledge of the general laws which govern the animal economy in health and disease. One of the latest writers on this subject, Dr. A. Pereira, (in a Memoir on Aneurisms at the arch of the aorta, and on the diag- nosis of commencing aortic dilatations, (in the Archiv. Gen. de Med. Paris, Juillet, 1845, 4e serie, tome VIII., p. 305—326,) confesses himself compelled to come to the following conclusions: "At the present day, numerous observations are found in the annals of science, and most of those which have been collected for thirty years past, are as remarkable for the precision of the diagnosis as for the rigorous (minutieuse) exactitude of the anatomical re- searches. We may, however, ask ourselves the question, in com- paring the epoch of Morgagni to our own, on the real value of the progress of science, whether we have not lost on one side what we have gained on the other ? Are we not, since the exact methods laid down for auscultation and percussion, somewhat neglectful of an enumeration of the occasional causes and general symptoms so well grouped by this great observer ? If it be true to assert that from those powerful resources, the diagnosis of internal aneu- rismal tumors,) is no longer left to the uncertainties of an obscure pathology, it is equally so to add, that we too often lose sight of the physiological changes produced upon the organization by the mysterious action of the dilatations of the heart in its commencing process, and which is then inaccessible to the physical aids of diag- nosis. When the evil has augmented in the dark, and the aortic dilatation acquired a considerable volume, and the walls of the artery become attenuated, and the neighboring organs profoundly altered by a continued pressure, the man of art sees himself reduced by a very exact but tardy diagnosis, to pronounce that the cure is hopeless. I am of opinion, therefore, that modern discov- eries, in other respects so precious and so glorious for our epoch, have made us forget, in some degree, the lessons of our predeces- sors. Yet what useful instruction might we not yet obtain from the writings of Valsalva and Albertini, who knew how to recog- nize AN ANEURISM OF THE AORTA WHEN IT HAD YET MADE BUT little progress, (Morgagni, De Sed. et Caus. Morb., Epist. 17,) and who had even laid down the treatment proper to be pursued for it." (Loc. cit., p. 305-6.) Continuing his reflections, and furnishing in illustration two cases of aneurism of the arch of the aorta at the Hotel Dieu, Dr. Pereira shows that in both (as the symptoms and autopsies proved) the great and important sign, palpable to the eye, of the arched form (la voussure) of the walls of the chest, the matite (obtained by percussion) and the various bruits, (bruit de souffle, de frottcment, baltement simple, etc.,) though all clearly demon- strated, were precisely such as the present received and much bruited modes of auscultation, percussion, &c, exhibit no evidences F lxXXii NEW ELEMENTS OF OPERATIVE SURGERY. of whatever in the commencing or formative stage of the disease, the only time when medication can be relied upon with a hope of cure. " Such (says Dr. Pereira, in conclusion,) are the different physical signs having their currency in science at the present day, and the simple enumeration seems to me to triumphantly demonstrate their insufficiency." While on the other hand he points out with much force the care- lessness with which a most important, constant and idiopathic symptom, (as such men as Morgagni, Mott, &c, have thought or think it to be. T.) viz., that of syncopes, faintings, and swoonings, (too trivial, nervous and palpable apparently, alongside of the stethoscope,) has been entirely overlooked. Thus how often does sudden death occur after their frequent repetition, and yet enor- mous aneurisms have been found, and without rupture or ex- travasation. Dr. Pereira very ingeniously supposes that these symptoms might possibly sometimes be re-produced by the fibrinous clots which had formed on the walls of the aneurism (and the production of which clots the retarded course of the blood in these syncopes mani- festly favours) becoming detached and drawn into the general cur- rent, and suddenly interrupting the course of the blood to the brain, by momentarily plugging up (tamponing, as it were,) the embou- chure of the brachio-cephalic trunk, or that of the left carotid. [As an illustration corroborative of the intimate and idiopathic connection of the symptom of syncope with arterial aneurismatic lesion, we may instance a case that fell under our observation, in which an aneurism of great extent, apparently connected with the renal artery on one side, and which had been of some duration, first indicated its existence by a sudden syncope succeeding, as it would seem, to rupture of the sac from violent muscular exertion. Fainting fus continued for several days, with extreme restlessness, and walking the room, and alternately lying on the bed, till death suddenly succeeded one of these turns of exhaustion. The patient was about 30 years of age, of small make, short stature, sanguin- eous, energetic temperament, and remarkable muscular strength. On examining the body, about one quart of coagulated blood, of the exact appearance of fine currant jelly, was found between the intestines and the peritoneal lining of the anterior wall of the cavity of the abdomen, and about half a gallon of black liquid blood in the neighborhood of the spine and arterial lesion. T.l On the subject of cethercmatous and stcatomatous morbid degene- rescence in arteries, Mr. Gulliver (Medico-Chirurg. Transactions, oi London, 2d series, Vol. VIII., p. 90) has, from much investigation, come to the following conclusions :— 1. The white or yellowish red plates, on the internal coat of arte- ries, are of a fatty nature. 2. The soft matters between the internal and middle tunic, and which are usually considered atheromatous, are also of fatty forma- tion. SUPPLEMENTAL APPENDIX. lxxxiii 3. Fatty matter is often found also in the substance of those coats, even when they are ossified. 4. The fatty matter is generally constituted of cholesterine and oleine, and sometimes also of margarine. Mr. Gulliver has also found fatty accumulations in the testicles, in gangrenous and inflamed lungs in aged persons, in the liver in phthisical subjects, and in children in various diseases. On concluding his interesting experiments on living animals and dead subjects, in illustration of the nature of traumatic lesions of ar- teries, (even those of the carotid, &c.,) and their spontaneous cure by a plugging clot, (caillot obturateur,) M. Amussat, (Arch. Gen. de Med., Paris, Juillet, 1845, p. 372, 373, 374,) has arrived at the fol- lowing deductions, in addition to those we have given in our notes in the text, under arteries :— 1. That this clot, even in large transverse wounds, forms very rapidly, and under the eyes. 2. That it is composed of the fibrine of the blood, and supported by the external cellular (or fourth) coat of the artery, and not by the sheath,a.s some suppose. 3. The central cavity of the clots resembles that of sanguineous tumors, as described by the author, and serves as a diagnostic cha- racter to discover an artery masked by a clot. 4. That the clot, (contrary to the views of Jones, Beclard, &c.,) is formed by the artery itself, is proved by its being found on the end of the vessel, where it comes out beyond the level of the wound. 5. The clot is the more voluminous and resisting in proportion as the artery and its cellular coat were more tense at the time of the section. Hence, says M. Amussat, the practical deduction from this fact, that before dividing arteries, we should make a strong trac- tion upon them, in order to give them the best chance of forming solid clots like those seen in wounds from avulsions, [of limbs, &c, (arrachment).] 6. When both carotids are divided at the same time in a living animal, without wounding the spinal marrow, clots always form on the cardiac extremities of those vessels, and these are always in di- rect relation with the greater or less degree of tension of the neck and vessel at the moment of the section. On the contrary, if the section is made one or two minutes only after the destruction of life by the section of the spinal marrow, strangulation, asphyxia, &c, there is no clot produced at the cardiac extremities of the caro- tid, or if it is formed, it is very small and resembles in no respect those which are found in animals, who die directly from hemor- rhage. [This fact, as suggested by M. Amussat, might if fully verified, become one of great importance in a legal point of view. Thus in murder, committed where the crime is attempted to be con- cealed by the murderer cutting the throat of the deceased after- wards, so as to make it appear that the victim had committed sui- cide. The more so as the murderer in such cases usually over- reaches himself by severing the tissues of the neck down to the spine, far more effectually than the person himself usually does, so lxXXiv NEW ELEMENTS OF OPERATIVE SURGERY. that a thorough division of the carotids, as well as vertebrals, per- haps would be thereby effected. T.] 7. The cardiac extremities of the divided arteries are then the point the most important to be observed, since in examining them with attention, we may with more certainty than by an inspection of the soft parts recognise whether the vessels have been divided during life or after death. The last information posted up on the subject of surgical ope- rations for varicocele, we find given apparently with much impar- tiality by Dr. J. Helot, (Arch. Gen. de Med., Paris, Juillet, 1845, 4e serie, tome VIII., p. 2S7-304. See also a notice in the text of this volume of another interesting memoir on this subject in the same journal, 1S44, &c, by this author,) who, after all his researches, appears like most other surgeons to have come to the conclusion to reject all the varied modes and processes devised, by constriction of the veins, whether sub-cutaneous or otherwise, excision of the scro- tum, &c, as too dangerous, and too often followed by a return of the disease, which upon the whole, it is conceded, had better, since varicocele is but seldom a formidable affair, be consigned to a pro- perly constructed suspensory bandage, [See one devised by me, and used with great effect at the Seamen's Retreat, New-York, described with a Plate in our Vol. I. T.] It is certain, M. Helot says, that both M. Ricord and M. Velpeau have had occasion both to lay aside their former processes, and substitute others, or make use of none but the suspensory. The latest method in vogue at Paris, or that of enroulement, or rolling up the veins on a sort of miniature capstan or windlass, as modified by M. Vidal, is deemed by M. Helot to be equally unsatisfactory and fruitless with the others. Nevertheless, M. Vidal, in the short space of time since he adopted it, has already operated upon eighty cases. But it will require years perhaps to determine in how many of these the dis- ease shall have been radically cured, and without a return. Among the new medicinal resources proposed for the cure of neuralgia, and which conservative surgery would now substitute for the surgical operation of dividing or exsecting the affected nerve, (a means generally abandoned at present,) we perceive a watery solution of the extract of tobacco, which Mr. Gower (London Lancet, 1845) has used with great efficacy in several cases, one sin- gle application of it assuaging the lancinating pains immediately. A modification of amputation at the knee-joint immediately above the condyles, so warmly insisted upon by Mr. Syme, (See our notes under amputation in this Vol..) has been proposed and found to an- swer excellently well by Mr. Fergusson, at King's College Hospital, London. In a case aged 24, where the left knee-joint had been for a length of time enlarged, with abscess and more or less pain on moving the joint, Mr. Fergusson made a transverse incision in front above the apex of the patella, then plunged his knife transversely in front of the ham-strings, cutting out a long thick flap from the calf, which, after dividing the femur close above the condyles and patella, was brought up into neat coaptation in front, healing nearly SUPPLEMENTAL APPENDIX. lxxxv all by first intention, and forming a capital stump. The surgeon of London was led to this modification after having made up his mind to give Mr. Syme's favorite place for amputating the femur below, a fair trial. It certainly strikes us as one that will prove useful in such cases. Difficulties were found, however, in securing the popliteal artery from the morbid alteration and condensed hard character of the tissues around it. Mr. Fergusson considers Mr. Syme's arguments, (which we have stated in the text,) in favor of this am- putation as evidently well founded, to wit, the less danger of in- flammation and necrosis in the spongy condyles, than in the solid shaft, and also avoidance of the danger of dividing through the joint itself. It is become an axiom also, as Mr. Fergusson says, to exsect no more than necessary, as is seen (See our notes) in scooping and trephining out the carious part only of joints, small bones, shafts of long bones, i.e., what is degenerated, and no other portions in other words, pro hac vice, and no more, (See London Lancet, July, 1845, p. 79.) Flap Operation in Amputations.—Mr. Fergusson (Pract. Surg.) invariably recommends the flap operation of Lo wdhain, (claimed as one of British origin.) So also do Messrs. Liston, Lizars, and others educated in the Edinburgh School. Sir George Ballingall, equally favorable to it, does not concede all the advantages claimed for it, nor coincide in the censures cast upon the circular incisions. In the Edinburgh hospital alone, over 400 amputations by the flap method were performed he thinks, in the space of twelve years. Rapidity of execution, and a far better and more fleshy and less cutaneous cushion to the stump, are two of the great advantages of the flap method. But the latter result may be obtained in the cir- cular, by giving a slope to the incisions from the divided edges of the bone to the surface. In thick muscular parts as at the deltoid and calf, the flap mode is objected to as giving too large a cushion; but whether by the circu- lar or flap, this redundance disappears and the end of the bone is ul- timately left in both cases with a similar covering, i. e., condensed cellular tissue, which forms the best stump. Non-union, suppura- tion, exfoliation, protrusion of bone, tumors on the ends of the nerve, &>c, are as common after the flap, as after the circular operation. Sir George Ballingall, after his extensive experience, confesses that it is difficult to relinquish the flap operation after having once been in the habit of performing it, because it presents facilities so much greater than other processes. Dr. W. Philson, (London Lancet, October 1845, p. 429-430,) shows by a successful case of his of a boy with complicated injury to the humero-tibial articulation, dislocation of the ulna and radius backwards, and the articulating extremity of the humerus, driven forwards through the skin and muscles in front, and denuded and protruded to the extent of an inch and a half, laceration of the cap- sular and lateral ligaments, and the coronoid process of the ulna and external condyle of the humerus fractured, that even here the ves- IXXXVi HEW ELEMENTS OF OPERATIVE SURGERY. sels and nerves being uninjured, there was no necessity of exsect- ing the protruded humerus; the surgeon having effected a perfect cure by replacing the parts, and dressing lightly with straps of ad- hesive plaster loosely attached, using cooling lotions and keeping the arm flexed on a pillow, i.e., by the mild and gentle treatment which is now justly in vogue in these severe injuries and which has recently procured such remarkable restorations in similar cases. (See our notes under Amputations.) Exsection of the Jaws.—Mr. Liston, (Lond. Lancet, Oct. 26, 1844, p. 121-122,) speaks of tumors of the upper jaw which involve all the parts, and are unbroken on the surface, as they are covered by an expansion of the men&brane of the mouth. There are, however seen upon them mammary or botryoidal, i. e., nipple-like processes. They are insensible, and do not bleed, and are quite different from medullary tumors here—but they do not destroy life. Mr. Liston says he takes no credit for removing the jaw, which he states has been performed by Gensoul, Lizars, Syme, and others; but I take credit, says this surgeon, for correcting the diagnosis in these cases, and for having pointed out the manner, in which an opera- tion could be performed, with safety and success. In the cases ope- rated upon (he continues,) by the gentlemen to whom I have refer- red, the disease almost uniformly returned. It was of a malignant character. In such cases, from the great vascularity, there is fear- ful hemorrhage in removing the tumor, especially if you leave a portion of it behind. He mentions a case where both carotids were tied, (one the external,) but such was the bleeding, that the surgeon had to leave the operation unfinished. WThen the tumor is con- fined to the honey cavity only, you may operate, but it is madness otherwise, especially if the tumor fills up the nostril. It will not do to remove the fungous portion of the tumor in the antrum only, for the disease will return and end fatally, as in one of his cases; but you must, he says, take out the whole of the upper jaw containing the tumor, and this at an early period. There is another kind of tumors, which may be exsected in this manner, with scarcely the least hemorrhage. But these also will bleed if cut into ; therefore they might be removed entire. In one case M. Liston from the size of the superficial veins, was induced to remove a portion of the skin, but regretted it. VLisprocess is this, for the upper jaw : to uncover a large tumor, he makes an incision outside of the zygoma from the point of the cheek bone to the corner of the mouth, and another from the angle, (inner ?) of the eye to the middle of the upper lip. If the tumor is of moderate size, you are, he says, to cut from the angle of the eye, and bringing the incision down under the ala of the nose, you divide entirely through the upper lip at the median line of the columna ; then make another shorter incision from the same point, (/. e., inner angle of the eye ?) along under the eye in the course of the fibres of the orbicularis palpebrarum muscle, to the zygoma, by which you dissect up a large flap which is to be turned backwards and outwards, after which you exsect the bones. SUPPLEMENTAL APPENDIX. lxxxvii , So little is the bleeding after you have turned the tumor out, that you scarcely have a vessel to tie. Mr. Liston says he has extirpated the upper jaw to remove fibrous tumors nine or ten times, and without losing a single patient, and he has also performed the operation for a case of erectile tumor, dis- placing the upper and lower jaw. Malignant tumors in the lower jaw, requiring an operation, gene- rally commence in the parts exterior to it and involve it. Cancer- ous tumors here are not to be meddled with. Mr. Liston deprecates the fuss, and hue and cry, which has been made about removing such tumors ; one gentleman he says, pub- lished that he had removed the whole of the lower jaw, which proved an entire mistake. There are tumors of the lower jaw which commence in the bone and speedily throw out a fungus; these are not to be meddled with. For another kind growing within, and separating the plates of the lower jaw, and sometimes composed in part of cysts, containing a glairy fluid, he has removed one half the jaw with disarticula- tion. He has also felt justified in removing some tumors of the lower jaw, which contained nevertheless, some fungous growths. [See above our account of an exsection, at Newark, New-Jersey, by Dr. Mott.] In one of these the disease had not yet returned, though 4 or 5 years had elapsed. In this case nothing but the ra- mus of the left side remained. Other tumors of the lower jaw are of solid bulk, composed of bone and cartilage of only two or three years' growth, or of greater age, and then attained to a monstrous size. These may be removed. It was Mr. Cusack, Mr. Liston thinks, who led the way in operating for such tumors. [We would remark here, that it is this erroneous expression of Mr. Liston, which has induced Dr. Mott to address to that surgeon the letter which will be found in the conclusion of this Vol. T.] The operation for these is, Mr. Liston thinks, fuilas justifiable and successful, as for amputations of the limbs. For these great operations, Mr. Liston recommends precisely the process of the curvilinear incision, brought up at its termination upon the symphysis, &c, precisely as first established by Dr. Mott. (See this Vol., under Exsections—also Baker's case—Preface of Dr. Mott, to Vol. I.) At the symphysis, however, he thinks you need not saw entirely through, but complete the section with the cutting forceps. In laying hold of this end of the exsected bone, you are to take care in some of the cases that you do not break it. The arti- culation is if practicable to be opened in front. This also, is Dr. Mott's process. In some cases Mr. Liston thinks this is impossible. If, for exampU>, you break the fragment from behind, you are then to seize it with a strong forceps, and open the articulation, twisting this portion inwards and forwards, by which you more readily de- tach the temporal muscle from the coronoid process. Mr. Liston after bringing the flap down, applies in a few hours, cold pledgets and unites by the twisted suture. Herein Dr. Mott pursues an- lxXXVih NEW ELEMENTS OF OPERATIVE SURGERY. other course. (See our description of his exsection of Baker's jaw in the conclusion of this Volume. T.] In exsections of the lower jaw, we perceive that M. Blandin of Paris, (Arch. Gin. de Med., Juillet, 1845, p. 368, 369,) has recent- ly performed this operation successfully in a female, after remov- ing the whole left ramus and a portion of the body of the jaw, as far as to a line with the commissure* of the lips on the opposite side. He managed to preserve the principal branches of the facial nerves, and thus avoided paralysis of the muscles of the face. The exsection of both the upper jaw bones is stated (Jour, fiir Chir. und Augenheilkunde, 1843-44, Gaz. Med. de Paris, Mars'l5, 1845, p. 169) to have been performed at Erlangen, by M. Heyfelder. The patient was aged 25, and the tumor, which occupied the vault of the palate, increased so much in a year as to invade the two up- per maxillary bones, crowding the nose upwards, compressing the tongue, and interfering with deglutition and respiration. The incisions were made from the outer angle of each eye to the cor- responding commissure of the mouth, and the teguments of the whole face included in them turned upwards on the forehead. The maxilla on each side was sawed at the zygoma and from the bones of the nose, &c. The vomer being then divided by strong scissors the parts exsected with the tumor were soon extracted. The wound was united by twenty-four sutures. The operation was performed July 23d, and on August 25th the patient quitted the hospital, cured. A recent case is related by Mr. French, (London Med. Gazette, 1845, also London Lancet, September, 1845, p. 352,) in which An- chylosis of the lower jaw had existed from infancy up to the age of 22, when the patient died of apoplexy. He had taken his food through an opening made by the removal of several of the incisor teeth. In this case no attempt appears to have been made to overcome the immobility, and the post mortem disclosed a thin osseous lamel- lated plate or expansion of the left ramus extending upwards and uniting by intermediate cartilaginous substance only, with a cor- responding lamella from the upper jaw. Here was a case in which a cure, as Mr. French hints, could un- doubtedly have been readily effected, if the true locale and charac- ter of the anchylosis could have been accurately diagnosed, as cer- tainly could have been done with equal facility by a careful in- spection. It shows how thorough and searching the manipulating exami- nations should be in such cases, and how intimately conversant every person who undertakes to practise the noble art of surgery should be with the minutest anatomy of relation in disease as in health. A mere division of the cartilaginous union and the screw- lever of Dr. Mott, which we shall give in the next volume, under his celebrated operations for immobility of the jaw, would have been all that could have been required. SUPPLEMENTAL APPENDIX. lxxxix A large central portion of the clavicle which had been necrosed from syphilis and fractured into two portions, the sternal fragment riding over the acromial, was successively exsected and extracted by its two fragments, (the sternal first,) by M. A. Asson, (see Gior- nale del Progressi, August 1S43, Arch. Gen. de Med., Paris, July, 1844, p. 374-5-6.) In cases where exsection of the head of the femur could be sub- stituted for amputation at the hip joint,'Mr. Guthrie and Sir Geo. Ballingall are disposed to give it a decided preference. Mr. E. Bonino {Braithwaite's Retrospect, Vol. X., July to De- cember, 1S44, p. 136, etc.,) relates twelve cases of this kind, five of which were perfectly successful. The cases in which he recom- mends it are:—1. Dislocation with protrusion of the head of the bone through the soft parts, which it is found impossible to reduce. 2. Gun shot wounds involving the upper part of the bone. 3. Caries of the upper part of the femur, whether primary or second- ary. In the last case there is doubt as to its propriety, as it is im- possible almost to say if the cotyloid cavity is involved or not If it should be, the operation would be worse than useless, and some of Mr. Bonino's fatal cases are supposed to have resulted from this implication. (See also Northern Journal of Medicine, August, 1844, p. 278.) In relation to a difficult point, that of the diagnosis of disloca- tion of the head of the Femur into the Ischiatic Notch, Mr. Syme, (Provincial Med. Journal, June 24, 1843, p. 260,) speaking of this form of dislocation of the femur, in which there is less displacement and fixture than in any other of the head of this bone, and in which greater obscurity ensues from a slight degree of extension only, causing the shortening and inversion to disappear, considers the most diagnostic and permanent feature, and one which is not found in any other injury of the hip joint, whether dislocation, fracture or bruise, to consist in an arched form of the lumbar part of the spine which cannot be straightened so long as the thigh is straight, or in a line with the patient's trunk. When the limb is raised or bent upwards upon the pelvis, the back rests flat upon the bed; but as soon as the limb is allowed to descend, the back becomes arched as before. On the subject of diseases of the articulations, which figure so prominently in this volume, we have not had an opportunity in time to avail ourselves of much valuable matter on this head which might have been extracted from a recent work of M. Bonnet of Lyon, (Traite des Maladies des Articulations, Paris, 1S45.) We can barely allude to a few of its more important details and princi- ples. M. Bonnet considers all morbid productions whatever, which are found in the tissues about the joint or in the joint itself,whether false membranes, fungosities, fibrous, lardaceous, cartilaginous or osseous, to have been formed from successive transformations of the original secretion and organization of plastic or fibrinous lymph effused in the depth of the tissues in consequence of inflammation. The same author inclines to the opinion that the cartilages of in- XC NEW ELEMENTS OF OPERATIVE SURGERY. crustations are un-organized and analogous to the cartilages of the teeth and to the hair. In the treatment of anchylosis, he insists with great force upon three points : 1, a proper position—often the reverse almost of the defective one the patient would instinctively prefer; 2, immobility; 3, after a certain time gentle movements upon the joint; 4, the ap- paratus should be one of his gutters of iron wire, as we have de- scribed above, for fractures of the neck of the femur. The author is led from his experiments on the dead subject, in illustration of the manner in which tractions or sprains, or cntorsions of the articulations, act in producing fibrous, muscular and osseous lesions in those parts, to commend in strong terms, as a powerful curative means, the employment of massage (a species of kneading or shampooing) in cases of chronic arthritis. In the decomposition of the pus of abscesses in joints, and which is favored and aggravated by the admission of air and the difficulty of eliminating this contained fluid, M. Bonnet finds another prolific source of what M. Berard denominates putrid infection. He considers, with M. Malgaigne, that Hey's disease of luxation of the semi-lunar cartilages of the knee-joint, is an incomplete luxation of the articulation. The editors of the Archives Generates de Medecine (Juillet, 1S45, p. 383,) however, differ from M. Bonnet in the supposition of the latter that in this luxation the innercondyle of the femur passes behind the fibro-cartilage crowded in front. It is gratifying, in conclusion, to find that the views of M. Bon- net, on many diseases of the articulations (as, white swellings, &c.) which were formerly deemed curable only by amputation, go to confirm those that we have endeavored constantly (in this work) to enforce; to wit, the substitution of a more efficient iuternal and external therapeutic, either by internal constitutional treatment or external medication, or both, in lieu of surgical mutilation of the body, thus sustaining the more humane system now coming into just repute, viz., that of conservative surgery. An Improved Fracture Cot for Sea-service.—Dr. Foltz, surgeon of the U. S. navy, in the memoir to which we have already fa- vorably alluded, gives an account of a new arrangement for the treatment of fractures at sea, which is one of his invention, and which by the description he gives, and the favorable results ob- tained from it, should be generally known. We extract, therefore, with pleasure his account of this contrivance, as given in his memoir in the New York Journal of Medicine, before quoted, (1843.) The other case of comminuted fracture occurred in the person of a seaman who had been on shore on liberty. Having been taken in charge by an officer, who was endeavoring to bring him on board, he threw himself over a precipice nearly forty feet in height, the officer himself narrowly escaping being carried with him. Fortunately he landed on a tiled roof beneath, which, giving way, broke the force of the fall, or he would doubtless have been instantly killed. He was conveyed to the hospital; and here, upon exami- SUPPLEMENTAL APPENDIX. xci nation, it was discovered that the left tibia was fractured near the ankle-joint, and also two of the ribs on the right side as well as the clavicle. The body generally was much bruised; and in addition to these ills, he was laboring under delirium tremens. The frac- tured leg was placed in Desault's apparatus, and tied down to the cot. Venesection I xvj. and tinct. opii et assafcetidae were ordered. During the first twenty-four hours after his admission, he suffered greatly from delirium, and much force was necessary to prevent his moving the fractured bones ; but after that, he became more tranquil, which was followed by a sound sleep ; and thus we were enabled to direct our attention to a more perfect adjustment of the fractures. On the fourth day he was placed upon the fracture-cot, which we invariably use in all cases of fracture of the lower extre- mities, both at sea and in hospital practice ; but it is for the treat- ment of fractures on board ship that we were led first to construct it; and for this it is peculiarly adapted. Bandages and compress were applied to keep the ribs and clavicle in their proper position; and this was readily accomplished, as the patient was necessarily confined to the horizontal position. No apparatus can, indeed, so well adjust the fractured extremities of a broken clavicle as the method here pursued ; and from this time, until the entire recovery of the patient, not a single unfavorable symptom was presented, notwithstanding the existence of four fractured bones, and the ex- tensive injuries in other parts of the body. Dr. Foltz continues, on treatment of fractures at sea :—This constitutes one of the most critical, as well as one of the most frequent duties of the naval sur- geon ; and almost every one who has had the treatment of such cases on board ship, has doubtless had the painful and disagreeable duty devolve upon him, to re-adjust the fracture—an event that no care on his part or that of his patient can prevent. Not unfre- quently, after the greatest vigilance and care, the naval surgeon has the mortification to find that the cure is not so perfect as it should be ; and these opprobria medicorum of the naval surgeon are often brought up in judgment against him, by those who know but little of the countless difficulties encountered in the treatment of fractures at sea, especially in gales of wind, when those with sound limbs are unable to keep their feet, and the knees and tim- bers,of the good ship herself are groaning and tearing asunder, as she sports about on the mighty waves. We have witnessed cases of deformity which had been treated by surgeons, whose eminence and reputation are a sufficient guarantee that everything had been done which judicious and careful attentions could effect toward preventing these unfortunate results. In a case, therefore, of so much difficulty, and one of such frequent occurrence, it is with no ordinary pleasure that we are enabled to recommend to the profes- sion, as well as to all those "who go down upon the sea in ships," a fracture cot, which will effectually guard against all accidents from displacement. This apparatus, as represented in the litho- graph facing the title-page, must, from its many advantages, and especially its simplicity, recommend itself to the profession. We XCU NEW ELEMENTS OF OPERATIVE SURGERY. are gratified in being able to add that such of our naval surgeons as have seen it in use, give it their highest approbation; and more- over, that it has met with the warm approval of several of the most experienced surgeons in the British and French service, by whom, when the apparatus was in use, it was carefully examined. The apparatus consists of an ordinary ship's cot. eight feet long and three feet six inches wide, without sides. On the centre of this cot, the mattress and bedding of the ordinary size are to be made up, excepting the sheets and pillows ; the head of the mattress is to be kept near to the head of the cot; and thus will be left a space of two feet between the lower end of the mattress and the foot of the cot. Over this, a large cot-frame or stretcher, also eight feet by three feet six inches, is to be suspended, by means of a tackle, as is seen in the plate. The canvass covering this frame is to have a hole, three feet and a half from its head, for the use of a bed pan; and on this frame the sheets and pillows are to be placed. Upon this moveable stretcher the patient remains throughout the treatment. As this frame can be elevated or depressed at pleasure, every necessity can be attended to without the least motion on the part of the patient. The cot may be daily removed, aired, or changed, which is so frequently necessary in warm climates; and thus can cleanliness be more perfectly preserved than by any other method; while the fracture is at no time disturbed. When lowered down, the mattress beneath, upon which the patient rests, should always be within the frame of the stretcher ; and this, by the way, is the only point necessary to guard against in the use of the cot; but its whole construction is so simple, that every forecastle-man will be able to make one. Fractures at sea are displaced in consequence of the limb or splint coming in contact with the sides, or end of the cot, during the pitching or rolling of the ship, or in moving the patient while using the bed pan. This fracture cot, however, is without sides," and the end is never touched; a slight pull upon the tackle will elevate the patient without any effort on his part, at the same time that the whole body moves together; and whether he is resting in the cot upon the mattress, or is suspended over it upon the stretcher, he always moves free in space, with the motion of the ship, without any occasion for muscular exertion. Our limits will not permit our going farther into the merits of this invention, but its simplicity and usefulness will always be its best recommendation. Indeed, a fracture cot of this description should at all times be readiness on board our ships of war, and on our excellent and incomparable European packets. In regard to the necessity, recently urged by M. Guepratte, (On Wounds of Bones, Annales de la Chirurg., Paris, Avril 1S45, and Arch. Gen., Juillet, 1S45, p. 354-5,) of more accurately defining and treating wounds of bones, as distinguished from those of soft parts, whether they are by cutting, blunt, or pointed instruments, or chemical agents, &c, or on flat, long or short bones, or merely fractures; he maintains that those from cutting instruments are SUPPLEMENTAL APPENDIX. XC1U more dangerous, more disposed to necrosis, and longer in consoli- dating, than those of fractures, because the osseous fibres and mo- lecules in the former are directly compressed and condensed, but in the latter only bent or deviated from their natural elasticity. The extraordinary case, however, we have noticed below, of a sharp chisel, embedded^/be inches obliquely transverse into, and through the dorsal vertebrae and spinal marrow, and the rapid cicatrization of the wound, without even suppuration, and followed by almost total restoration of the paralyzed limbs, &c, to their normal func- tions, is a strong case in point, in total discrepancy with M. Gue- pratte's doctrines. M. Guerin, of Vannes, (Arch. Gen., Mai, 1845, p. 33, &c.,) has given some new directions for treatment of certain difficult fractures, and especially fractures of the clavicle, which appear to possess a good deal of force. While according his approbation to the great advances made in this part of surgery by Desault, in recommending the dressing to be applied in such way as to give a direction up- wards, backwards, and outwards, to the acromial fragment, justly as we think, points out the error of all surgeons, from Hippocrates to the present day, in attaching too much importance to this frag- ment, and in its traction downwards by the weight of the shoulder, and in overlooking the great mobility of the sternal portion. This he shows has a movement from before backwards and the reverse, and especially a more important one from below upwards by the trac- tion of the clavicular portion of the sterno-cleido-mastoideus muscle, and which is greater in proportion to the extent of the insertion of that portion of that muscle—for example, greater in robust persons and less so when the insertion is nearer to the sternum. Hence, the riding of the fragments in transverse fractures is greatly owing to the mobility of the sternal fragment, apart from those exceptions where there is an oblic/ue fracture of that character which places the acromial above the sternal fragment. All bandages however in use, and that of Desault included, are defective, this, surgeon says, in preventing the ascent of the sternal fragment, while the figure of 8 has the preference from giving more or less fixity to the sound shoulder. Even the starch bandages, he says, do not prevent the movement upwards of the sternal frag- ment. M. Guerin then lays down these rules :— 1. The diseased shoulder should be carried upwards, outwards and backwards, for which purpose we are to use Desault's bandage and the starch bandage associated with it. 2. The thoracic limb of the opposite side is to be fixed to the chest so as to prevent its movement. 3. To prevent the contraction of the sterno-mastoid muscle on the sternal fragment, the face of the patient is to be kept turned towards the fractured side by means of starched bandages embracing the head and diseased shoulder, by which the muscle (sterno-cleido- mastoid) is maintained in a state of relaxation. The inconvenience to the patient is, that he is deprived for a XC1V NEW ELEMENTS OF OPERATIVE SURGERY. month or more of all movements of the upper part of his body. But for the sake of a uniform consolidation, most persons will readily submit to this treatment. The treatment seems judicious with this exception, that the starch bandage should never in any case of fracture whatever be applied until all symptoms of inflammation have passed off, i. e., after the lapse of three or four days—this case of the clavicle being perhaps the only one in which it is sooner admissible. The same surgeon, in continuation of his observations on frac- tures, (Op. cit-, Archiv. Gen., 4e serie, torn. VIII., June, 1845, p. 154, et seq.,) has made some new and interesting pathological re- searches, touching the mooted subject of fractures of the neck of the femur. In these fractures which he found with M. Rodet were most readily produced on the dead subject, (as they are probably on the living,) by a blow (a true contre-coup) on the heel while the leg is being extended on the foot, he proves conclusively, as he thinks, by his colored injections (after tying the femoral generally on a line with Poupart's ligament, and above therefore the giving off of the nourishing artery of the femur) into the aorta just above its terminating bifurcation, and also into the obturator, (which fur- nishes a branch to the reddish adipose tissue at the bottom of the cotyloid cavity,) and into the ilio-lumbar, (which furnishes the prin- cipal nourishing branch to the ilium,) and also finally into the glu- teal artery ; that the head of the femur and its connecting fragment of neck may thus, contrary to received opinion, obtain an ample supply of blood to form a true callus directly from the arteries of the ilium through the bottom of the cotyloid cavity, and the round ligament which connects this cavity with the head. Hence he seems to doubt the opinion of Sir A. Cooper, (deduced by that sur- geon from an examination of 44 subjects, or specimens with frac- tured neck of the femur, in which not one had united,) that these intra-capsular fractures never consolidate. Inclining to the more favorable opinion of Bichat as to the supply of vascular nourish- ment by the reflected duplicative of the capsule upon the head and neck, constituting a substitute for a periosteum, M. Guerin doubts also the explanatory theory of Sir A. Cooper to account for al- leged ununited intra-articular fractures generally, viz., the more abundant secretion of synovia caused by the irritation of such frac- tures, whereby the capsule becoming distended, keeps the edges of the fragments of bone too far apart to be kept in coaptation. Most usually as is well known the union of the fragments of the neck of the femur within the capsule, is made by an intermediate fibrous tissue, which at least so far we ourselves should consider to be proof positive of an active supply of arterial plastic nutriment to those parts. M. Guerin refers to the astonishing results of anaplastic restora- tions by the narrowest pedicular attachments, which have necessa- rily left only a very slight vascular connection; and remarks, also, that were there really the defective vitality in the femoral neck gene- rally supposed, there would have been found one case at least of SUPPLEMENTAL APPENDIX. XCV necrosis in such fractures, the same as gangrene of the soft parts is found where anaplasty fails. But an instance of necrosis in the neck of the femur, it is asserted, has never been found. [Was not, however, that of Dr. Batchelder, cited above, one of this descrip- tion, ending in a necrosis and total separation of the entire neck and head ? T. ] The same surgeon has noticed the curious fact, in support of his experiments, (above,) that, in examining ancient non-consolidated fractures of the neck of the femur, he has always found the round ligament in a remarkably high state of vascularity, and its vessels greatly dilated. It is then the mobility of the fragments and the difficulty of maintaining their coaptation which he deems to be the chief obstacle to osseous union in these intra-capsular fractures of the neck of the femur, and the chief cause of the formation of an intermediary fibrous ligament as the substitute. In the treatment of these fractures, which is after all the most im- portant point, M. Guerin discards the processes of Desault, Boyer, &c., and the inclined planes, &c, of others, and prefers to make exten- sion by cords, (lacs,) one embracing the upper part of the thigh, and to be attached to the head of the bed; the other to fix the foot to the foot of the bed. This is the mode lauded by Heister, and gene- rally employed in the time of Petit, and now revived by M. Jobert, (de Lamballe,) who makes this extension less painful by adjusting the lower cord to a leather shoe. The great point is to prevent the transmission of movements of the pelvis to the fragments of the fracture, and consequently both limbs should be kept in an im- movable state. The customary modes are precisely such as would be adopted to keep up the mobility of the fragments, in order to form an artificial joint. It is to be noted that, by way of contradistinction, the intra-cap- sular fractures of the femur are usually transverse, and the extra- capsular oblique ; hence, the more or less movement of the latter during the cure does not prevent coaptation of the osseous surfaces. M. Guerin, however, deems the apparatus of M. Bonnet, of Lyon, as the most perfect: This consists in a solid gutter, which embraces the two posterior thirds of the fractured limb, and the two posterior thirds of the pelvis and abdomen. It is constructed of solid iron wire posteriorly, and which is thinner on the sides, and so supple as to be separated from, or approximated to, the axis of the gutter at pleasure. The gutter is lined with a thick layer of hair, and over this a solid ticking, (maintenue par un coutil solide.) On the sides of this gutter, above the two trochanters and on a line with the knees, are buckles from which proceed cords, which ex- tend to sheaves and pulleys at the tester of the bed. A large notch is left, on a line with the anus. The patient can raise himself horizontally from his bed at pleasure, by pulling upon the cords. By this apparatus, the body, when moved, is so moved in its to- tality, and. the vertebral column makes no distinct movement on the pelvis, nor the pelvis on the thigh ; consequently the fragments are not displaced. To prevent rotation outwards, (always a seri- XCV1 NEW ELEMENTS OF OPERATIVE SURGERY. ous impediment,) the borders of the gutter are raised on each side of the foot to the height of the extremity of the great toe. The continued extension is made by means of a weight, which passes over a pulley fixed to the apparatus. The lateral movements of the trunk are limited by lateral prolongations, which ascend nearly as high as the arm-pits. M. Guerin regrets that this admirable contrivance is not yet in use in the hospitals of Paris. In fractures of the patella and olecranon, M. Guerin finds the same objections existing in the apparatus employed, as none of them effect the great object in view, that of opposing successfully the strong retracting power of the extensor muscles "upon the up- per fragments, from whence arises a fibrous instead of osseous union for want of contact and immobility of the fragments. To control the action of the triceps in fractures of the olecranon, he proposes three splints of wood, to be adapted to the three portions of the muscle, and the whole to be fixed by the starched bandages or starched pasteboard; our objection to which latter inamovible dressings, until after all inflammation and tumefaction have totally subsided, we have too frequently expressed in this work to recur to again. M. Guerin has had as yet no experience in the appara- tus he proposes for the olecranon. In fractures of the patella, this surgeon commends (without any personal experience in the matter) the apparatus of M. Malgaigne, which consists of a double erigne, which secures the tendon and ligament of the patella, the two portions of which erigne, approxi- mated by means of two plates of steel, are fixed by a pressure- screw (vis de pression.) M. Guerin, however, would be inclined to use splints to the tri- ceps cruris reaching from the upper part of the thigh to the patella, and over these a dextrine bandage as for the olecranon, the limb at the same time to be kept in extension and the fragments kept in contact by the bandage for transverse wounds. [We refer for a more ingenious contrivance to a box with morticed holes to effect the last-mentioned and most important and only essential ob- ject, and which we have noticed in our Vol. I. .T.] As a corroborative evidence of what is now daily becoming more and more established as a physiological axiom, that the upper por- tions of the lobes of the brain may undergo great destruction and diminution by wounds, surgical operations, &c, without causing death, we have to record a remarkable fact related in the Raccogli- tore Medico for April, May and June, 1845, (Italian Journal—see Gaz. Med. of Paris, Sept. 27, 1845, t. XIII., No. 39, p. 613, 614,) in which a foetus, in consequence of its suspension on the upper strait of the pelvis, had to be extracted by Levret's perforating for- ceps, during which, though there was, "it is thought, at least owe quarter part of the entire brain discharged (!) the child was born alive, cried lustily, showed vigorous muscular power, and lived twelve hours ! The accoucheur was M. Reali. [It might, a priori, be conceived that the vital functions gene- SUPPLEMENTAL APPENDIX. XCVii rally, would be less affected by lesions of the encephalon at this period of the first moment of birth, when respiration is the pre- dominating function that commences and constitutes the first link of extra-uterine life. The brain, it is true, is like the liver, largely and disproportionably developed in intra-uterine life, but after birth exercises certainly a less controlling influence over the economy than the respiratory organs and those of the blood and its secre- tions which now for the first time begin to be called into action. T.] Among the received opinions of the last twenty years, now call- ed in doubt by that able pathologist, M. Longet, is the one which considered it as established, that the abstraction of the cerebrospinal, or cephalo-rachidian liquid, was the cause of the tottering gait in the muscles of locomotion which animals exhibited (as if intoxi- cated) on making this experiment. M. Longet has shown (Sitting of the Academy of Sciences of Paris, Arch. Gen., Juillet, 1845, p. 376-77,) that the division of the posterior cervical muscles and supra-spinal ligament, produces the same results; and also that they were not produced by abstracting the liquid from the dorsal portion of the spine by opening down into its cavity, without dividing its muscles and ligaments. The case we have cited in the notes to the text of this volume of a cure of spina-bifida, by freely evacuating this liquid by a large wound, and then by the twisted suture procuring a firm protecting cicatrix from the wound, is certainly in favor of the truth of M. Longet's experiments. Supposed Entire Division of the Spinal Marrow and Perfect Recovery.—A case is related (unprecedented we believe in surgical records) by Dr. E. Hurd, of Middleport, Niagara county, New- York, (New-York Jour, of Med., Sept., 1845, p. 165, &c.,) in which a man falling upon a long sharp chisel in his pocket, caused the instru- ment to penetrate into the spinous processes and bodies of the dorsal vertebra;, where it was embedded solid and fixed to the depth of five inches transversely and obliquely across the spine, so firmly that immense force was required to extract it; which was effected, however, by the surgeon, some few minutes after the accident, by a blacksmith's pincers, the patient being on the instant of the acci- dent more or less insensible in the parts below the wound, and therefore fortunately unconscious, to a great degree, of the violent efforts of traction required to extricate the implanted instrument. The wound healed rapidly, with little or no suppuration, and the patient after some years recovered almost perfectly the use of his lower limbs, so as to walk and mount on horseback without diffi- culty. The clean division made by the chisel through the bone and medulla, though probably not totally through the latter, must account for the extraordinary cure without interruption of the func- tions of the column; a fact which, from what is now familiarly known of the ready union of the ends of nerves in their section in neuralgic tenotomy, continue the pressure for a long time, we should make use of both thumbs or two fingers of each hand, alternately applied in such manner as to relieve each other. III.—Arteries of the Thoracic Extremity. a. In the fingers we may, as Parry has done, easily compress the collateral arteries with the view of moderating the pain of whitlow (panaris) or the acute suffering (acuite) from certain kinds of. inflammation, should any one have the patience to keep the fore- finger and thumb applied over each other for a day or two at a time. We could also effect the same object by maintaining a small graduated compress at the junction of the palmar surface with each border of the diseased finger, and fixing it in this position by a few circular turns of bandage. b. The radial artery could be compressed with great ease either by means of the finger, a pelote, or a mechanical compressor, on the lower fourth of the anterior surface of the radius, at every point in fact where it is sought for as the pulse ; but as it commuuicates extensively with the ulnar artery in the palm of the hand, it would be requisite that the ulnar artery also should be compressed at the same time. We should be enabled to do this by placing the thumb crossways upon the forepart of the ulna, at the distance of an inch above the wrist; while the two first fingers of the same hand should take a point d'appui behind. It is to be understood, however, that when we do not wish to use the fingers, the pelote of the compressor (compresseur) or of the bandage or seal should bear on the same point. In the remaining part of the continuity of the fore-arm, the compression of these arteries would neither be easy nor secure. c. Nor in the bend of the arm can we make compression with suf- ficient effect to rely upon it, which is the less to be regretted, inasmuch as we obtain the same result on the arm itself. d. The brachial (humtrale) artery, if necessary, could be com- pressed any where on the whole length of the arm, by following the track of a line which would reach from the middle of the hol- low of the axilla to the middle of the bend at the elbow. The most convenient point, however, is to be found above the upper insertion of the brachialis intern us, and better yet under the surgi- cal neck of the humerus between the two borders of the axilla. At this point, in fact, confined by the coraco-brachialis muscle in front, and by the teres major or the latissimus dorsi behind, it is not sepa- rated from the bone by any layer (plan) of soft parts, and neither the nerves nor the veins form a complete sheath to it. This point being selected, we may moreover adopt several modes. The thumb passed into the hollow of the axilla, generally suffices, if we take care to select a point d'appui on the outer surface of the arm for the other fingers, and to press directly against the humerus between the tendons above mentioned. We succeed still better, by grasping the upper part of the arm with the two hands, in such TREATMENT OF ARTERIAL LESIONS. 21 •manner that the fingers may all press against the humerus in the hollow of the axilla, while the thumbs serve as a point d'appui on the outer side of the shoulder. In the supposition that the fingers alone might be insufficient, we should place either a roller bandage or any description of pelote possessing the requisite solidity upon the same point, in the hollow of the axilla, after which the pressure should be made upon this solid body, either with the fingers, or by means of a bandage or a garrot. There is no necessity of adding that the different instru- ments that have been contrived for the compression of the arteries, are applicable also to the arm and to the point of the axilla which I have just designated, as well as to the other portions of the limbs. e. The axillary artery. None of the indications above men- tioned can make it advisable to compress the axillary in preference to the brachial artery. If it were deemed desirable to diminish the afflux of blood to the shoulder as well as to the rest of the arm, it would be the subclavian artery to which we must direct our atten- tion. We might also by making the pressure a little higher in the hollow of the axilla, compress the axillary artery against the head of the humerus near the clavicle. But this compression being im- practicable except where there is no tumor in the upper part of the arm, is not applicable to aneurisms. It has been proposed in that case also to make pressure upon the axillary artery through the whole anterior wall of this region, and in this manner to flatten it as it passes upon the second rib. The finger or the thumb pressed with a certain degree of force from without inward, and from before backward, upon the pectoralis major muscle, immediately under the clavicle and upon the interstice which separates the head of the humerus from the thorax, generally enables us by this means to suspend the arterial circulation throughout the whole extent of the limb. If it were required only to obstruct in a slight degree the course of the blood, we could effect this by carrying the arm behind the trunk, in such manner as to draw the shoulder forcibly downwards. Only it is to be remarked that this movement, involving also the compression of the nerves and vein, is apt to occasion shortly after a considerable degree of numbness in the hand. If it were neces- sary to continue the compression a long time, or entirely to suspend the circulation, we should find advantage in making use of the tourniquet of Dahl, or some of the other compressors invented since. The pelote of these instruments being applied upon the point where I have advised the thumb to be placed, enables us by means of the elastic arc which supports it, to select a point d'appui between the shoulders or under the axilla of the opposite side. It is however ^rery seldom that we are obliged to have recourse to this kind of compression. There are only certain amputations of the arm, and «ome unusual operations that would call for its employment. f. The Subclavian Artery. The compression of the subclavian .arteries is precisely that which is now substituted for the compres- 22 NEW ELEMENTS OF OPERATIVE SURGERY. sion^of the axillary artery, in those cases in which the compres- sor of Dahl was formerly employed. It is upon the first rib, be- tween the two scaleni muscles, that this artery may be most easily flattened. Resting as it here does, naked upon the bone, with no intervening muscle between it and the skin, and bridled as it were by the fibro-muscular attachment of the two scaleni, it admits of the application of all the different kinds of compression. The most simple, and at the same time the most effectual process consists in pressing with the thumb or two first fingers of the hand in the su- pra-clavicular depression. Pressing thus from above downwards, and from without inwards, we soon perceive either the pulsations of the artery, or the tubercle of the first rib which borders its track below. Nothing more is then required than to press with a little more force inwardly and backwards, in order to be sure of acting directly upon it. In this manner the vein remains intact in front while all the nervous branches of the brachial plexus are given off above. As the thumb and fingers, however, would soon be- come fatigued, it is advisable when we wish to continue the pres- sure upon the subclavian beyond the period of some minutes, to effect this object by means of a seal furnished with a pelote, or with some compressor similar to the tourniquet of Dahl, which we should take care to apply with accuracy upon the region which I have designated. IV.—The Artery of the Lower Limb. The lower aortic system may also be compressed upon many points of its course. a. The Dorsalis Pedis Artery, (artere pedieuse.) In the toes the collateral arteries are so small and short that it would be diffi- cult and is scarcely ever necessary to undertake their compression. The plantar arteries, being deeply concealed in the soft parts, are also placed beyond the reach of the modes of compression which I have now under consideration. The dorsalis pedis artery, there- fore, is the only one that can, under this point of view, claim our attention. This artery is to be sought for between the instep and the commencement of the first inter-osseous space of the metatar- sus; that is to say, on the dorsal surface of the scaphoid bone, or of the two first cuneiform bones. By placing the two thumbs transversely upon that space, and one over the other, while the fingers take a point d'appui on the plantar surface of the foot, we compress the artery with certainty and in such manner as not to be over-fatigued. The pelote of any kind of compression ap- plied to that region, might easily be substituted for the thumbs, if the operation was to continue for a considerable length of time. The nerves, veins, and other tissues in the neighborhood of this artery, are of too little importance to be any obstacle, to its com- pression. But as the blood returns directly to the dorsalis pedis through the plantar artery, we cannot see how this compression can, in reality, be of any great assistance. TREATMENT OF ARTERIAL LESIONS. 23 b. Arteries of the Leg. Buried, as it were, in the depth of the muscles, the arteries of the leg do not readily admit of compres- sion between the knee and the lower part of the calf. It is only, therefore, in the vicinity of the tibio-tarsal articulation, that we are enabled to reach them, and the anterior and posterior tibial more- over are the only ones that the surgeon should look to in such cases. The anterior tibial artery, where it courses upon the outer sur- face of the tibia, might be perfectly flattened, if in selecting a point d'appui for the thumb above and behind the internal malleolus, between the tendo Achillis and the bones, we should compress it from without inward, and from before backwards, with the fingers placed crosswise. If we were to apply a tourniquet, garrot, &c, to the same point we would effect the same result. To compress the posterior tibial artery, we must place the fingers of one hand, or of the two hands, crossing each other, in the groove which separates the tibia from the os calcis, and by this means press from behind forwards, or from within outwards, against the posterior border of the internal malleolus, while the fingers take a point d'appui on the outer part of the instep. It is evident that we could obtain the same result by placing the fingers in front and the thumbs behind the malleolus, in the same way as we could by applying the projecting part of any compressor whatever upon this last point. Were it absolutely requisite to do so, the compression of the posterior tibial, regulated upon the same principles, might also be practicable nearly as high as the upper part (racine) of the calf; but then it would be almost impossible to flatten the vessel per- fectly. c. The Popliteal Artery. The artery of the ham being situated at considerable depth, is utterly incapable of being flattened by in- direct (mediate) compression. As it would also be impossible to reach it without compressing at the same time both the nerves and the accompanying vein, the operation in this part would be at- tended with more disadvantage than utility. It would not be advisable, therefore, to think of attempting it except as a tempo- rary means of relief in certain hemorrhages of the leg. In this case it would be necessary to place the compressing force in the hollow of the ham, above the line of the articulation, a little nearer to the internal than the external border of that region, and to select a point d'appui above the patella, upon the front part of the thigh ; the tourniquet or the mechanical compressors would in such cases be manifestly preferable to the fingers. d. Arteries of the Thigh. The femoral artery may be compressed near its two extremities, that is, at the fold of the groin, and at its entrance into the fibrous plane (plan) of the adductor muscles. 1. Formerly, during amputations of the leg, the femoral artery was often compressed at the lower third of the thigh. It is true that in placing the two thumbs from within outwards, so as to fall be- tween the vastus internus and the adductor muscles, Ave soon flatten it against the inner side of the femur, if the fingers take a proper 24 NEW ELEMENTS OF OPERATIVE SURGERY. point d'appui upon the outside of the limb. But it is rare that the hands suffice for this compression, and Ave accomplish it best by means of the tourniquet, or ordinary compressors. We should not, however, if Ave wish to make use of the fingers, attempt com- pression at this point, unless some disease or some abnormal con- dition should prevent our effecting it in the groin ; for Ave can effect the compression of the femoral artery with the tourniquet with much greater certainty and ease in this region than in the upper part of the thigh. 2. To compress the femoral artery at the fold of the groin, Ave Tarely employ any other means than the fingers. The best mode consists in fixing the thumb upon the outer part of the thigh, a little below the great" trochanter, and the four fingers on the fore part of the gracilis and adductor muscles, directing them outwardly and backwards, and placing over them the fingers of the other hand to serve as a support. The artery is so perfectly confined by the adductor muscles behind, the triceps in front, and the femur outside, that it is impossible for it to escape or slip in the slightest degree. The thumbs substituted in the place of the fin- gers, or vice versa, Avould, it is true, produce the same effect, but would cause more fatigue, and be less certain. It Avould be the same Avith a padded seal, or any pelote whatever. 3. Most usually Ave compress the femoral artery against the body of the pubis; this in fact, is one of the most convenient places to do it. There Ave find the artery at an equal distance from the an- terior superior spinous process of the ilium and the symphisis pu- bis. By placing, then, the fingers, the thumb, or the pelote of a seal on this point, so as to press from before backwards, and slightly from beloAv upAvards, as if Ave Avished to push back or depress the middle of Poupart's ligament, Ave are almost sure to succeed. It is requisite, moreover, that Ave should not apply the compressive means in such cases until after having distinctly felt the pulsalions of the artery Avith the fingers. The most sure and least fatiguing mode, however, of compressing this artery, as Avell as all the others, consists in placing the pulp, either of the fingers or the thumb, across the course of the vessel, and in such manner that the fingers of the other hand, pressed against the first, may thus serve to add to their force, and take their place Avhen they are tired. If it is the right side, for example, the surgeon, turned towards the feet of the patient, places his left thumb transversely upon the place I have designated, and immediately puts the thumb or fingers of the right hand upon the nail of the first, so that the thumb acts Avith its own individual force while it is not fatigued, and acts the part of a pelote under the fingers of the other hand Avhen it has need of repose, and so on in succession as long as the compression is to be continued. To make permanent compression, and to avoid as much as pos- sible any interference Avith the course of the venous blood, it would be necessary to make use of pelote compressors that have more projection than Avidth, and which should be directed a little TREATMENT OF ARTERIAL LESIONS. 25 outAvardly, and applied so as to take their point d'appui upon the posterior surface of the pelvis. V.—Arteries of the Abdomen. The enormous volume of the arteries in the lower belly (bas- ventre) would render their compression, if it were possible, a mat- ter of great importance ; but there are none except the aorta and the iliac arteries that are accessible in this cavity. a. To compress the iliac artery it is requisite, after relaxing the parietes of the abdomen, that Ave should exert with the fingers, thumbs, or a pelote, a pressure sufficiently strong to fall upon the contour of the upper strait (detroit superieur) of the vessel, or between this and the inner border of the psoas muscle, upon the track of a line which Avould reach from the side of the sacro-verte- bral angle to the middle of the crural arch. By this compression we may temporarily suspend, or prevent Avhere they have not already taken place,hemorrhages from the thigh. We might also,in the same Avay,by pressing upon the common iliac,arrest hemorrhages from the branches of the hypogastric arlery. It is evident, however, that compression upon the iliac fossae cannot be indicated but for certain disarticulations of the thigh, and for lesions at the commencement of the femoral artery, or at the lower part of the iliac artery itself. b. The Aorta. Since surgery has presumed to penetrate even into the abdomen to reach aneurisms, Ave have felt the necessity of some means whereby Ave might make pressure through the abdo- minal Avails on the aorta itself. Treating of the relations of this artery, 1 had already said in 1825, (Anatomie des Regions, le edit., t. IL, p. 126,) "Cases might occur in Avhich the aorta Avould have nothing intervening between it and the umbilical Avail except the peritoneum and omentum; so that in Avounds of this great arterial trunk it would be possible, in fact, after having relaxed the muscles by the flexion of the trunk forwards, temporarily to suspend the hemorrhage by pressing on the left side of the spine." From that epoch the compression of the aorta has become the subject of particular researches, and of applications altogether neAV. I employed it, in the year 1831, upon an occasion in Avhich I Avas made fully sensible of all its advantages, in a case of wound of the external iliac artery. It is easy to conceive Avhat assistance might be derived from it if Ave Avere applying a ligature to the common, or to the external or internal iliac, and in all cases of Avounds of those very large trunks. The compression of the aorta however, has principally attracted the attention of practitioners, as a means of suppressing external hemorrhages, and especially those that occur after parturition. Since the period at which M. Trehan (Bullet, de Ferussac, t. XVI., p. 452) and M. A. Baudeloque (Jour, dss Conn. Mid. Chir., t. I., 1834) contended for its discovery, in 1826 and 1S28, it has been ascertained that Saxtorph, Plouquet and Sch weigh aeuser, 26 NEW ELEMENTS OF OPERATIVE SURGERY. had already extolled it under various forms, and that Borr, Madame Lachapelle, and Duges had also spoken of it. There are also a multitude of practitioners, as for example, MM. Ulsamer, Eichel- berg, Siebold, Blount, Lovenhart, Brossart, Latour, and Martins, Avhose observations I have elsewhere referred to, (Tocologie, ou, Traite de l'Art des Accouchem., 2d edit., t. IL, p. 545,) who assert that they have employed it Avith advantage in cases of excessive flooding from the uterus. I will add, that I have recommended it, or performed it, four times Avith success, under similar circum- stances, since 1834. This compression, suspending the whole circulation in the uterus, as Avell as in the loAver extremities, necessarily, as Ave may perceive, puts a period to the dangers which the Avoman is then exposed to. Had it no other value than to give time to act, and to enable the surgeon to promote by suitable means the retraction of the uterus, it Avould be a most important resource; but from Avhat I have seen, and it is in accordance Avith the observations of M. Baudeloque, I feel authorized in giving it as my opinion, that if it should be con- tinued for a quarter or even half an hour at a time, and alter- nately suspended and resumed, it Avill, in a certain number of cases, be sufficient to put an effectual stop to the hemorrhage. Three conditions may be met Avith where it may be considered necessary to make compression upon the aorta. 1. In pregnant Avomen. If the pregnancy has not advanced be- yond three months, the state of the Avomb requires no change to be made in the manipulation of the process. At a later period, and especially after the fifth month, it Avould become necessary in the first place, to compress the uterus, and this is the aspect under wxhich the first authors, Avhom I have mentioned, seem to have considered this subject. By pushing upon the Avomb from below upAvards, and from before backwards, Avith the hands or Avith a bandage, taking care to incline this organ gently to the left, we would then succeed Avithout difficulty in compressing the aorta. It is probable that the compression of the belly, of Avhich so many writers have spoken, and Avhich has been employed in hemor- rhages during pregnancy or parturition, OAved its success to this principle. 2. In a woman Avho has just been delivered, the Avails of the ab- domen are ordinarily so pliant and flabby, that it becomes exceed- ingly easy to press them into contact with the vertebral column. The surgeon, after elevating the head and thighs of the patient, by means of pilloAvs, presses the abdomen opposite to the umbilicus, or a little below it. Taking care to push aside (ecarter) all the neighboring organs by certain undulating (ondulatoires) move- ments, he quickly comes to the spine, where he soon perceives the pulsations of the aorta. To flatten this artery he has then nothing more to do than to place one of his thumbs crosswise upon it, and to support that thumb by the other, in the same manner, as I have said in speaking of the femoral artery. We may make use of the fingers as well as the TREATMENT OF ARTERIAL LESIONS. 27 thumb, or of the pelote or the seal properly arranged; but the thumbs are evidently better. By pressing also a little more to the left than to the right, Ave should avoid the vena cava sufficiently, so as not to interrupt any other than the arterial circulation. 3. In a man, or in Avomen Avho are not pregnant, the operation is performed in the same manner, but Avith more difficulty, because of the little pliancy, and also the thickness of the Avails of the belly; also, it would require greater precautions in the relaxation of the muscular system, and in the exact application of the compressive forces. B.—Compression of the Arteries in the Case of Wounds. WThen an artery has been Avounded, and a hemorrhage results from it, compression is the first thought that presents itself, not only to the mind of the surgeon, but also to that of the bystanders. Whether the blood escapes outwardly, as in traumatic hemor- rhages, properly so called,or that it is effused and infiltrated into the tissues, as in diffused aneurism, compression nevertheless may be employed in various Avays to remedy the difficulty. The practi- tioner, in such cases, is to look also to two indications : first, either he has no other object in view than to arrest the hemorrhage tem- porarily, Avhile permanent means are being prepared ; or, se- condly, he attempts at once a definitive cure by compressing either on the point wounded, or on some other region of the bleeding artery. I. Temporary (Provisoire) Compression. In cases of arterial Avounds, temporary compression is ahvays indicated. We perform it either on the Avound itself, or outside of it. a. To compress outside the wound, Ave must conform ourselves in every respect to the rules laid down in the preceding chapter. This kind of compression will not in general answer in certain re- gions of the body. On the carotids, for example, it sometimes al- lows the blood to return by the upper end of the vessel, whereby the hemorrhage is renewed. If Ave should compress but one of the arteries of the fore-arm, in a Avound of the hand or Avrist, the other artery in the same region might in like manner keep up the hemorrhage. It is important therefore to compress at the same time the radial and ulnar artery, if Ave ha\re it not in our power to make the compression both below and above the Avound. What I say of the fore-arm must be equally understood of the foot and leg. There are cases also in which, in consequence of some anomaly in the arm or thigh, the same difficulty is experienced in attempting compression upon the root of the vessel only. To effect this com- pression there are also required certain anatomical conditions Avhich are not always present. The Avounds of the subclavian and of the lower third of the carotid, render it manifestly inapplicable. 28 NEW ELEMENTS OF OPERATIVE SURGERY. [See note 30, Mott, infra.] When the size or rigidity of the belly is an impediment to the compression of the aorta, we should be in a similar embarrassment for Avounds of the iliac arteries and those of the upper part of the femoral. b. From this Ave may perceive, that compression on the wound itself ought to be in more general use, and that it would be some- times more efficacious than upon a sound portion of the track of the artery. In this mode compression may be made by means of the thumb, fingers, bandages, &c. The fingers or the thumb should be preferred as often as they can be applied to the bottom of the wound. If there should be too much inequality in the division of the tissues, and too many difficulties encountered in searching for the AVDund of the vessel, we should succeed better by tampon- ing (le tamponnement, i. e., plugs, or tampcns or tents, vid. vol. I. T.) or by small balls of lint, pieces of agaric or graduated com- presses, than Avith the fingers. In case this wound Avas very oblique, and the situation of the artery not very deep, it might be advisable to seize it in a flap of the soft parts, betAveen the thumb and forefinger, or between the two first fingers. There is no ne- cessity of adding that this kind of compression is attended Avith the serious inconvenience of irritating the Avound, and of prevent- ing the surgeon from being enabled to examine its interior. It is consequently only admissible in the event of the failure of the other method, or while we are looking for a suitable point upon the root of the artery. II.— Curative Compression. II. If we should desire also to put a definitive termination to the hemorrhage by means of compression, we may recur to either one of the two preceding methods. The ancient surgeons having but very vague ideas upon the circulation of the blood, and ignorant of all the advantages that were to be derived from the strangula- tion of the vessels, had, for the most part, no other remedy for arte- ria] hemorrhages than compression, caustics, or astringents, Avhich they applied directly to the Avound itself; but since the ligature has become known, and that surgeons have demonstrated the impossi- bility of arresting certain traumatic hemorrhages Avithout obliterat- ing the artery that supports them, compression on the Avounded point is rarely any longer employed. Nevertheless there are some surgeons Avho still recommend it in preference to the ligature, and who do not accept the aid of this last until they have ascertained the insufficiency of compression. Mr. Guthrie, (Malad. des Ar- teres, p. 320,) for example, recommends that before we come to the ligature, Ave should always make trial of compression, unless the wound is manifestly upon the principal arterial trunk of the limb. There are also an infinite number of facts to prove that Ave may by this means effectually control hemorrhages from arteries of very considerable calibre, (d'assez grosses arteres.) TREATMENT OF ARTERIAL LESIONS. 29 A.—Direct Compression. By means of direct compression and astringents, Jacques De- marque (Traite des Bandages, p. 504) cured a Avound of the bra- chial artery in four patients. A similar case has been published by Chappe, {Jour. Gen. de Mid., t. XXV., p. 26.) Cacstric (Gaz. Salutaire, 1767, No. 46, p. 3) Avas not less fortunate in compressing by means of agaric, and by bandages and the hand, a wounded carotid. Special instruments had obtained tAvo similarly fortunate results for the father of Muys. Formi (Bonet, Corps de Mid., t. IV., p. 190) cites a hemorrhage of the fore-arm, Avhich he radically cured by plugging (tamponuement) and compression. In a case of Avound of the fore-arm, the ligature upon the radial artery not having arrested the hemorrhage, compression was had recourse to, Avhich put a termination to the difficulties, (Dudaujon, These, 1803, p. 20.) Bourienne, Avho blames the ligature and too strong a compression, says he has cured, by moderate compression, a hemorrhage from the inter-osseous artery of the fore-arm. A hemorrhage from the leg, caused by fracture, Avas thus arrested by Colomb, (Obs. Med. Chir., p. 403.) I have several times, and once also in 1838, at the hospital of La Charile, effectually arrested, by direct compression, a hemorrhage from a Avound in the palmar arch. M. Champion has not been less fortunate in compressing a primitive false aneurism, and it is not to be doubted that a great number of Avounds of the brachial artery Avere for- merly cured by the same means. Among the curious examples of them that science possesses, I cannot avoid citing the following: Sent for to a lady of eighty years of age, and Avho had been bled tAventy days before, Myngelouseau found a hemorrhage which had resisted astringents and bandages. It. Avas arranged that students in surgery should hold their fingers upon the open- ing of the artery night and day for twenty days, by which means a cure Avas obtained. We should not, hoAve\Ter, rely upon the efficiency of this means but in a very small number of cases. On the dorsum of the foot, behind the internal malleolus, above the instep, at the palm of the hand, a little above the Avrist, and sometimes at the bend of the elbow, it may suffice ; everywhere else direct, compression Avould expose to too many dangers, and present too slight a prospect of suc- cess, to authorize its general use. It Avould not, in fact, be allow- able, under the circumstances I have mentioned, until after Ave had assured ourselves of the difficulty or impossibility of seizing hold of, twisting or tying the injured artery at the bottom of the Avound. As to the manipulation of this mode of compression, it is the same as for indirect compression, or that Avhich I shall point out in the next article, in speaking of aneurisms. B.—Indirect Compression. Applied to wounds, compressive means cannot be maintained 30 NEW ELEMENTS OF OPERATIVE SURGERY. there a long time Avithout causing acute pains, and occasionally endangering very serious accidents. When Ave Avish to effect, by this means, the obliteration of the diseased vessel, Ave should give the preference to making the compression at some distance above, or, if the condition of the arteries required it, below the Avound. Numerous examples of success obtained by this method have been published at every epoch of science. It is for this kind of com- pression that Verduc (Pathol. Chir., chap. II., art. ler, p. 147) con- trived his collar, (collier,) and that M. Chiari (PI. Portal, Clin. Chir., t. I., p. 154) boasted of his. A compressing bandage, ex- tended from the wrist to the shoulder, enabled Faivre (Ancien Jour. de Med., t. LXXIIL, p. 376; to cure a Avound of the radial artery Avithout ligature. M.Wytterhoeven (Rev. Med., 1835, t. I., p. 231) speaks of aAvound of the brachial artery, followed by a severe he- morrhage, AvhichAvas arrested by making circular compression above the Avound for thirty-six hours only. I have seen a case nearly similar to this in La Charite, in 1837. A young Avorkman, Avhile breaking a square of glass, had made a large opening into the ulnar artery, in the lower third of the fore-arm. To arrest the hemor- rhage, his comrades bound the arm up tight Avith a pocket hand- kerchief, twisted in the form of a cord. Having on the folloAving day removed this species of bandage, Avith the intention of tying the artery, I saw no hemorrhage re-appear, and the cure toak place without any necessity of applying a ligature. Nevertheless, the artery had been completely divided, as Avell as the nerves, tendons, and muscles in its neighborhood. Consequently, the temporary compression which Ave are sometimes compelled at first to make above the Avound, upon the track of the injured artery, might in certain cases be converted, Avith some chances of success, into a curative means of compression. Nevertheless, as it is impossible to effect it without interfering Avith the venous circulation, the dis- tribution of the nervous fluid, (l'influx nerveux,) and all the other functions of the part; and as it is generally painful, and of doubt- ful efficacy, I Avould not advise to have recourse to it, unless it should be found too difficult to reach the artery, at the bottom of the wound. I shall, hoAvever, in the folloAving article, treat of the means by which this is to be accomplished. [Traumatic Lesions of large Arterial Trunks, Direct Compression, Ligature, Sf-c. Dr. Mott believes he has seen an instance lately, in Avhich the subclavian artery, Avithout the scaleni muscles, may have been wounded during an operation for the removal of a small tumor above the clavicle. The wound Avas probably of the nature of a small flap on its superior surface, bet\veen the first rib and the scalenus anticus muscle. In fact, the artery Avas perhaps nicked in this part, as a terrific hemorrhage ensued. In this dilemma, Dr. Mott, being sent for, adopted instantly a treatment someAvhat novel, but which proved eminently successful, and went to cor- TREATMENT OF ARTERIAL LESIONS. 31 roborate his suggestion that it was the subclavian which was Avounded. The practice consisted in the immediate application of a small portion of compressed sponge upon the bleeding part, Avhich was situated at nearly the depth of the forefinger. This Avas followed successively by other small portions of sponge, until the wound Avas entirely and compactly filled up. An entire flat piece of sponge, just the size of the external opening of the wound, Avas noAv nicely adjusted over the ten or dozen smaller pieces Avhich had been pre- viously impacted. Finally, a larger flat piece of sponge, of still greater dimensions than the last, Avas now used to cover the whole mass, and to extend some distance on every side beyond the mar- gin of the wound. Pressure Avith the hand Avas then made, by a succession of as- sistants, unremittingly for three days and three nights. After this, the pressure Avas confided to adhesive straps and a bandage, until suppuration made it proper to commence the removal of the sponges. This Avas done from day to day, with the utmost care, and by taking aAvay piece after piece, Avithout the least violence, until the last Avas separated, Avhich Avas finally effected at the ex- piration of a Aveek from the time that this surgeon commenced Avith their removal. The Avound then granulated, and healed beau- tifully. The advantage of the use of sponge, as a means of arresting hemorrhage, has long been favorably knoAvn ; but Dr. Mott con- siders that its great value, in cases like that here related, consists in the application of a number of small and separate pieces, by Avhich portion after portion, at a suitable time, may be removed, with the least possible violence to the wounded artery. Every surgeon, who has been in the habit of using compressed sponge to arrest small and vexatious hemorrhages, must be aware of the great inconvenience and hazard of one entire large piece ; for Avhen the time arrives for its removal, the granulations are found to have penetrated into its cellular texture to such extent, that the force required to take it away, and to tear it loose from these connections, endangers a renewal of the bleeding. All of which is obviated by the successive superposition of small and separate pieces or chunks. This treatment appears to have been so nicely adapted to the little flap or nick supposed to have been made in the subclavian in this case, and to have compressed and secured it so perfectly to its place, (as in the restitution of organs, see Vol. I.,) as to have reunited its lips to the parent trunk by first intention. Dr. Mott sees no reason, from experience and observation and the records of surgery, to doubt the possibility of such a Avound, even in a large arterial trunk, being healed, Avithout the trunk itself being obliterated, or its calibre being sensibly diminished. He is of the opinion that, if the subclavian itself in this case Avas not Avounded, it must have been an enormous anomalous branch, close to the great trunk ; for his finger, which commanded the hemor- 32 NEW ELEMENTS OF OPERATIVE SURGERY. rhage, Avas upon the subclavian artery, and the first piece of sponge Avas passed quickly under the point of the finger itself, and there held until another Avas stowed away by its side. T.] \Wounds of thz Arteries of the Foot. The treatment of Avounds of the larger arteries of the foot, is in the opinion of Dr. Mott, a subject Avhich has not received a suffi- cient degree of attention. In recent wounds for example, of the dorsalis pedis, both ends of the cut artery ought to be tied on the spot. If some days should have elapsed after the injury, it Avould be necessary to tie the anterior and posterior tibial arleries, and generally he has found this sufficient to arrest the hemorrhage. But in one instance Avhere several days had elapsed after a wound of the dorsalis pedis, and in Avhich strong compression over the wound had been made, without, hoAvever, preventing considerable hemorrhage from time to time ; he found Avhen visiting the patient some miles in the country, that though after immediately tying the anterior and posterior tibial arteries, the bleeding ceased, yet in about a Aveek it Avas renewed to an alarming degree. Being again sent for, he found himself much embarrassed, not knowing whe- ther the hemorrhage proceeded from the inter-osseal or some com- municating branch of the anterior or posterior tibial arteries above where they had been tied. Thinking that it might proceed from a branch of the anterior tibial above the ligature, communicating with the trunk below, he concluded, rather than to tie the femoral, that he Avould cut through the annular ligament as near the Avound as possible, and there apply a ligature, Avhich being done had the desired effect. The patient Avas a Avheehvright Avho had been wounded by an adze. In recent wounds of the plantar arteries where some days may have intervened before surgical assistance is obtained, you cannot tie the plantar arteries themselves, and it is infinitely preferable in fact, indispensably necessary to tie both the anterior and posterior tibial. For Dr. Mott has several times seen after tying the poste- rior tibial only, that profuse hemorrhage has returned at the expi- ration of a Aveek or ten days, and Avhich could only be controlled by tying also the anterior tibial. It must be obvious to any per- son, that it takes some time for the collateral circulation to be es- tablished, and that Avhen established, the reflux or distal hemor- rhage may prove serious in those cases in which only one of the tibial arteries has been tied. Dr. Mott has seen the same difficulty occur, and the same prac- tice necessary and effectual, Avhere the communicating branch has been cut in a Avound between the great and adjoining toe. T.] [Alveolar Hemorrhage. Tamponing or Plugging, properly and carefully performed as in the case related by Dr. Mott, (supra,) Avith pieces of sponge to the TREATMENT OF ARTERIAL LESIONS. 33 subclavian artery, will succeed, Avhen all manner of styptics, cau- teries, caustics, and ordinary modes of plugging, fail. Dr. Balaffa of the General Hospital of Vienna, appears to have acted thus very judiciously in the case of a butcher, who Avas attacked Avith one of those fearful hemorrhages which are so Avell known to folloAv oc- casionally extraction of the teeth, in this instance a loAver carious incisor, as he had already experienced, after the extraction of an- other incisor in this jaw ten years before. For three days and nights the bleeding continued profuse. Brought to the Hospital, Dr. Ba- laffa, (see the case as draAvn up by Dr. Joseph Hartmann, Jour, des Connaissances, 8fC, Paris, Oct. 1844, p. 163,) prepared a conical dos- sil of lint and Avax (plumasseau et de cire) the size of Avhich cor- responded to the diameter of the alveolus : this dipped in a mixture of eau de Theden, creosote and sulphuric acid,Avas adjusted firmly into the bleeding socket. Upon the top of this cone he applied a layer of the same nature, above this a second, wider and thicker,and still over that a small square plate. This arrangement adapting itself exceedingly Avell to the jaw, from the patient having lost the adja- cent teeth on the left side, M. Balaffa ingeniously secured the Avhole by means of a rather narroAV bandage, which Avas pass- ed in a transverse direction, tOAvards the angles of the mouth, and downward towards the chin, from Avhich latter it Avas conducted to the occiput tOAvards the vertex, finishing Avith circular turns around the forehead. This bandage Avhile it firmly secured the plug, made also pressure upon it. The hemorrhage ceased and the patient slept well. On the third day after the most rigid repose the. dressings Avere reneAved, and on the sixteenth he Avas dis- charged. T.] C.—Compression in the Treatment of Aneurisms. Two kinds of compression—indirect (mediate) and direct (imme- diate) have been employed for aneurisms. ~ ■ I.—Indirect Compression. Aneurisms of the carotid and subclavian, have been cured by Acrel, by means of methodical compression made upon the tumor. Those of the ham, thigh, groin, hand vnd elbow, have been suc- cessfully treated in the same manner by Fabricius of Hilden, (Bonet, Cours de Med., p. 96,) Waltin, (Ancien Jour, de Med., t. LXV.,) Tulpius, (Bibl. de Manget, ou, Obs. Med., p. 305, lib. IV., cap. 17,) Platncr, (Theden, Progrcs de la Chir., p. 26,) De Haen, TreAV, (Ibid.,) Plenk, Petit, Theden, Guattani, and a multitude of others; so that Ave cannot call in question its efficacy ; it has been employed in a great variety of Avays ; sometimes the compression Avas made upon the aneurism only; at other times on the aneurism and the rest of the limb simultaneously; in other cases on the contrary, it Avas only made beloAV or above the tumor. 3 34 NEW ELEMENTS OF OPERATIVE SURGERY. a. On the Tumor or the Diseased Part. Galen is one of the first who used compression in the treatment of aneurisms ; plasters, and pieces of sponge kept on by bandages, perfectly succeeded with him in curing a patient Avho had the artery Avounded in bleeding. At the time of Dionis, (Huitieme Demonslr., p. 693,) they applied upon the wound pieces of papier-mache, agaric or tinder, supported by a piece of money, then by other pieces of a larger size, so as to form a pyramid whose point Avould correspond to the opening of the artery ; the Avhole being supported by an appropriate bandage. The Abbe Boudelot (Dionis., edit. Lafarge, p. 697) relates that he cured himself of a false consecutive aneurism, by keeping for a year a cushion strongly pressed upon the tumor. Since then, in the first half of the last century especially, Surgeons occupied themselves much Avith improving this kind of compres- sion. Arnaud, (Mem. de Chir., t. I.,) Heister, Ravaton, Verduc, &c, proposed different bandages with the view of rendering it more easy and sure; each one of them proposed to modify the compressive instrument of Scultetus or the tourniquet of J. L. Petit, and all sup- posed that they had found the means of curing aneurisms Avithout an operation. Foubert had a steel ring constructed of oval form, carry- ing upon its broadest part a plate, (i. e., plaque) [meaning doubtless a metallic plate,] provided Avith a cushion; the other part of the ring being perforated by a quick screAV (vis de rappel) Avhich Avas also provided with a cushion upon its extremity, so that on being applied it was intended to compress only the diseased point and the part of the limb diametrically opposite. This machine more ingenious than many others, and better than those plates of lead, silver, or iron, whether provided or not with cushions, or sponges, and Avhich were fixed upon the aneurism by means of ribbons, straps of leather or bands, Avas nevertheless attended Avith this serious inconvenience : viz., that of being easily displaced, and of not establishing any com- pression, except upon a diseased and very limited portion of the artery, while it also produced engorgement of the part situated below, and was not supportable but by a small number of pa- tients. [Tubular Aneurism (so called) cured by direct compression to the sac itself.—New Nomenclature for Aneurisms. A case of Tubular Aneurism has been recently cured by Mr. Luke of the London Hospital, by direct compression to the. sac it- self, and a new classification of Aneurisms is proposed by him. This tubular aneurism as he denominates it, being to all appear- ance an aneurismal enlargement or dilatation of the femoral artery, and that assuming an unusually cylindrical or tubular shape, occurred in a dock laborer, aged 31, admitted in the above hospital, Feb. 19, 1845. The tumor according to Mr. Luke, (London Medical Gazette, May 9, 1845, No. 910. Vol. XXXVL, new series, No. 2, p. 78, &c.,) was soft and compressible, of an oblong form extending from Pou- TREATMENT OF ARTERIAL LESIONS. 35 part's ligament, down the thigh, between three and four inches, in the direction and situation of the femoral artery ; measuring trans- versely immediately beneath the ligament about tAvo inches ; hav- ing a strong pulsation perceptible Avhen the fingers Avere applied, throughout its Avhole extent, enlarging equally in all directions at each pulsation, and capable of being entirely emptied by temporary compression. There Avas no sound or bruit, there Avas some weak- ness in the limb and occasional cramp in the muscles of the thigh, Avhile all the arteries of the diseased member pulsated as normally as in the sound one, and both Avere of natural temperature. It came on about a year before, suddenly from lifting, as he thinks, heavy Aveights, and had not materially increased in size, nor given him any particular inconvenience except now and then, when he exercised, a cramp in the thigh, pulsation and slight pain in the part and coldness of the limb. On March 3d, an adhesive plaster spread on leather Avas placed over the tumor and the part embraced by a spica bandage. On the 8th of March, the dressings being removed, the tumor Avas found to have already undergone a considerable change. Instead of being soft and compressible and capable of being emptied of its contents, it Avas hard and unyielding and slightly painful on pressure. Its pulsation also had entirely ceased as Avell as that of all the arterial trunks of the limb, the femoral, popliteal, and anterior and posterior tibial arteries—Avhile the foot and leg felt colder than those of the opposite limb, though not in- dicating any change of temperature to the thermometer. The pa- tient stated that the first application of the bandage had produced a violent throbbing, which however, soon ceased, and nothing of the kind returned. The plaster and bandage Avere reapplied and the limb Avrapped in wool. On March 22, the tumor Avas still hard, consolidated, and Avithout any pulsation. There Avas apparently an obliteration of its cavity, the contents of Avhich had undergone some diminution from absorption. Mercurial ointment spread on lint was applied, and the patient alloAved to move out of bed. April 2, he walked about Avith greater ease and freedom than Avhen ad- mitted, but the pain in the calf remained. April 19, after a visit out, returned as he promised—still complained of pain in the calf, especially when going up stairs. There Avas also numbness of the foot at times. The circulation, says Mr. Luke, was apparently re- stored sufficiently for the proper nourishment of the limb, yet pul- sation had not returned in any of the arterial trunks. The size of the tumor had undergone very considerable diminution, and the aneu- rism had been Avithout doubt cured. Remarks. This must be added as another to the extremely rare instances of success by the ancient process of the cure of aneurisms by com- pression to the part itself, (Vide Velpeau, supra, in this volume, Section IV., Chap. III., Article IL, § IL, C. Compression,) though the process in this case is someAvhat in collision with the new and 36 NEW ELEMENTS OF OPERATIVE SURGERY. successful mode of alternate and moderate compression on various portions of the sound trunk above the aneurismal tumor, as recom- mended by the Dublin Surgeons. (See further on beloAV.) In an aneurism of such volume, to say nothing of its abnormal shape, some courage seems to have been required, in the surgeon to revert back to the ancient direct and even forcible mode of compression to the sac itself; made Avith such constrictive power, too, it seems, as almost to obliterate at once the Avhole circulation and tempera- ture, and consequently to become an immediate source of danger to the vitality of the limb; exposing to gangrene, &c. The consolidation Avas effected almost as speedily as by the liga- ture, and there can be no doubt that the river-bed of the aneurismal sac, if it may be so termed, continued to admit constantly a gentle current through the tumor and femoral trunk to all the divisions of the latter vessel, however tardy the anastomosis may seem to have been in reestablishing the collateral circulations. The case cer- tainly goes in every Avay strong in support of the principles of cure laid down by the Dublin Surgeons, (Avhich Ave shall soon speak of,) notwithstanding the pressure Avas made to the sac itself, and in a more poAverful manner rather than Avould seem to have been ad- visable. Considering however the peculiar and anomalous tubular form of the tumor, naturally leading to the inference that the tunics of the artery Avere uniformly dilated throughout the Avhole extent of the aneurism, and did not probably form any kind of pouch upon. the artery communicating by an aperture or apertures Avith the trunk of the vessel, the mode adopted by Mr. Luke of making uni- form compression on the Avhole tumor, Avas probably the most rational, and the case may be considered as one of those rare ex- ceptions in Avhich the precautions of the Dublin Surgeons not to attack the tumor itself, must be dispensed Avith. Had the Dublin mode been followed, though the pressure it makes Avould have been more moderate, there Avould also probably have been more danger of rupturing the tumor, from the whole of the sac consti- tuting as it Avere a part of the femoral trunk, or an aneurismal dilatation of it, and from its coverings being so very thin. It is to be regretted the final issue of this case is not yet known. Upon the strength, hoAvever, of the pathological facts disclosed by this anomalous case of aneurism, Mr. Luke proceeds at once to propose an entire change in the nomenclature of aneurisms, and to abolish altogether the old phrases of false, true, diffused aneurism, &c, long since rendered objectionable by the incoherent, confused, and careless manner in Avhich such terms are used. His proposed arrangement is : 1. Saccuted Aneurism—Avhere there exists the ordinary sac. This is the most common. But by some latitude of expression, and considering too the pathology of the cure as advocated by this surgeon, could not his tubular or cylindrical aneurism also be called a sac ? The traumatic constitute, he says, a species of sac- cate d aneurisms. TREATMENT OF ARTERIAL LESIONS. 37 2. His tubular (spindle-shaped or fusiform, Avhich latter term Ave prefer) aneurism, he makes a distinct or second species. 3. Dis.-ecting, as noAV received. 4. Varicose also. These two last he adopts as they stand in the •existing nomenclature. 5. Capillary Aneurism.—aneAV name butnot a new species—i.e., aneurism by anastamosis, (or naevi materni or erectile tumors. T.) Thetubular form he saysis never so globular as it is spindle-shaped or fusiform, Avith the long axis on the track of the arterial trunk. In the saccated aneurism he leaves us to infer that there is an aperture or cut or wound or rupture in the arterial trunk, and through which the sac is formed by the current of blood thus diverted from its course. Hence from this diversion the natural tendency in such aneurisms to spontaneous coagulation and cure. Not so in the tubulated, Avhich is one continuous expanded dilated volume of the Avhole trunk and mass of blood, and by Avhich these two con- ditions or circumstances are in great part coincident with each other in their action and direction. Hence its greater softness and thinness, its capability of being entirely emptied, &c. Hence, too, its slow increase. This latter, he thinks, is partly owing to the force of the current in these dilated portions being by a knoAvn hydraulic principle, he says, less than that of the resistance of the tunics. Finally, these forces he supposes may be poised. This idea, to say the least, is plausible ; and finally perhaps, (he might have added,) that it Avould result that the enfeebled current, as old age advances, Avould become an exact measure of power to the gradually petrifying Avails of arterial tubes. A status appears in fact to have existed, he thinks, in the case in question. In saccated aneiirism the cure is usually imputed to the forma- tion of a clot of blood in the artery or sac, plugging up the aperture of the sac. Mr. Luke denies this, nor do Ave know that any per- son has ever seriously advanced that this Avas the true and only process employed in the cure. Mr. Luke, as Avill be seen, accords Avith the more sound views long since entertained upon organic consolidations, (see vieAvs of M. Velpeau, also Jno. Hunter, Ev. Llome, Sir A. Cooper, &c, Chap. IL, Art. I., § III., § IV., and § V. of this volume,) and considers that of the tAvo portions of blood found in such sacs, one colouied and consisting of coagulum, and usually in the centre of the sac, and the other colourless, (see War- drop in the Cyclopaedia of Surgery,) the latter is the one on Avhich the curative process mainly depends. This portion mostly adheres to the interior of the sac, but the adhesions are easily separable ; so that it is sometimes found Avholly or partially detached, owing perhaps, he says, to causes exterior to the sac. Its arrangement of concentric layers is clearly recognizable, and these are sometimes but loosely connected. Mr. Luke says, " the common explanation" (which however Ave are not at all aAvare of,) is that they are pro- duced by successive deposit, from the blood flowing into the sac; thus, says Mr. Luke, Mr. Hodgson speaking of the spontaneous cure says, " the cavity of the sac is gradually filled Avith layers of 38 NEW ELEMENTS OF OPERATIVE SURGERY. coagulum." But does Mr. Hodgson specify by Avhat mode ? On the contrary Mr. Luke says, these layers are successive organic depositions (of a membrana decidua Ave suppose) from the parietes of the sac, a true fibrinous concretion, and very different as Mr. Wardrop (Ib.) says', from a common clot of blood—as the concreted fibrine has its interior surface smooth and polished, and there is, Mr. Wardrop thinks, and Avhich no reasonable person as Ave supposed had ever doubted, a vascular connection between this fibrinous concretion and the sac ; for the same connection in certain morbid structural changes is seen betAveen the truly fibrinous layers of a membrana decidua in dysmenorrhea a, and the internal vascular villous menorrhagic or lining coat of the uterus, or betAveen the layers of the fibrinous finger-of-a-glove-like tubular membrane, Avhich forms in croup and the internal lining of the trachea, or be- tAveen the layers of the similar tubular membrane sometimes seen in dysentery and the mucous lining of the colon and rectum; and in granular diseases of the kidneys, as recently discovered by Dr. Julius Vogel of Gottingen, (London Medical Gazette, May 2,1845, Vol. XXXVI., New Series, No. I., p. 1, &c.,) in his interesting mi- croscopic investigations, the same connection is found to exist between the cylindrical fibrinous coagula of detached epithelium and rusty coloured granules of altered blood found in the urine in such granular diseases, and the internal lining membrane of the tubuli uriniferi of healthy kidneys, to the diameter and shape of which tubuli, these fibrinous cylindrical coagula are found to cor- respond exactly ; all Avhich normal surfaces pour out those fibrinous laminae by, as M. Velpeau would say, their peculiar organic molecu- lar action, as in cicatrization, first intention, &c. Mr. Luke also finds sometimes betAveen the colourless layers of this fibrinous membrane or concretion in aneurisms ; or betAveen them and the sac, minute clots of coloured coagulum. These he considers con- clusive evidence of their radical difference from the fibrine both in character and origin. Now Mr. Luke supposes these clots have been caught and become insdecated, if Ave may use the term, by the successive depositions of fibrine—i.e., have been entangled and inclosed in them. The presence of these minute clots seems fortui- tous, and the concentric process of intra-lamination of fibrine, if Ave may make a term, continues till the whole sac is consolidated. Finally the sac itself and its vessels are, he thinks, as all sound pathologists have ever thought, the true agents in these fibrinous formations. These plastic operations of nature from without inwards, point out to us as Mr. Luke justly remarks, that Ave ought so to conduct our treatment as not to interfere Avith her efforts; hence the wrong practice of depletion and low diet, thereby diminishing the vital poAver of the blood, Avithholding and abstracting from it its fibrin- ous qualities, and incapacitating it from accomplishing such salu- tary depositions of this indispensable material for consolidafion. Such views are just; but Ave are sure Mr. Luke has omitted to examine the authors of other times, or he could not have imagined TREATMENT OF ARTERIAL LESIONS. 39 that he or Mr. Wardrop Avere advancing a new doctrine in the plastic pathology of aneurismal consolidations. So true is it that the past and all who laboured so gloriously and arduously in it are soon forgotten, and that the debris of their reputation build up, like molecular action itself, that of the successive generations Avho follow. T.] b. On the whole extent of the limb. Compression on the Avhole length of the diseased limb has therefore seemed preferable to local compression. Gengha practised it in the folloAving manner. I make, says he, on each finger an expulsive bandage by means of a small band; then I envelop the hand and fore-arm in the same manner nearly up to the Avound; I place on this last a large tent (tampon,) (Avhich Avord noAv means a plug, T.) of fine linen, satu- rated with a melange of red earth, (terre sigillee,) Armenian bole, dragon's blood, (sang-dragon,) haematite stone, plaster, white of egg, and plantain; I apply over that a layer of thick lead, some compresses, and three or four turns of bandage till it reaches above the elbow ; afterwards by means of the same bandage I fix upon the track of the artery, on the inner side of the arm, a cylinder of Avood, enveloped in linen to serve as a splint; I then bring my band- age upon the Avound to fasten it there by a feAv more turns ; after Avhich I moisten this bandage Avith an astringent liquid, and put the patient under a very restricted (tenu) and cooling regimen. This, Avith the exception of the cylinder of Avood, is Avhat is ge- nerally knoAvn at the present time under the name of the bandage of Theden, (Progres ulterieure de la Chir., etc., p. 27,) Avho more- over made application to the tumor of compresses saturated Avith eau vulneraire. In this manner there is less to apprehend of infiltra- tion in the limb; the pain is less acute and the compression more easily supported; but the circulation of the collateral or supple- mental arteries is thereby rendered much more difficult than by the other method, and so much the more so as Ave are obliged to make the compression Avith so much the greater force. c. Below the Tumor. According to Boyer, (Boyer, Mal. Chir., 2d edit., t. IL, p. 157,) a military surgeon, named Vernet, had conceived the design of curing aneurism of the limbs by estab- lishing a point of compression on the course of the artery beloAV the tumor. Vernet tried this method on a patient affected Avith inguinal aneurism; but the pulsations in the sac increased Avith the greater force, and the author felt himself compelled to renounce his invention; it is a method which has generally been censured,even by those Avho adopt the ideas of Brasdor for the ligature, but Avhich nevertheless does not appear to have merited unqualified proscrip- tion. If, for example, Ave had to treat an aneurism above Avhich it Avould be impossible or at least exceedingly dangerous to apply a compressive dressing or a ligature ; and if, on the other hand, no important branch was given off between the cardiac extremity and the free part of the tumor, it does not follow that by compressing the artery upon the other side of the tumor, Ave might not succeed in interrupting the circulation in the aneurism, promoting the for- -40 NEW ELEMENTS OF OPERATIVE SURGERY. mation of a solid coagulum in its cavity, and ultimately effecting the obliteration of the arterial canal and a perfect cure. d. Above the Tumor. Remarking that the bandage of Theden, that of Guattani, and all the machines for partial compression tend to interrupt the collateral circulation in the limb, or to induce the rupture of the aneurism, if it does not yield to their action, surgeons at an early period directed their attention to some mode of com- pressing the diseased artery at the point Avhere it is most superfi- cially situated, between the tumor and the heart. M. Freer (Caza Mayor, These No. 151, Paris, or, Observations on Aneurisms, 1807) has greatly extolled the bandage of Sennefio,designed for this object. This practitioner first surrounded the Avhole extent of the limb with a roller bandage moderately tightened, (serre,) and after- Avards placed a small cushion at some inches above the tumor. A plate Avas applied to the opposite surface of the limb, Avhich he surrounded with a tourniquet in such manner as to enable him to press the artery upon a single point by means of a screAV. At the expiration of a feAv hours, says M. Freer, the limb becomes cede- matous and tumefied; after Avhich the tourniquet may be removed, and no other dressing used but a cushion and a bandage applied sufficiently tight. This bandage, Avhich is a combination of those of Theden and Foubert, might, as it appears to me, be employed Avith some pros- pect of success. Dubois, (Bullet, de la Facul de Med., 6e annee, p. 40,) a long time ago, effected the cure of an aneurism of the thigh, by making use of a species of spring, constructed upon the principles of the tourniquet of Petit, and Avhich acted only on tAVO narroAvly circumscribed points of the limb. Albert of Bremen (Caza Mayor, Oper. cit.) obtained similar success from a bandage Avhich he calls the inguinal compressor, Avhich is composed of a pelote in- tended to be applied against the pubis on the track of the femoral artery, and of two leather straps, (courroies) Avhich embrace the Avhole circumference of the pelvis and the upper portion of one of the thighs. M. Verdier (Appareil Compressif de l'Art. Iliaque, 1822) effected the same result by means of a bandage Avhich has some analogy Avith the hernia bandage of Camper. Dupuytren (Bullet, dela Fault., t. VI., p. 242) had another constructed, which is composed of a semi-circle of solid steel, surmounted on one side by a broad, thick, and concave pad (coussinet) Avhich Avas to be ap- plied upon the surface of the limb opposite to the artery; and having on its other extremity an iron plate Avhich, by means of two uprights, (montants) and a quick screAV, sustains a rounded pelote, Avhich was to be applied to the artery, and could be made to approximate or recede from the other pad at pleasure. By means of a species of dog-collar, (collier de chien,) making compression above the tu- mor, M. Viricel (Bullet, dela Facult, 6e annee,p. 132) has effected in the hospital of Lyons unquestionable cures. The author of an an- cient thesis (Morel, These de Strasbourg, 1812) asserts that Ave should succeed yet better, if the compression Avere made at the same time upon many points of the limb. This last precaution, the sugges- TREATMENT OF ARTERIAL LESIONS. 41 n tion of Avhich has been contested by MM. Leroy (Depot, a l'lnsti- tut, 1830.—Gaz. Med. de Paris, 1835, p. 202, 239) and Malgaigne, (These de Concours pour la Clin. Chir., 1834,) is described Avith care, and Avarmly extolled by M. Guillier de la Touche. (These, Strasbourg, 1835.) Finally," M. Blizard, and M. A. Cooper (S. Cooper, Diet., etc., trad. Franc., p. 120) have employed another instrument, not less ingenious than those that have been men- tioned. A long piece of steel is first adjusted to the outer side of the knee and the great trochanter; from the middle of this piece there proceeds another Avhich advances in a half circle tOAvards the femoral artery, and carries upon its extremity a plate pro- vided Avith a pad, capable of being moA*ed by means of a screAV, and of compressing the artery Avithsuch force as to cause a cessa- tion of pulsations of the aneurism Avithout interrupting the circula- tion in vessels of less calibre. The compression employed in this manner may Avithout doubt succeed, and should be had recourse to in some cases, for example, in aneurisms of the neck, of the subclavian artery, and the up- per part of the femoral, if from any cause whatever, we Avere pre- vented from using the ligature ; in other cases, it is certain it will but seldom ansAver. The patient of whom M. Cooper speaks, could not support it but a very feAv hours. In one of those Avhom Dupuytren treated, it became necessary to shift the bandage succes- sively to different points of the artery, and in a short time to lay it aside altogether. M. Roux relates a similar case, and in the patient mentioned by M. Verdier, it required all the constancy and resig- nation that he exhibited, not to reject the apparatus, a few days after having begun the use of it. To obtain moreover every advan- tage possible from it, Ave should associate Avith compression, a rigid regimen, and also topical refrigerants or astringents. It has, I know, succeeded Avithout these adjuvants, even in persons Avho per- sisted in using violent movements and the most fatiguing exercises. Lassus (Medecin. Operat., p. 452) speaks of a man Avho, after having applied to an aneurism in the ham a bag filled with salt, fastened by four Jong bandages of linen, and then effected compression upon the artery of the thigh, imagined that he could accelerate the cure by making every day a forced march, and taking far more exercise than he had been accustomed to, and Avho, in fact, ultimately succeeded by this means, after the ex- piration of eight months, in curing himself of the disease; but the surgeon must not take exceptions like these for his guide. e. Appreciation. If the compression did not at the same time act upon the veins, and also occasionally upon the nerves, if it Avere true that it would at least prepare the way for the application of the ligature, by forcing the collateral arteries to dilate, and that it Avas never attended with danger, we should undoubtedly be wrong in neglecting to have recourse to it under all circumstances; but the ligature in these latter times has been rendered so easy and simple in its application that Ave can no longer, in reality, place any great degree of reliance upon other means. 42 NEW ELEMENTS OF OPERATIVE SURGERY. j Even up to the time of Scarpa, compression had been Avarmly advocated, because in conformity Avith the prevailing doctrines of J. L. Petit, (Acad, des Scienc.,' annees 1731, 1732, 1735,) it ap- peared to be naturally calculated to effect a cure of the aneurism without obliterating the artery. When the blood is arrested, says Foubert, the wound upon which a sufficient compression has been made closes up; the skin, the fat, and the aponeurosis cicatrize ; the wound in the artery, hoAvever, does not unite pri- mitively, but leaves a round aperture occupied by a clot of blood (caillot.) If the compression is continued for a sufficient length of time to effect the induration of this clot, the patient is radically cured ; but if Ave allow the arm to be moved before the clot has acquired sufficient solidity to complete the adhesion of the tissues, it escapes from the opening, and the blood insinuates itself around it, and detaches it from the place it occupied. It has since been ascertained, however, that cures thus obtained were not radi- cal ; that the clot which constitutes a kind of cork (bouchon,) or nail, (clou,) as J. L. Petit called it, and Avhich fills up the opening of the artery never becomes identified Avith the tissue of the ves- sel ; that sooner or later it is driven out, and that the aneurism then returns. Thus, in the case related by Saviard, of an aneu- rism at the bend of the arm, the patient, to all appearance, had been cured for the space of near fifteen years, when, in consequence of some effort made, the tumor returned. It is, therefore, useless to hope for the cure of aneurism by any other mode of compression than that of the obliteration of the artery. This point being conceded, it remains only to ascertain Avhich one among the methods that have been proposed is the most suit- able for effecting this result. Scarpa thinks it absolutely necessary that the two opposite walls of the canal should be placed and kept in contact during a certain length of time, but that the compression upon the tumor effects this result Avith difficulty; consequently he advises us to act above the tumor, except, hoAvever, in cases of re- cent traumatic aneurisms. Experience does not corroborate the opinion of Scarpa. Guattani has cured four aneurisms out of the fifteen which he treated by applying his bandage upon the tumor itself. Flajani has obtained the same proportion of cures, under the same circumstances, and every day Ave still hear of the announce- ment of similar results. The aneurismal varix (varice aneurismale) so Avell described by Guattani (De externis aneurismatibus, etc., 1772) and W. Hunter, accommodates itself much better than any other kind of an- eurism to the compressing bandage, and is often cured by this application. The tAvo Brambilla and Monteggia, each relate an example of this kind; it is, at least, a palliative remedy, even though it may not succeed in accomplishing a radical cure. An elastic sleeve, or a simple laced stocking arrests the progress of the disease, and gives to the limb the power of fulfilling its customary functions, Avithout exposing the patient to the slight- est risk of danger. A lady thus treated by Scarpa, Avrote to this TREATMENT OF ARTERIAL LESIONS. 43 surgeon at the expiration of fourteen years, that she experienced no other inconvenience in the affected arm, except occasionally a slight degree of numbness, (engourdissement.) If Cleghorn, instead of advising his patient to change his trade of shoemaker for that of barber, that he might be enabled to hold his arms elevated, had employed compression, he Avould, without doubt, have obtained the same advantage from it. But inasmuch as the state of the patient of Avhom Hunter speaks, had not, after the lapse of thirty-five years, groAvn any worse, that in three seve- ral cases Pott did not feel himself obliged to perform the opera- tion, and that B. Bell, as Avell as Bertrandi, and many others have seen the same result, prudence recommends that in cases of aneurismal varix, Ave ought, before proceeding to the ligature, to make trial of compression. A man Avho has an aneurism of this kind in his thigh since 1813, and whom I have had an opportunity of seeing during the space of two months at La Charite, has never Avorn a bandage, and is scarcely sensible of his infirmity. If we Avish only to support the parts, the laced stocking, or the simple roller bandage of Theden suffices; but if our object is to obtain a radical cure, compression requires other precautions to be adopted, the same, in fact, as for other kinds of aneurism, that is to say, that in addition to the roller bandage carefully (exactement) applied from the free extremity to the upper part of the limb, Avhere it is to be fastened by one or two turns (anses) of spica around the trunk, it is requisite that Ave should previously place upon the tumor, supposing that a tumor exists, some lint, sponge, or gra- duated compresses, saturated Avith cold and repellant (repercus- sives) liquids, and that Ave should apply a long compress (lon- guette) over the track of the artery between the Avound and the heart, and adjust over that, after the method of Sennefio, a special compressor, one for example, like that of Foubert or Du- puytren. Wherever these aneurismal arteries rest upon bones or other solid parts capable of furnishing them Avith a sufficient point d'ap- pui, and Avhere they are not separated from the surface of the body but by the common integuments, the aponeurosis or cellular tissue, compression offers every possible advantage, and should be fre- quently had recourse to, in conformity Avith the rules laid down in the chapter Avhich I have devoted to this subject above. [The Newly Improved Method of Curing Aneurisms by Pressure above the Tumor, (i. e., on the cardial side of it,) and without Oblite- ration of the Artery. The cure of aneurisms by pressure, applied in a more ingenious, methodical, and philosophical mode than by any of the ancient processes above described in the text by the author, has lately been revived by some surgeons of Dublin, and been followed by such happy results, a t have attracted the general notice of the pro- 44 NEW ELEMENTS OF OPERATIVE SURGERY. fession. The actual present condition of our art in relation to this method, and its vast improvement upon the imperfect, painful, and unsatisfactory contrivances hitherto employed, is so Avell described, so clearly explained, and judiciously commented upon, in the re- cent Avork on the Principles of Surgery, by Professor Miller of the University of Edinburgh, (with the exception that, recent as his notice is, it does not embrace the greatest improvement of all, and which has been established Avithin this present year,) that Ave can- not do better, previous to a more particular description of the lately adopted, still more greatly perfected, mode of conducting the pro- cess and of applying its apparatus, than transfer his remarks to this place : " In ancient times, the surgeon who was afraid to cut into the aneurism and take his chance of arresting the flow of blood, had recourse to direct and energetic compression of the part, with the hope of cure. The name of Guattani is chiefly as- sociated Avith the practice. Local sloughing, suppuration, or ulceration, Avith severe constitutional disturbance, yet Avith an unclosed artery and aneurism, resulted more frequently than the cure. Subsequently to the establishment of the Hunterian operation, its principle was extended to the mode of treatment by pressure ; this being applied not to the tumor itself, nor in its im- mediate vicinity, but at some distance—at a part such as would be selected for Hunterian deligation, in the hope of the arterial tissue there being in a sound condition. This method Avas made trial of by Dubois, A. Cooper, Blizzard, &c, but Avith no satisfactory issue. The pressure Avas continued and severe, their object being to keep the tube close at that point, and by plastic deposit, to obtain its com- plete consolidation. The result Avas the occurrence of great pain and constitutional disturbance, folioAved by inflammation, ulcera- tion, or sloughing of the compressed parts—exposing or perhaps including the vessel. The practice found no favor Avith the gene- ral profession. Lately, however, the treatment by pressure has been revived in a more scientific form, and Avith a better success— conducted rather as if itself were not the agent of cure, but only the means Avhereby the spontaneous cure may be originated and favored. The pressure is made at a Hunterian site as before, but is neither constant nor severe. By means of a compressor, such as invented by Crampton and Signoroni, or any other suitable appli- cation, a moderate degree of pressure is applied to the vessel, at a point where its coats may be expected to be sound, and conse- quently not prone to ulcerate from slight causes. This is main- tained so long as it can be conveniently borne by the patient, but no longer. So soon as the uneasy sensations become at all intense, Avith SAvelling and numbness of the limb, and throbbing in the part, the pressure is either slackened or altogether removed. After a time, the parts having recovered, it is reapplied; again it is re- moved ; and thus, by its occasional and modified use, ihe disasters formerly attendant on the treatment by pressure may be alto- gether avoided. At the same time, the circulation in and near the aneurism is decidedly moderated, so as to favor solidification. TREATMENT OF ARTERIAL LESIONS. 45 The tumor is not only arrested in its groAvth, but begins to dimi- nish ; its pulsation is less, and its dimensions contract; it feels harder and less compressible ; ultimately pulsation wholly disap- pears, and induration is complete; absorption then advances, and the obliterative cure is obtained, Avith or without a pervious con- dition of the vessel. But the pressure is not trusted to alone. The same preparatory treatment is necessary as before the operation by ligature; and throughout the Avhole period of treatment, absolute repose, with recumbency, is maintained, as Avell as antiphlogistic regimen and all other means likely to favor the desired beneficial change. Also the limb below the compressed point must be uniformly and equably supported by bandaging, lest passive congestion and cedemas supervene; and this pressure may from time to time be somewhat increased, on that part of the limb Avhich includes the aneurismal tumor. Let no haste be indulged in. The process is necessarily one of Aveeks, not of days ; gradual, not sudden; in- terrupted, not continuously progressive. The pressure requires to be neither great nor constant; for we do not desire obliteration, even temporary, of the arterial tube there; it is sufficient to moderate— not essential to obstruct the flow; and only by a constant remem- brance that such are the principles of cure by this means, will the pressure be so leisurely and prudently conducted as to ensure avoid- ance of the disaster to Avhich compression is liable. The advan- tage of such a mode of treatment, Avhen properly conducted, is im- munity from ulceration and hemorrhage; the disadvantages are, the protracted period and ultimate uncertainty of cure. If impro- perly conducted, it is in every point of vieAv inferior to the ligature, less certain of cure, and even more certain of danger at the selected part of the vessel. Even skilfully managed, it is obviously less capable of general application, there being not a feAv systems pos- sessed of an intolerance of pressure, even Avhen modified and occa- sional. The improved revival, hoAvever, is as yet but in its in- fancy. In the hands of Liston, Cusack, Hutton, and others, it has already succeeded. But a Avider experience is still required, ere surgical opinion can be at rest upon the question. The leading points of the system, it may be again stated, are : The pressure is at some distance from the tumor, moderate, and only occasional; it is not necessary, and it is not our object to obliterate the vessel at the compressed point; in other respects the same treatment is folloAved out, regarding both part and system as in the favoring of spontaneous cure without any surgical interference. (Princi- ples of Surgery, by James Miller, F.R.S.E., «fec, Professor of Surgery in the University of Edinburgh, &c. Edinburgh, 1844, p. 457, 459.) Truly Ave are noAv enabled to add, that Avhen the above Avas published, (last year only,) the process, though it had made such advances since its revival at Dublin in 1842, was still in its infancy; as the greatly improved plan now, it may be said, so far satis- factorily established, by the surgeons of the Irish capital, Avithin the last twelve months, goes far to make this mode of treatment one of 46 NEW ELEMENTS OF OPERATIVE SURGERY. the most invaluable discoveries (for its present perfection makes it a discovery) in the annals of surgery. As it may be justly thought, therefore, by some, that the Pro- fessor of Edinburgh above quoted may have expressed himself with rather too much caution, or, in other Avords, someAvhat doubt- ingly of the brilliant picture anticipated by the Dublin Surgeons in the substitution of their improved modes of applying the ancient process of indirect compression for aneurism, Ave feel obliged, as well by our OAvn favorable impressions as from a strict sense of justice to our brethren of Dublin, and to the profession at large, to lay before them a full, clear, and, to all appearance, impartial re- sume of all that has been achieved up to the present moment by this process. It was first introduced or revived by Dr. Hutton, of the Richmond Hospital, Dublin, for popliteal aneurism, and the last perfection given to it consists in those most important improvements made in the instrument or choice of instruments used for compres- sion, and in the now just-adopted and most successful and philo- sophical principle upon which, according to axioms of sound physi- ology and pathology, that pressure, as happily elucidated by Dr. Bel- lingham, should be applied. WTe therefore take great pleasure in availing ourselves freely of the excellent paper of this eminent Irish surgeon, Avho himself has been one of the most successful in this neAV treatment; Ave mean Dr. Bellingham, one of the surgeons of St. Vincent's Hospital, Dublin. (Vide Dublin Journal of Medical Science, May 1, 1845, art. 5, p. 163, 176.) After enumerating the Avell knoAvn objections and dangers of ligatures upon large arteries, such as phlebitis, gangrene, &c., Dr. Bellingham alludes to the language he used in bringing this subject before the Surgical Society of Dublin, some years since, and after, as we believe, the first successes of Dr. Hutton. Upon that occa- sion, says Dr.* Bellingham, I observed " the application of Avell- regulated pressure in the treatment of popliteal aneurism, cannot but be looked upon as a most important improvement in surgery. The operation of tying the femoral artery is, perhaps, the least successful of that of any of the larger arteries; and Avhen three cases have occurred in succession, in three different hospitals,Avithin a short period, it is not too much to expect that the necessity for performing this operation Avill in future be much diminished. This result, hoAvever, must depend upon the trial of compression in a larger number of cases ; though its success in these offers great en- couragement to surgeons to attempt it, inasmuch as the difficulties which hitherto surrounded it, in the imperfect construction of an instrument for the purpose, have been in a great measure overcome, and the correct theory of the mode of action of compression, and the amount of pressure required for the success of its application, have been nearly established." " That I was not then over-sanguine," continues Dr. Belling- ham, " has been sheAvn by the subsequent results of this mode of treatment; and the success Avhich has attended the treatment of aneurism by compression, may be judged of by the following list TREATMENT OF ARTERIAL LESIONS. 47 of cures which have been effected since its introduction by Dr. Hutton, in November, 1842. The cases are arranged, as nearly as possible, in the order of their occurrence. Cases of Popliteal and Femoral Aneurism, cured by Compression, between November 1842 and February 1845. 1. Dr. Hutton, Richmond Hospital, Dublin, popliteal aneurism. 2. Dr. Cusack, Stevens's Hospital, Dublin, popliteal aneurism. 3. Dr. Bellingham, St. Vincent's Hospital, Dublin, popliteal aneu- rism. 4. Mr. Liston, University College Hospital, London, femo- ral aneurism. 5. Dr. Harrison, Jervis-street Hospital, Dublin, popliteal aneurism. (»'. Mr. Liston, University College Hospital, London, femoral aneurism. 7. Dr. Bellingham, St. Vincent's Hos- pital, Dublin, femoral aneurism. 8. Dr. Kirby, Jervis-street Hos- pital, Dublin, popliteal aneurism. 9. Dr. Allan, Royal Naval Hos- pital, Haslar, popliteal aneurism. 10. Mr. Greatrex, assistant sur- geon, Coldstream Guards, popliteal aneurism. 11. Dr. Cusack, private patient, Dublin, popliteal aneurism. 12. Dr. Porter, Meath Hospital, Dublin, popliteal aneurism. Eight of these twelve cases were treated in Dublin; and in all the cure has been permanent. The aneurismal tumor, in a few in- stances was of very large size, and in a feAv the operation by liga- ture Avould very probably have failed, OAving to the diseased con- dition of the vessel, or some other cause. In the history of the cases it is noticed that the femoral artery could be traced after the cure, to near the sac of the aneurism ; proving that the artery is never obliterated at the point compressed. Dr. Bellingham had al- ready remarked (Dublin Journal,vo\. XXIIL, p. 465,) that such an amount of pressure as Avould obliterate the artery is never neces- sary ; and that a cure would be more certainly and more quickly brought about, by allowing a feeble current to pass through the sac of the aneurism, than by completely checking the circulation in the vessel. As this principle, says Dr. Bellingham, appears to have been established by the results of the cases which have occurred in this country since, I shall now merely quote Avhat I then said upon the subject: " When it Avas considered absolutely necessary for the success of compression, that such an amount of pressure should be applied as was almost certain to occasion sloughing of the part, and very certain to occasion intense pain and suffering to the pa- tient ; and Avhen, in addition, this Avas to be prolonged through five successive nights and days, we can readily understand Avhy patients refused to submit to it; and we can easily account for the disrepute into Avhich the practice fell, and for the unAvillingness of surgeons to adopt this treatment in preference to the simple opera- tion of placing a ligature upon the femoral artery. It Avould ap- pear, hoAvever, that it is not at all essential the circulation through the vessel leading to the aneurism should be completely checked, but rather the contrary: it may perhaps be advantageous at first, 48 NEW ELEMENTS OF OPERATIVE SURGERY. for a short period, by which the collateral circulation Avill be more certainly established. But the result of this case, if it does no more, establishes the fact, that a partial current through an aneu* rismal sac, will lead to the deposition of fibrine in its interior, and cause it within a few hours to be filled and obstructed, so as no longer to permit of the passage of blood through it. Pressure, so as al- together to obstruct the circulation in an artery, must necessarily be slower in curing an aneurism, as it must in some measure, act by causing obliteration of the vessel at the part to Avhich the pressure has been applied; Avhereas a partial current through the sac, enables the fibrine to be readily entangled in the parietes of the sac in the first instance, and this goes on increasing, until it becomes filled ; the collateral branches having been pre- viously enlarged, the circulation is readily carried on through them." No reasoning, in our vieAv, could be sounder than these argu- ments of Dr. Bellingham, or in more perfect conformity to the gradual and simple evolution of the laAvs which nature herself al- Avays observes in all her organic processes. For it is obvious that the sudden and instant interruption to the course of blood in the large trunks, must necessarily be attended Avith serious danger, in a great variety of Avays, and that the true secret of cure by com- pression seems at last to have been reached by following nature herself in her modes of accomplishing her purposes, Avhenever she chooses to bring about the obliteration of vessels. Thus the very partial stream itself more slowly moving through the dilated pouch in proportion to the greater calibre of the latter, (as Mr. Luke re- marks—see above,) not only continues to supply increments of plastic fibrine to the internal chorion-like, shaggy lining of the diseased tumor, but to favor its entanglement, deposition and con- solidation there, as so clearly explained by Dr. Bellingham. (See also the admirable explanations and descriptions of these natural organic processes by Prof. Velpeau, in this and the preceding vo- lumes of this Avork.) But we are anticipating this surgeon. 'It is deserving also of remark,' he continues, 'that in the cases Avhich have been detailed in full, an enlargement of the articular arteries about the knee, coincided almost Avith the cessation of pul- sation in the tumor. This increase in size in the anastomosing vessels, shewing that collateral circulation is becoming established, is obviously a very favorable sign ; and if it occurs early during the treatment, Ave may look for a speedy cure, as it indicates the filling up of the aneurismal sac' The principal improvement Avhich has taken place in the treat- ment of aneurism by compression, consists in the mode of applying the pressure ; that is, instead of employing a single instrument, we employ tAVO or three, if necessary ; these are placed upon the arte- ry leading to the aneurismal sac ; and Avhen the pressure of one be- comes painful it is relaxed, the other having been previously tight- ened; and by thus alternating the pressure, we can keep up con- tinued compression for any length of time. By this means the TREATMENT OF ARTERIAL LESIONS. 49 principal obstacle in the Avay of the employment of pressure has been removed; the patient can apply it, with comparatively little inconvenience to himself; time Avill not be lost owing to the parts becoming painful or excoriated from the pressure of the pad of the instrument; and as the pressure need not be interrupted for any length of time, the duration of the treatment Avill be necessarily considerably abridged. "Some of the success," continues Dr. Bellingham, "of the im- proved method of applying pressure must, hoAvever, be referred to the improvement of the instrument used. That Avhich I employed, (made by Millikin of Grafton street, Dublin,) is a modification of a carpenter's clamp, Avhich Avas invented by a patient under Dr. Harrison's care, for popliteal aneurism, whom I had the opportu- nity of seeing several times, both Avhile under treatment and after a cure had been effected. It consists of an arc of steel, covered with leather, at one extremity of Avhich is an oblong padded splint, the other extremity terminating in a nut containing a quick screw, to which a pad similar to that of the tourniquet is attached. The principle of this instrument is exceedingly simple, so much so, that the patient can regulate its application himself; and it can be made of every size, so as to compress any Aressel Avithin the reach of compression. It appears to be a much superior instrument to that Avhich Avas employed in the treatment of the cases in the London hospitals, the application of Avhich cannot be maintained for any length of time Avithout occasioning severe pain." § I- The advantages of Compression over the Ligature in the treat- ment of external aneurism, are, as enumerated by Dr. Bellingham, as folloAvs: a. There is not the slightest risk to the patient, and it is exempt from all danger; Avhich of itself, on the score of humanity alone, is an argument of great Aveight; but Avhen connected Avith the fact that the cure has been complete in CAery case Avhere the process has been carried out, it becomes, in comparison Avith the ordinary mode by the knife and ligature, inestimable. b. Pressure is applicable to certain cases of aneurism, Avhere the ligature is not, or Avhen the ligature Avould be likely to be followed by unfavorable results. Thus, large sized aneurismal tumors act injuriously by pressure on the collateral circulation, both the Areins and arteries,sometimes obliterating the latter, and causing,as a gene- ral result, from this obstruction, cedema of the limb beloAV, or on the application of a ligature under such circumstances, Arery probably gangrene. Whereas this cannot happen from the treatment by pres- sure, Avhich acts as Ave have already remarked, slowly and gradu- ally, giving time for nature herself to accommodate her OAvn laws to this mechanical modification, applied to them, and Avhich pres- sure moreover, can be interrupted at any time, or removed, beinsj perfectly within our control. 4 50 NEW ELEMENTS OF OPERATIVE SURGERY. c. Dr. Bellingham, indeed, is of opinion that pressure Avould be likely to succeed more generally in curing a large than a small aneurism, inasmuch as the lining of the sac of a large aneu- rismal tumor, is generally rougher and more irregular than that of a small one ; it Avill therefore more readily entangle the fibrine of the blood, Avhich is allowed to Aoav through it. Moreover, in several of the examples of aneurism, cured by compression, Avhich have been published, the tumor Avas of a large size. d. Again, Avhen an aneurism has attained a large size, if its con- tents are principally fluid, and its parietes are much thinned, inflam- mation and suppuration of the sac very commonly folloAv the application of the ligature, Avhich may bring the patient's life into danger, and at best must render the recovery very tedious. This has never occurred yet after the use of compression, and such a result is evidently much less likely to folloAv it. Mr. Cusack's last case of popliteal aneurism cured by compression, is an example in point; the tumor Avas of large size, the circumference of the limb at its seat, being five and a half inches greater than on the opposite side ; its parietes were so much thinned that " great apprehensions were entertained, lest they should give Avay;" the limb was like- wise cedematous; and yet every thing proceeded as favorably as could have been desired, and the cure Avas completed Avithin a shorter period than in several of the other cases Avhich have been related. Mr. Liston's second case of femoral aneurism cured by compression, is also a good example ; here the aneurism is stated to have been no less than sixteen inches in circumference. e. Aneurism not unfrequently occurs in individuals in Avhom the coats of the artery betAveen the tumor and the heart are so much diseased, that the vessel, instead of taking on the adhesive inflam- mation after the application of the ligature, ulcerates ; or the liga- ture cuts its Avay through, (causing often dangerous if not fatal secondary hemorrhage where such diathesis of arterial degenera- tion exists—T.;) or aneurism may occur in subjects laboring under vascular or other disease of the heart. In such cases the operation by ligature is contra-indicated, and Avould almost neces- sarily fail; Avhereas pressure may be applied with the same pros- pect of success as in subjects in whom the heart and arteries are perfectly healthy. In one of the earliest cases of popliteal aneu- rism treated by compression, since its re-introduction by Dr. Hut- ton, the patient Avas not considered a favorable subject for opera- tion. We question, however, if Dr. Bellingham may not be a little too sanguine on this point, in cases Avhere an actual arterial degene- racy or a general vitiated tendency in the structure of the great trunks exists. Here, as Ave conceive, general or internal constitu- tional treatment, Avere any such ever to be brought to light, for such organic maladies, and Avhich the recent brilliant discoveries by Leibig and others on the constituents of the blood and its secre- tions, and the functions of the heart, arteries, and other vessels and organs, Avould encourage us to believe should consist in all those Kinds of nutriment that would increase the amount of the plasti: TREATMENT OF ARTERIAL LESIONS. 51 or gelatinous products of nutrition, and diminish the earthy and uric deposits, Avould come in as admirable therapeutic adjuvants to the humane and bloodless surgical discoveries, on the cure of aneurism by compression. While the enlightened principles of the Dublin School of Surgery, regardless of the eclat of dazzling triumphs with the knife, looks disinterestedly and Avith a noble feeling Avorthy the chivalry of the Irish heart, to the great ends of philanthropy, by devising all modes of ingenious mechanical appa- ratus that can be found as substitutes for cutting instruments, in the same Avay that mechanical art has been made so subservient in this respect to the almost miraculous and also bloodless conquests of myo-tenotomy, so Ave repeat may the rapid and unanticipated progress of rigid analysis as applied to the living organic elements of the human body, under the auspices of German, French, and British chemists, constitute and create a new era in physiology, pathology, and therapeutics, that may in time supersede the harsher expedients of chirurgical science in the great and yet imperfect department of aneurismal as Avell as other diseases. /. Dr. Bellingham, hoAvever, in his defence of this new process, as its Avonderfully improved modes entitle it to be called, continues thus : " Pressure is applicable to cases of the aneurismal diathesis, and Avhen more than one aneurism exists at the same time ; cases in which the operation by ligature is likeAvise contra-indicated; as Avell as to cases of spontaneous aneurism occurring in individu- als of intemperate habits, or of broken doAvn constitution, in Avhich the surgeon Avith great reluctance would perform any operation." We Avould apply to this part of Dr. Bellingham's arguments the same remarks Ave have made upon the last subdivision. g. A feAv cases have been related in which the operation by liga- ture failed, in consequence of some irregular distribution of the artery above the aneurism. Noav in such cases, compression promises to be equally effectual as in any other. h. Again, cases occasionally occur Avhere the patient has too great a horror of the knife to submit to its application on any con- ditions, but Avould readily conform to the mild and more natural, and to all men's senses more rational, process of compression. In- deed it may be said, remarks Dr. Bellingham, to have been this accidental circumstance Avhich led to the recent re-introduction of compression in the treatment of aneurism. i. Lastly, if pressure should fail to cure an aneurism, (which from the results hitherto observed is very unlikely,) its employment Avill not preclude the subsequent operation by ligature; but by retarding the increase of the aneurism, and assisting in the estab- lishment of the collateral circulation, it Avould tend rather to render the chances of the operation by ligature more favorable. This undoubtedly is a ATery solid argument Avhich cannot be gainsaid, and considering the now perfected and almost painless mode of employing continued pressure, as at last established by the perse- A'ering and honorable efforts of the Dublin Surgeons, no practi- tioner Avould be justified, in any case to Avhich this method could 52 NEW ELEMENTS OF OPERATIVE SURGERY. be applied, in Avithholding a full and fair trial of its poxvers before proceeding to the knife. § II. Objections to the Treatment of Aneurism by Pressure answered. Dr. Bellingham continues : a. That the arteries are few in number to Avhich this treatment can be applied ; but Avhat is really the fact ? The artery above all others, in Avhich aneurism is most frequent, after the aorta, is the popliteal, and next in frequency come the femoral and brachial. Lisfranc has given a table of 179 cases of aneurism, (exclusive of those of the aorta,) collected from various Avorks, and of this num- ber there were 59 cases of popliteal aneurism, 17 of the carotid, 16 of the subclavian, and 5 only of the external iliac. But even this must be much beloAV the average, for feAV cases, comparatively, of operations for popliteal aneurism have been published, (owing to its frequency,) unless there happened to be some peculiarity in the case ; Avhereas most of the operations upon the iliac, subcla- vian and carotid arteries, ha\^e been brought before the profession, on account of the infrequency of the disease in those vessels. It must be recollected also, that aneurism of the subclavian or carotid arteries, near their origin, and of the common iliac or innominata, which do not admit of the application of compression, do not admit either of the employment of the ligature. It surely therefore ought not to be urged against this method, that because aneurism occurs in arteries beyond its reach, we should refuse to apply it to vessels to which it is adapted ; or that the practice should be denounced, because it is not applicable to every vessel. We do not despair Avith Dr. Bellingham, such is the prestige in our vieAv of the neAV mode, that it may not. yet come to be applied both to the arteria innominata and common iliac. To the abdominal aorta trunk Ave haAre had within a feAV years ample proof of the value of pressure in the saving of life in formidable uterine hemor- rhage, and the ligature itself on the innominata has proved in the hands of Dr. Mott, and others Avho succeeded him in that operation in surgery, the incontestable truth that life and all its functions may bs prolonged for three or more weeks after the sudden interruption of at least one-third of the whole column of blood throAvn from the heart. Nor is it by any means established, since the number of times that a ligature has been placed upon the innominata is noAV only six, and that, as an offset, if Ave please, to the tAvelve cases of complete cures by pressure, (vid. list above,) all these innomi- nata-ligature cases haAre without an exception ended fatally ; that some more skilful mode of curing aneurisms beyond the trunk of this vessel may not yet be devised by some more fortunate surgeon than those who have hitherto attempted it. Moreover if it be now certain that life, and the whole organization can be thus sustained after so great a concussion as this may be termed to be, upon the hydraulic movements of the vital current, and if compression shall come to be substituted for the knife, why may not the day arrive TREATMENT OF ARTERIAL LESIONS. 53 on the other hand, where the knife itself, in cases Avhere pressure cannot be applied, might not be brought into use perhaps as an adjunct to carry out the very principles of compression. Thus it has suggested itself, that some plan may yet be devised by which indirect pressure could be made to include the innominata and its immediate cellular connections, and by Avhich a graduated and ex- ceedingly moderate force would, instead of ulceration, promote the thickening, granulation, cicatrization, and consolidation of the surrounding tissues, so as to bring about a gradual approximation of the tunics of the artery, and a corresponding diminution in the calibre and volume of blood in its trunk. This suggestion may seem to be almost chimerical, if not fanciful. In the strides, hoAv- ever, that surgical science and human ingenuity are daily making, it would seem that there should be no hypothesis, hoAvever absurd, that might not be indulged in as a stimulus at least to the new application of the laAvs of ascertained scientific truths, or to the dis- covery of neAV laAvs and truths. Acupuncture too, perhaps, and electro-puncture which have not, as it seems to us, kept pace Avith the progress of surgery, may be destined in this age of astounding discoveries in electro-magnetic science, to be employed as a means to effect by a gradual process, the partial consolidation of the plastic and fibrinous portions of the blood in all aneurismal tumors Avhere- cver situated, and upon Avhich result after all, the whole treatment by compression, (and by the ligature also it may be said,) ultimately reposes, as constituting the great laAV of vascular obliteration Avhich nature herself has adopted and folloAvs. (See acupuncture and electro-puncture as considered by M. Velpeau in this and the pre- ceding volume.) The experiments of physiologists and chemists, skilled in re- searches into organic life, might also, Ave should suppose, be Avell combined to discover some mode different from any Ave have sug- gested, and far more efficient than the above improved method of compression itself; Avhereby, through means of sub-cutaneous or sub-tunic puncture, for example, and some stimulating injection as well as electro-puncture, aneurismal tumors and pouches might, to- gether with the auxiliary means of pressure on the trunks leading to them, be made to have their contents gradually consolidated throughout the Avhole extent included Avithin their parietal cover- ings. For this, Ave repeat, is the great principle to be constantly kept in view in our investigations, and which the above remark- able cures by pressure have fully established. We see Avhat chem- istry, by means of electro-magnetic agency, is now doing in the arts by the coating and embossing of substances with metallic pre- cipitates ; and though Ave are far from looking upon the vital fluids, canals, and tissues as inorganic hydraulic tubes or troughs in a laboratory, we know enough now of Avhat may be done by chemi- co-organic re-agents upon the living blood in its own vessels,* * Death by electricity, and the fluidity of all the blood which it instantly effects, though militating against consolidation, is perhaps a per contra argument for these speculations, an the reverse phenomenon of the separation and coagulation of the fibrinous portion of the blood in Asiatic cholera, from 6omc similar electric influence, perhaps, is a direct ar- gument. 54 NEW ELEMENTS OF OPERATIA'E SURGERY. to lead us to hope that the day is not distant when not only aneu- rismal sacs shall be consolidated, and the collateral sluices opened by some such processes, but Avhen, on the other hand, Ave shall be placed in possession of far more potent and rapid discutients than are yet known, Avhereby consolidated morbid growths and tumors may be dissolved, and dispersed, and carried harmlessly out of the system, by absorption, into the general current of the circulation. In support of Avhat may be now denominated this, in our opin- ion, clearly-established process of plastic or fibrinous consolidation of aneurismal sacs, Ave Avould call to our aid the more recent re- searches on the subject of the composition and nature of fibrinous and other tumors, (which will be treated of in the beginning of and also throughout our last volume,) and also to what Avas so lu- cidly expounded by the practical though less chemico-analytical observers of other days, (by John Hunter, especially,) in their graphic, though brief descriptions, of that peculiar plastic process by which Avounds heal by first intention, and which, Avhile it is so like apparently to the natural process of nutrition or accretion of healthy organic matter, yet Avould seem different from it. This process, the nature of which has again come actively into discus- sion through the important uses to which it is made subservient in sub-cutaneous and anaplastic surgery, in the restitution and repara- tion of parts, &c, Avill be found ably treated of by our author, M. Velpeau, and others, in the animated debate Avhich took place in the French academy, and of which Ave have given an extended abrege in our first volume. Professor Miller, of Edinburgh, has gone so far as to discard, upon such views, all the received notions on inflammation, and to consider it little more than excessive nutritive action. In curative processes, Ave knoAv for a long time how happily this organic plas- tic power has been employed in the treatment of hydrocele, and from time immemorial, in the granulation and cicatrization of all purulent sacs, passages, &c. A new and most ingenious applica- tion of it both Dr. Mott and myself had an opportunity of Avitness- ing in the cure of formidable hernice, such, Ave mean, as Avere reducible, though large and of long standing. We have thus, in several instances, seen the contents of a large inguinal hernia first replaced in the abdomen, and then, through a careful sub-cutane- ous puncture at a suitable distance from the external ring, a stimu- lating injection (of diluted tincture of cloves) throAvn upon the out- side of the sac, Avhich, followed by a slight inflammation, redness, and tumefaction externally, without suppuration, has, after a feAV days in the recumbent posture, resulted in complete closure of the hernia by the agglutination of the outer walls of the tumor and of its neck, with those of the external ring—effecting thus a perfect cure of the disease. In fact, a proposition has recently been made to inject tannin into aneurismal sacs, to corrugate and contract their muscular fibres and to promote the consolidation of their blood. We mention these facts, Avhich might be largely augmented by what occurs in every day's experience, as illustrations of a great TREATMENT OF ARTERIAL LESIONS. 55 organic law, Avhich seems destined to be brought into requisition to fulfil a yet more important part than it hitherto has done as a great therapeutic agent. b. " It has been objected," says Dr. Bellingham, " to this method of healing aneurism, that the pulsation is likely to return, in con- sequence of the artery not being obliterated at the point at Avhich the pressure is applied, and that the patient, therefore, cannot be considered safe from a relapse for a considerable period." Dr. Bel- lingham deems the reverse to be true, and that pulsation is more likely to folloAv a ligature than pressure above (i. e., on the cardial side of the tumor) the artery ; because the manner in Avhich pres- sure brings about the cure of aneurism, appears to be nearly that by Avhich nature, under the most favorable circumstances, effects a spontaneous cure. The fibrine of the blood is entangled by the lining membrane of the aneurismal sac, successive depositions occur until the sac is completely filled, the tumor becomes solid, and all pulsation ceases. The sac no longer permitting the pas- sage of blood through it, the collateral branches become enlarged, and the circulation is carried on by them. The tumor then gradu- ally diminishes in size, OAving to the absorption of its contents and the gradual contraction of the sac, and finally it disappears. On the other hand, Avhen a ligature is applied to an artery, as, for in- stance, to the femoral, for popliteal aneurism, the current of blood into the sac is at once interrupted ; after a time, hoAvever, the blood finds its way into it by the collateral branches : now if an anasto- mosis of large vessels exists between the branches of the arterv above the ligature and those betAveen it and the aneurism, a strong current of blood will come to pass through the sac, and the pulsa- tion Avill return ; Avhich cannot happen in the former case, for the reasons stated. The sac of the aneurism, likeAvise, after the ap- plication of the ligature, not being necessarily filled by solid fibrine, but by a coagulation Avhich may be more or less loose, pulsation is more likely to return, as the sac must contract considerably be- fore the patient can be considered safe from a relapse; and this, from the inelastic nature of the parietes of the sac, must require, sometimes, a long time to be accomplished. Dr. Bellingham has admirably comprehended the superior effi- cacy of the process by Avhich compression effects a cure, because, different from the violence of a ligature, it is a process entirely conformable to a great normal organic law of nature in the groAVth and reparation of parts. c. This mode, by compression, it is asserted, is more tedious and more painful than that by ligature. That it is, says Dr. Bel- lingham, less tedious sometimes, several of the cases published clearly prove. In one of the last by compression published, the pul- sation in the aneurism ceased in a feAV days after the application of the two instruments ; in some of the others the cure Avas also rapid ; and if in a few others, in Avhich this mode of treatment Avas adopted, a larger time elapsed, it depended probably upon the im- perfection of the instrument, the irritability of the patient, or upon 56 NEW ELEMENTS OF OPERATIVE SURGERF. two compressors not having been employed together. With respect to the treatment of compression being more painful than the ope- ration of placing a ligature on the A'essel, including the subsequent dressings, until the ligature separates and the wound is healed, this might have been an argument against the method, Avhen so great a degree of pressure was supposed to be necessary, as would oblit- erate the vessel at the part to Avhich the instrument Avas applied; but the fact is, the application of the compressor (according to the rules laid down now) really relieves the pain which the aneurismal swelling occasions; after it has been applied, hoAvever, for a cer- tain time, the pressure does cause pain, but the patient then can relax it, after having tightened the other instrument, and so con- tinue to compress different parts of the vessel for any length of time. The power or capacity of the living organization, to sustain for a greater or less period of time an incredible amount of pressure from external bodies, Avithout being destructive of life or materi- ally impairing the functions of the part compressed, has (Dr. Bel- lingham might have added) been long familiar to every one: as, for example, in the ancient usage of tight swaddling clothes to the new-born infant; the reprehensible and, until lately, universal practice of early and severe pressure by bandaging to the limbs, &c, in fractures, ordinary wounds, &c.; the instances Avhere, in casualties by the crushing and falling of buildings, &c, masses of persons have, Avithout injury or destruction of life, been Avedged, jammed, or impacted. together, for days even, in a manner which it Avas difficult to suppose could be for a moment reconcileable to, or compatible Avith, human existence ; and, lastly, the remarkable changes Avhich the form and dimensions of the organization itself may be made to assume from continued, severe, and apparently intolerable pressure, as to the cranium, as is related of the infants of Caribbean and other Indian tribes, and as to the feet among the Chinese, Spaniards, &c, &c. A more familiar, every-day example of the capacity of the external tissues and coverings to undergo severe pressure, prolonged to such extent as to cause almost entire absorption of the part pressed upon, is seen in the withering, atro- phy, and absorption of certain muscular tissues, as the glutei mus- cles in shoemakers, actors, students; all the muscles of the ham in cavalry soldiers, postillions, carriers, &c.,from their sedentary occu- pations or their position causing constant pressure on certain mus- cular and soft tissues, being the reverse of the extreme develop- ment which, on the contrary, certain muscles undergo, a fortiori, by constant use, as in the biceps, deltoid, pectoral, and other mus- cles of the arm in the blacksmith, forgeman, &c, the entire muscu- lar masses of the thigh and leg, (especially the flexors of the thigh and leg, and the gastromenii and tendo Achillis,) in the dancing mas- ter, circus vaulter, pedestrian, &c. The therapeutic value of pressure also has long been familiarly known in the cure of certain morbid growths, tumors, &c. By means of this mechanical resource alone, as is more particularly TREATMENT OF ARTERIAL LESIONS. 57 illustrated in the perfect cure of old ulcerations and cedematous and varicose enlargements of the legs in intemperate persons, or those Avho are constantly standing on their feet, by means of the adhesive straps, &c. first introduced by Baynton; and the cure of many cases of lateral or other curvatures of the spine and limbs by means of counteracting pressure (redressement) to the parts' which have been deviated by the too great power of the antago- nistic muscles. (Vid. Vol. I. of this Avork.) M. Velpeau shows its value as a means of radical cure in Avounds of the brachial artery, in the operation of bleeding; and M. Amussat has also lately called special attention to it. On the other hand it is a someAvhat singular coincidence that pressure should be found to be a perfect cure for that kind of aneu- rism more especially (Ave mean the popliteal) Avhich has itself been supposed to be most generally produced by excessive pressure to that artery in the ham, as in postillions, carriers, cavalry soldiers, and others accustomed to pass a great part of their lives on horse- back. The formation of the aneurisms too in these cases goes to corroborate the vieAvs of Dr. Bellingham; for in such persons the column of blood in the arterial trunk or popliteal, is subject to fre- quent and total interruptions, not partial and incomplete. d. It has been also urged, says Dr. Bellingham, that the period which has intervened since the re-introduction of this method of treating aneurism, is too short to alloAV us to conclude, that the cures will be permanent. I do not know the exact period of time Avhich it is considered necessary should elapse, before a cure in such a case can be pronounced permanent; tAvo of the cases of aneurism cured by compression in this city (Dublin) have remained well for upAvards of two years, and tAvo others for nearly the same period, and in none of the remaining cases has there been any tendency to, or appearance of a relapse. Noav, supposing for argument sake, that the aneurism should return—the same thing has occurred after the application of the ligature; and if there should be a relapse, would not pressure then be as applicable as in the first instance ? and would not its employment be much more certain and safe, than the application of the ligature a second time ? e. The last objection is from Mr. Syme of Edinburgh, who urges that the ligature is so easy, so perfectly safe, and gives so little suf- fering, that the laborious, distressing, and tedious procedure, by compression re-introduced by a Surgeon of Dublin, will he thinks, return to its original obscurity. Mr. Syme having tied the femoral artery thirteen times Avithout meeting with the slightest unpleasant symptom—will not, he says, deviate from this line of practice. Se- veral surgeons of Dublin however, says Dr. Bellingham, who have tied the femoral artery more than thirteen times, have thought proper to deviate from this line, and to adopt pressure. Dr. Bellingham feels warranted in coming to the following con- lst. That the arteries to Avhich pressure is applicable, being far more frequently the subject of spontaneous aneurism, than those to 58 NEW ELEMENTS OF OPERATIVE SURGERY. Avhich it is inapplicable, compression promises to supersede the li- gature in the great majority of cases. 2nd. Pressure has several obvious advantages over the ligature, being applicable to a considerable number of cases in Avhich the li- gature is contra-indicated, or inadmissible. 3rd. The treatment of aneurism by compression, does not involve the slightest risk; and even if it should fail, its employment not only does not preclude the subsequent operation by ligature, but renders the chances of the operation by ligature more favorable. 4th. That such an amount of pressure is never necessary as will cause inflammation and adhesion of the opposed surfaces of the Aressel at the point compressed. 5th. Compression should not be carried so far as completely to intercept the circulation in the artery at the point compressed ; the consolidation of the aneurism Avill be more certainly and more ge- nerally brought about, and Avith less inconvenience to the patient; byalloAving a feeble current of blood to pass through the sac of the aneurism. 6th. Compression by means of two or more instruments, one of Avhich is alternately retained, is much more effectual than by any single instrument. 7th. Compression, according to the rules laid doAvn here, is nei- ther very tedious nor very painful, and can be maintained in a great measure by the patient himself. 8th. An aneurism cured by compression of the artery above the tumor, according to this method, is much less likely to return than when the ligature had been employed. Dr. Bellingham regrets to add that some of the objections to this new and hitherto successful mode of compression, by the Dublin Surgeons, haATe sprung as he considers from a discreditable feeling of jealous rivalry tOAvards the Irish school, on the part of those of London and Edinburgh, a feeling which Ave cannot permit ourselves to believe could exist in any generous mind, when all should be alike emulous to surpass each other in the discovery or invention of improved or neAv modes of affording relief to suffering humanity ; for that is, or should be, the common end and aim of all. The two great principles then of this cure of aneurism by com- pression, as laid down by Dr. Bellingham, and which are undoubt- edly the only rational grounds by Avhich Ave can hope for success, resolve themselves into these :— 1. Alternate Compression on different parts of the sound portion of the track of the Artery on the cardial size of (he tumor, by means of the ingenious and simple compressors now used Avith such un- varying success by the Dublin surgeons. 2. The diminution of the volume of blood in the affected trunk and not its total interruption.—Of these tAvo fundamental axioms, how- ever, it must be borne in mind, that the latter which is of infinitely greater pathological importance of the two, and necessarily the result of the mechanical means of compression employed in the first, is not as might at first be inferred a new principle, but Avas Avell TREATMENT OF ARTERIAL LESIONS. 59 known to those Surgeons who advocated and made trial of com- pression in the early part of the present century. Various instru- ments, after extensively detaching the femoral, Avere then tried, for pressing upon the vessel, without impeding circulation through the limb, and Avith success in cases of popliteal aneuism. (See Cor- mack's London § Edinburgh Monthly Jour, of Med. Science, Oct. 1844, p. 824, &c.,and Boyer, Traite de Malad. Chirurg., Vol. II.,p. 234.* T.) § II.—Direct Compression. It often happens, that surgeons find themselves so situated as to render it impossible for them to tie an artery which they have opened either by mistake or design ; in such cases it is their usage, in order to save their patient from death, to plug up (tam- ponner) the Avound, and compress the vessel by applying to it, directly, the different substances eulogized by Trew, Teich- meyer, &c. This method, besides being much less frequently em- ployed than indirect compression, possesses in fact much fewer ad- vantages, and ought, at the present day, to be Avholly rejected : some success has nevertheless been imputed to it. (See obser- vations of Dr. Mott, supra et infra. T.) a. Plugging or tamponing, (tamponnement.)—Guattani, having to treat a very large inguinal aneurism, caused it to be opened by Maximini, Avith the intention of applying, immediately upon the artery at the bottom of the sac and against the pubis, graduated compresses, firmly secured by a spica to the groin. Everything succeeded to the satisfaction of the surgeon; the dressing Avas Avas removed at the end of thirteen days, and the patient Avas per- fectly restored. A man had an aneurismal tumor on his groin as large as the head of a child. Mayer (Rougemont, Bibliot. du Nord, p. 189) took it at first for a hernia, and deciding to lay it bare in order to reduce it, did not discover his mistake until after having divided the common integuments and the aponeurosis. A great quantity of bloody matter, Avhich had accumulated between the sac and the adjacent parts Avas iioav removed ; in place of laying open the tumor, Avhose pulsations sufficiently indicated its charac- ter, Mayer confined himself to making methodical compression upon it, Avhich he subsequently renewed Avith every possible care. The patient was cured. Desault, in a case very similar, compressed, it is said, the upper end of the artery Avith tAvo pieces of wood, united together in the * See hIgo the numerous authorities arranged by our author M. Velpeau, in the text immediately preceding this note, and wherein it will be perceived that compression above the artery, i. e , on ihc cardial side of the aneurismal tumor, was long since the subject of invest g;it.ion, and obtained success even by the then crude modes of applying it. And it will a'6o be seen thnt the very germs too of the great principles so successfully applied to practice by the Irish Surgeons, were years since anticipated in France and elsewhere,. not only as to highly ingenious contrivances and to compression on several points of tha yeisel, but also as to tho master principle of only partially interrupting the current of blocwL 60 NEW ELEMENTS OF OPERATIVE SURGERY. manner of a forceps, by means of a portion of thread, by Avhich means he Avas enabled to dispense with the ligature. A young student of medicine, aged fifteen, saw the blood burst from the femoral artery Avhile he Avas dressing a Avound in the groin; his dressing forceps served him instead of Desault's pieces of Avood; it was left undisturbed, and M. Champion assures me that the ar- tery Avas rapidly becoming obliterated, Avhen the patient Avas attacked Avith hospital gangrene, and died on the fourth day. But this procedure, excusable at the epoch at which it occurred, and in so young a student, Avould be censurable at the present time. If the aneurism is so high up as not to admit of our cutting down to, or compressing the femoral artery betAveen the tumor and Poupart's ligament, we apply a ligature to the iliac artery, and avoid the danger Avhich Guattani and Desault made their escape from, only as it Avere by a miracle. Sabatier himself, nevertheless, thought it advisable to undertake direct compression for an aneurism in the upper third of the thigh ; the patient was a young man aged tAventy- two years; two tourniquets Avere applied—one on the fold of the groin, and the other a little loAver doAvn. The tumor being opened and freed of its clots, the aperture of the artery Avas discovered, and found to be perfectly round. Sabatier passed under this vessel, above and below the opening, a needle armed Avith a strong thread, Avith the intention of completing the ligature, should that become necessary. A pad (coussinet) Avas placed on the posterior part of the thigh opposite the wound, Avhich latter was filled up Avith a pyramid composed of pieces of agaric and compresses; lint Avell sprinkled Avith colophane Avas arranged around the pyramid, in such manner as to support it, and everything kept in place by com- presses and an ordinary bandage; some slight hemorrhages su- pervened, but the patient ultimately recovered, and Avas enabled to walk at the expiration of tAvo months. Notwithstanding so many fortunate results, obtained by surgeons of the first rank, Ave ought nevertheless to reject this mode of treat- ment from sound practice. The only cases in Avhich we Avould be permitted to make trial of it, would be those of false primitive aneu- risms. At the farthest, it would be applicable only to arteries of the fourth order, or in those cases where, after having opened an aneu- rismal sac, it becomes impossible to find the artery—a difficulty Avhich Ave can scarcely conceive possible, and Avhich, moreover, could not become a source of embarrassment at the present time, except in cases Avhere the disease Avas in too close proximity Avith the splanch- nic cavities. b. The Artery-presser, (presse-artere.)—Desirous of avoiding the vein, nerve, &c, and of concentrating as much pressure as pos- sible upon the artery, many surgeons have substituted instruments in the form of a forceps, in lieu of the bandage and lint formerly in use. Percy, [Soc. Med. d'Emulat., t. VIII, p. 689,) in order to fulfil this intention, recommended, in the year 1792, first a plate of lead; then, in 1810, a steel forceps, terminated by two small plates, and cleft in the direction of its length, hi order that Ave TREATMENT OF ARTERIAL LESIONS. 61 might be enabled, by means of a button, to graduate at pleasure the pressure upon the artery, (.Soc. Mad. d'Emulat., t. VIII., p. 711.) In the same year, Duret, of Brest, (These, Paris, 29 Aoul, 1810,) made knoAvn an instrument constructed upon similar principles; that is to say, a forceps similar to the valet a patin, and Avhich he denominates the aneurismal forceps. According to M. Roux, (Md. Oper., 1.1.,) an artery-presser, (presse-artere,) almost in every respect similar to this, had been devised, in 1808 or 1809, by M. Levcsque, a description of which is given in his Thesis. (These No. 153, Paris, 1812.) A third kind of artery-presser, invented by Assalini and formed of tAvo branches of silver united in the manner of a dressing-for- ceps, and having between their handles an elastic spring Avhich constantly tends to shut them, bears much resemblance to that of Duret. Assalini affirms that he has cured aneurisms in the thigh and ham, by leaving his instrument in place for the space only of three or four days, and even after an interval of tAventy-four hours. The artery-presser of M. Henry, (Soc. Med. d'Em. t.VIIL, pi. 6, fig. 7, 8 et 9,) shaped after the manner of the angular ex tremity of the shoemaker's podometre, or that of the pelvimeter of Coutouly, has the advantage of being kept more securely in its place, and of giving less fatigue to the parts than those of Percy, Duret, and Assalini. (Manuel de Chirurgie, fyc.) Forceps and other metallic instruments, which have also been proposed for effecting the same object, by combining them with ligatures, will claim our notice a little further on. Such are the artery-presser of Deschamps, Dubois, Cramp ton, Ayzer, Ristelhueber, and the one which M. Chiari (PL Portal, Clin. Chirurg., t. I., p. 156) says he has made use of eight or ten times with success. § II.— Various Means. A. Cauterization.—Cauterization has been applied in two modes, in the treatment of aneurism. Some, in fact, before the knowledge of the circulation of the blood, ventured to apply escharotics more or less poAverful upon aneurismal tumors and the skin Avhich covers them. Others commenced by opening and emptying the bloody sac; aftenvards they cauterized the lacerated part of the artery, either Avith red-hot iron, or the concentrated acids, or by introduc- ing into this orifice lozenge-shaped plugs (trochisques) and pegs (chevilles) of alum or vitriol. Then also, and eAren since, they con- fined themselves sometimes to filling the Avhole wound Avith lint or oakum, (etoupe,) impregnated Avith the same cauterizing sub- stances. Such means Avere good Avhen the nature of aneurisms Avas unknown, and Avhen no one Avas possessed of anatomical knowledge sufficiently accurate to venture to use the bistoury; but at the present time they are named only to be proscribed, and to show Iioav advanced modern surgery is from that of the ancients. B. The Suture.—ToAvards the middle of the last century, Lam- 62 NEW ELEMENTS OF OPERATIVE SURGERY. bert, (Med. Obs. fy Inquir., t. II.) an English surgeon, proposed to cure arterial Avounds by means of the tAvisted suture. From the fact that, after phlebotomy, veterinary surgeons usually close the vein by a stitch Avith the needle, he thought that if this means, which Guy de Chauliac (Traict. 3, doct. l,chap. III.,p. 254) seems to have hinted at, Avere applied to man, it might be attended Avith the same advantages. Some trials confirmed him in his opinion; and his efforts, it is said, Avere crowned Avith complete success in the case of a man Avho had a traumatic aneurism in the arm, and whom he presented for examination before the members of a medical society at London. The great importance of the su- ture, hoAvever, according to Lambert, consists in its enabling us to preserve the calibre of the artery. But Asmann, (De Aneurismate, Groningue, 1773,) having proved that he was deceived on this point, and shoAvn, as Galen has done, that the suture can effect a cure only by obliterating the vessel, his proposition, which has not been since revived, and Avhich does not merit any further descrip- tion, Avas soon forgotten. C. Torsion.—Torsion having been examined as a haemostatic means, (Vid. Vol. I.,) I haA^e only to consider it here in its relations Avith aneurisms. Torsion being found sufficient to arrest traumatic hemorrhage, Avhenever the gaping extremity of the bleeding vessel can be iso- lated and conveniently grasped, seems, according to the experi- ments of M. Thierry, (Z> la Torsion des Arteres, Paris, 1829,) to be of a nature calculated also to effect the cure of aneurisms. After having publicly sustained this idea in a concours, M. Thierry made a certain number of experiments on the carotid of horses. His process consists in raising up the artery Avith the needle of Deschamps, Avhich he afterAvards makes use of as a garrot to tAvist it, ahvays in the same direction, and a certain number of times, in proportion to its calibre; that is, four times for a small artery, six for a middle sized one, and eight to ten for the trunks of the largest volume. The experiments were invari- ably folloAved by the complete obliteration of the tAvisted vascular canal, so as to admit of immediate reunion, and leave nothing at the bottom of the Avound. Nevertheless, I do not think that this method should be adopted. To perform it, it is necessary that the artery should be isolated to a very considerable extent, and the shortening which it is to undergo must have its influeuce on the ultimate success of the operation. It would appear to be al- most impossible to avoid making traction upon the veins, nerves, and other surrounding parts, even in proceeding in the manner of M. Lieber, (Annal. de Hecker, 1830,) who has also occupied himself with this subject; moreover, it is not certain that the tAvisted vessel will not, in mortifying, constitute a foreign body more injurious than the simple ligature. D. Crushing, (ecrasement.)—Others have thought, after Briot, (Soc. Med. d'Emulat., t. VIIL, p. 276,) Avho had already spoken of crushing, that if, after having laid bare the artery, it was seized TREATMENT OF ARTERIAL LESIONS. 63 with tAvo forceps with flattened points, (a mors applatis,) to twist it laterally, in order to crush (broyer) its internal and middle coats, and that if these ruptured, (brisees,) tunics Avere then crowded up into the cellular coat, and the solution of continuity were immediately closed, it Avould enable us to arrive at the same result. M. Carron du Villards says he has made numerous experiments on this point Avith M. Maunoir, and that he has generally succeeded. " These experiments," says he, " Avere suggested to me in 1820, by Professor Maunoir, Avho, at this epoch, spoke to me of an instrument for crushing (briser) the internal coats of the arteries Avithout recurring to the ligature. This in- strument consists of a forceps much resembling that of M. Amus- sat for the torsion of the vessels, but it has no teeth, (mors,) and its free extremity is formed by two catches, of the shape of barley grains, (aretes a grains d'orge,) Avhich, encountering each other Avhen they are pressed together, crush the artery and break its internal coats, Avithout altering the external one." By means of this instru- ment of M. Maunoir, we can in general effect the obliteration of the arterial canal. With this instrument, also, Avhen used upon an artery of large calibre, and rupturing only a third of its canal, by making only two turns Avith the forceps, as if for the purpose of removing a flap (losange) from its tube, Ave may obtain almost always, in a short space of time, an aneurismal tumor. " I have shoAvn," says M. Carron to M. Pacoud of Bourg, " a tumor created in this manner." The experiments of M. Carron have since been repeated, by M. Amussat, with entire success; but, Avith this surgeon, the push- ing up (rebroussement) of the ruptured (brisees) coats is the prin- cipal part of the operation, and that by Avhich his process is cha- racterized. It is to be apprehended, however, that Ave should de- ceive ourselves in relying upon this last-mentioned modification as an adArantage. The membranes thus croAvded back Avould some- times, doubtless, shut up the artery ; but, in addition to the objec- tion that such a result Avould not ahvays take place, I see in it, also, that of being obliged to lay bare the vessel completely, (large- ment,) and to isolate it all around and to a great extent from the veins and nerves, as in the process of M. Thierry ; all Avhich cir- cumstances are calculated to tlnvart immediate reunion, and to render the operation longer, more painful, and less certain, than by the ligature, properly so called. This, therefore, is a method Avhich must also be rejected. E. Acupuncture.—While I was endeavoring, some years since, to disengage in a dog the femoral artery from its accompanying vein, and had separated it Avith a pin, some one came in and obliged me for a moment to suspend my operation. A movement of the animal caused the pin to penetrate through the artery, and become lost in the tissues of the limb ; it still remained there on the fifth day. In examining the parts Avith care, I Avas enabled to satisfy myself that the obliteration of the vessel had been the result of this puncture. Such an effect Avas calculated to surprise me, and at 64 NEW ELEMENTS OF OPERATIVE SURGERY. first appeared A'ery extraordinary. Nevertheless, I soon explained it, in a manner that seemed to me satisfactory. Impressed Avith the idea that the contractions of the heart have less influence upon the movement of die blood than is generally supposed, I Avas soon enabled to comprehend how a foreign body, even though very small, when placed at rest across a vascular canal, or making some pro- jection (relief) in its interior, is capable of producing the same. effect as a ligature. Thus, if an osseous or calcareous plate or lamella, free at one of its borders and adherent at the other, should be turned back and make a projection into the artery at the point Avhere it had been developed, there is every reason to believe that it might be- come the nucleus, root, or source of a fibrinous concretion, capa- ble of deadening (amortir) to a greater or less degree the impul- sion of the blood, and of ultimately conducing to the obliteration of the vessel. The obseiwations published by M. Turner, [Trans- actions Medico-Chir. of Edinburgh, vol. III., p. 105, 172, part I.,) those which M. CarsAvell has communicated to me, and some others of my OAvn, place this fact beyond doubt. What I say of a bony plate, is evidently applicable to all kinds of projections, (saillies,) roughness, (asperites.) or inequalities, to those Avhich are the re- sult, for example, of a laceration, or of a deposit of fibrine, plastic lymph, or any growth (vegetation) Avhatever; in a Avord, to everything which in any Avay Avhatever diminishes the normal regularity of the tube through Avhich the blood is obliged to Aoav. Wishing to ascertain if it could be possible for me to procure at pleasure the result Avhich I had obtained by chance in the experi- ment related above, I made some hcav essa)^. An acupuncture needle, about an inch and a half long, Avas, without any previous dissection, plunged into the thigh of a dog, over the course of the artery ; I placed two others on the opposite side, in order to see the difference of effect Avhich might result from them. In examin- ing the parts, on the fourth day, I found my first needle transfixed through the outer third of the femoral, which, hoAvever, had not closed up, except to the extent of one half its calibre. Of the tAvo others, one Avas found entirely outside the vessel, Avhich latter Avas obliterated by a solid clot of blood of about an inch in length, pierced through its middle by the remaining needle. I reneAved these essays in the month of NoArember, 1829, and afterwards in the month of February, 1830; and they have since been repeated by M. Nivert, then prosector (preparateur) for my course of operations, and noAv Doctor of Medicine at Azai-le- Rideau ; I have subjected them to farther trials in the hospital of La Pitie, and their effect has been invariably the same. In these last experiments, in order to be more certain of not passing outside the artery, I haA'e ahvays taken the precaution to lay it bare: sometimes I have made use of but one needle; at other times I have employed tAvo, or even three, according as the vessel upon which I Avas operating Avas of greater or less size. As often as the foreign body has been enabled to keep itself in its TREATMENT OF ARTERIAL LESIONS. 65 place at least for four days, a clot of blood has formed at the point punctured, and the obliteration of the vascular canal has resulted from it; the aorta, hoAvever, thus healed underAvent no change, but as the needles did not remain in it but a little over tAventy hours, I do not think it just to draw any conclusions from this ex- periment. It is proper also to premise, that up to the present time my ex- periments have been made upon dogs of rather small size, and that the femoral artery is the largest vessel I have perforated. It is enough to say, that before draAving rigorous conclusions from them, they should be repeated and varied upon larger animals, for example, upon the horse. I ought also to add, that according to M. Gonzales, (These No. 233, Paris, 1831,) my experiments, as repeated by M. Amussat, have not been attended Avith results as conclusive. A single pin, or a single needle has appeared to me sufficient in arteries which do not exceed in size that of a Avriting quill; two or three Avould be necessary for vessels of one-half larger calibre, and nothing Avould prevent our employing four or even five for very large arteries. When we place in several it is proper to in- sert them at the distance of four to six lines from each other, and in a zig-zag direction, rather than upon the same line. If such a thing could be relied upon, immense advantages Avould result from it. In the place of incurring the risk of Avounding veins and nerves, and making that minute dissection, often so dan- gerous, Avhich is required for the ligature, torsion and pushing up of the artery (refoulement,) it would be sufficient, in order to procure its obliteration, to lay bare one of the sides (faces) of the artery to the smallest extent possible, and without the necessity of displacing anything Avhatever. Perhaps by this means Ave might succeed in curing aneurisms of the most formidable character, among others those of the thigh and popliteal space, without dividing the skin; that is to say, by confining ourselves to piercing the femoral artery in the fold of the groin Avith a pin, needle, or any metallic substance Avhatever, or by perforating, Avith these foreign bodies, the aneurismal sac itself, in various directions. An English Surgeon, M. B. Phillips, (A Series of Experiments on Acupuncture, &c, London, 1832,) Avho was in Paris in 1S30, and repeated my experiments in London in 1831, Avrites me, that proceeding upon these principles he had succeeded in curing an aneurismal tumor in the parotid region. We shall see further on the neAV methods Avhich have been projected for these results for the treatment of varices and erectile tumors. I have, neverthe- less, my fears that for aneurisms, properly so called, it will be Avith acupuncture as it has been Avith the seton, torsion, suture, and crushing, and that the ligature will for a long time to come be pre- ferred to these different modes, in spite of the species of infatuation upon this subject Avhich has taken possession of many practitioners other Aviso respectable. Very recently, and since the publication of my experiments 66 NEW ELEMENTS OF OPERATIVE SURGERY. upon acupuncture of the vessels, it has been recommended, as it had also been by me, but with another object in vieAv, to plunge a needle into the sac so as almost completely to transfix it, and to attach to this needle a metallic chain or rod by Avhich electric shocks and galvanic currents could be transmitted through it. I knoAv of no fact Avhich exists in support of this proposition. All that I am aware of is, that M. Pravaz has endeavored to assimilate such a process to that of cauterization, and that it Avould not be too un- reasonable to suppose, that by means of such experiments we might sometimes promote the coagulation of the blood in the tumor, and perhaps the cure of the aneurism. M. Liston, (Gaz. Med. de Paris, 22 Septembre, 1838,) hoAvever, after having in vain tried it in a case of aneurism of the subclavian artery, felt himself obliged to abandon this means and proceed to the ligature of the vessel. [In noticing, in our first volume, the brilliant success which has attended the practice of Dr. Mott and others, in this country, by the insertion of red-hot needles through those forms of varicose aneurism, or erectile tumors, known as nsevi materni, for the most part congenital, and therefore usually met Avith in children, it will be perceived that we had unintentionally omitted to do justice to our estimable author, M. Velpeau, to whom, as Avill be seen above, we are alone indebted, as we think, for the germ of this great im- provement in Surgery.] § III.— The Ligature. If the obliteration of arteries is indispensable, or nearly so, in the cure of aneurisms, the ligature must be the surest mode of obtain- ing it; this is a truth which no one questions, and which never has been contested. But in order to apply a ligature upon an artery it becomes necessary to perform a serious (sanglante) operation; we are obliged to divide vital (sensible) tissues Avith a cutting instrument. Hence the attempts so often made to substitute for it some milder means. A.—Nature and Forms of the Ligature. Nearly up to the pre- sent time threads of flax or hemp only had been employed; a single round thread was preferred to the small arteries; for the large trunks, however, several were united together with Avax, in the form of a ribbon (ruban.) It appears, however, that the ancients had already used silk to tie the arteries. Guy De Chauliac (Traict. 3. doct. 1., chap. Ill, p. 255) asserts it positively of Avicenna, in cases of Avounds accompanied with a Aoav of blood. Things were in this state when Scarpa and Jones proceeded to submit to the test of experiment and reasoning what had hitherto been adopted only by imitation. I. Scarpa, the first of these authors, proved, that to obliterate an artery, it was necessary to place its walls into contact without lacerating them, and to promote adhesive inflammation. He, there- fore recommends that we should make use of flat (plates) ligatures formed of six flaxen threads ; and moreover, that we should place TREATMENT OF ARTERIAL LESIONS. 67 between the ligature and the artery a small roll of linen (rouleau de toile) six lines long and three broad, Avhich roll is spoken of also by Pare, Platner, and Heister, used also by almost all the Italian sur- geons of the last century, by Funchall, and also by Forster, who substituted for it a small cylinder of wood, a quarter of an inch in breadth and three quarters of an inch long, a roll Avhich Saviard (Observ. Chirurgie, p. 172) mentions as being in general employ in his time, but one Avhich Le Dran did not approve of and for Avhich Cline aftenvards substituted a piece of cork. By this means the internal and middle coats of the vessel are neither bruised (froisses) nor torn ; their contact is perfect, and they unite solidly, and are blended together before even they can be cut through by the ligature which embraces them, and which with difficulty effects their ulceration. [Dr. Mott thinks that there cannot be a doubt that the small round ligatures, either of silk, flax, or hemp, (that of silk the best,) are preferable on all occasions; that the flat ought to be abolished ; and that there should never be any- thing Avhatever interposed between the knot and the artery.] II. Jones. According to Jones (On the Use of the Ligature, &c, 1806,) the opinion of Scarpa is wholly erroneous ; it is not by in- flammation upon the internal surface that arteries close, but by means of the effusion of coagulable and organizable matters Avhich folloAvs the rupture of their two inner coats; consequently, in place of flat or broad ligatures, and all kinds of rolls of linen, or cylinders, which to a greater or less extent impede this rupture, Jones recommends that Ave should make choice of threads Avhich will do it in the neatest and best manner. Numerous experiments were made by him upon dogs and horses, and all have been attend- ed with results conformable to his theory, which soon became a law Avith most English surgeons. According to M. Hodgson, (On the Diseases of the Arteries, &c, 1815,) the truth of this hypo- thesis is so evident that he cannot conceive how some persons still venture to use the broad (larges) ligatures, and little rouleaux of Scarpa. M. S. Cooper also, Avith some degree of bitterness, cen- sures the French surgeons for having been so Teluctant in adopting the practice recommended by Jones, a practice Avhich has been carried so far as to induce some of his countrymen to make use of threads of an extreme degree of tenuity, those for example made of gummed silk, and used by dentists and fishermen, so fine, in a Avord,that in cutting them near the knot, after the manner of M. Law- rence, there remains in the Avound the Aveight only of the tAventieth, or even forty-sixth part of a grain. [This practice Dr. Mott has also tried, and the absurdity of it consists in this, that the wound aviII be healed by the first intention, and the ligatures by being left to remain as an extraneous substance, will, in the course of five or six weeks manifest their injurious action by producing suppura- tion. This practice is one that goes to the other extreme of Scarpa. T.] III. Without calling into question the importance of the labors of Dr. Jones, M. Roux has persisted, and still persists, in usii^ flat 68 NEW ELEMENTS OF OPERATIVE SURGERY. (plates) ligatures, which he usually ties upon a small roll of ad- hesive plaster of diachylon, (sur un petit rouleau de diachylon gomme.) In support of his practice we may cite the names of Boyer, Scarpa, and M. Petrunti, (II filiatre Sebezio, Aprilc, LS36, p. 239,) and the authority also of the older Avriters since Saviard, in his Observations on Surgery, speaks of the little rouleau as a thing in common use. M. Crampton, in Ireland, has never employ- ed any other method, and has had no reason to be dissatisfied Avith it; he has in fact opposed the doctrine of Jones Avith such force of reasoning as to prevent its being universally adopted in the three kingdoms. M. Richerand supposed he could reconcile those different opin- ions by calling attention to the fact, that a flat (plate) ligature be- comes rounded, (s'arrondit,) in proportion as we tighten it, and that its final result is like that of the cylindrical ligature, to rupture the internal and middle coats of the artery; which argument Avould go to strengthen the mode adopted by the practitioners of Great Britain. IV. Jameson. But next comes M. Jameson, (Journal des Pro- gress, t. VI., p. 117; t. VII., p. 126 ; t. IX., p. 150,) Avho, on the strength of new experiments, rejects the principal assertions of Jones as erroneous. It is not true, says he, that the rupture of the delicate (fragiles) coats of an artery is an advantage ; on the con- trary Ave should do everything in our poAver to prevent it. The fine threads and round ligatures are dangerous, both because they cut the internal and middle coats, and especially because they strangulate the vasa vasorum of the cellular coat. M. Jameson ne- vertheless rejects every kind of foreign body recommended to be placed between the vessel and the ligature ; also ligatures of thread, (fil) Avhatever may be their form or size. Strips of untanned deer skin appear to him to be infinitely preferable in all cases, inasmuch as these ribbons (rubans) have an elasticity and pliancy which al- Ioav of their gently closing, and bringing into contact (plisser*) the sides of the artery, without rupturing anything, and Avithout lace- rating the vasa vasorum, and because also they may be left in the wound Avith impunity. V. Threads (fils) of animal matter. Another question naturally connects itself Avith this discussion. It has been asked if it Avould not be possible to substitute for threads of vegetable substance, cords of animal matter, Avhich are of a nature to soften (ramollir) and dis- solve in such manner as to be carried away by interstitial absorption in the midst of the living tissues, without incommoding, in any manner, the reunion of the divided parts. A series of trials of this kind, Avith silk, Avere made at London in 1815 ; an experiment of M. Lawrence and another of M. Carwardine (S. Cooper's Surgical Dictionary, p. 131,) Avere attended Avith all the success that could be expected from them; the Avound Avas cicatrized in the space of four, five, or six days, and the small knot left upon the artery Avas attended Avith no disadvantage ; other experiments, hoAvever, have * Literally plait, but fold expresses the idea better. T. TREATMENT OF ARTERIAL LESIONS. 69 been less fortunate; either the immediate reunion did not take place, or there appeared at a later period, small purulent collec- tions (foyers) and abscesses which did not dry up until after the expulsion or exit of the portions of silk that had been left in the tissues. In a patient operated upon the 29th of March," 1819, by M. Lawrence himself, the cure was not completed till the end of May. In a patient in Avhom M. Watson had tied the brachial artery by this method, he found the silken knot had lacerated the cicatrix, and that it did not come aAvay until after the expiration of iavo months. The same result Avith M. Hodgson did not take place un- til the expiration of six months; the Neapolitan surgeons (De Renzi, trad. Ital. de ce livre, p. 81,) Avere not more fortunate ; and M. Cumin cites a case of a patient who retained one of these liga- tures in him for the space of two or three years. So that the result is, that silk has not been found susceptible of. being destroyed by absorption. M. A. Cooper succeeded perfectly by using a small cord (cordon- net) of cat-gut (boyau de chat;) this substance dissolves much better than silk, and would be preferable to it in every respect, if it were not necessary from its Avant of strength to use it of so large a size. In M. A. Cooper's first patient the cure Avas completed on the twentieth day; in another patient, Avho Avas eighty years of age, the wound took but four days to cicatrize, and in neither case did the ligature ever reappear. M. Norman (On the Operation for Aneurism, 1819) was not so fortunate. This physician made trial of the method of M. A. Cooper, on two occasions, and in both cases the cure was protracted to a long period. M. Wardrop, in some of his operations, conducted upon the plan of Brasdor, (On Aneurism, &c, 1S28,) made use of the intestine of the silk-AVorm in lieu of thread. By employing silk called morte peche, or raAV (native) silk, immersed (mise) for tAventy-four hours in saffron, in order to color it, M. Carron du Villards (Lettre privee du mois d'Aout, 1837,) obtained the same results that M. Lawrence had in view. According to M. Jameson and Dorsey, Physick, in the year 1814, Avas the first Avho made use of ligatures of animal matter; those that he prefers are round, and made of deer-skin or cat-gut; but like M M. LaAvrence and A. Cooper, (Dorsey, Ehments of Sur- gery, vol. II.,) Physick's intention Avas to cut through or rupture the arterial coats, while M. Jameson positively advises that they should be saved. The surgeon of Baltimore, gives to his deer-skin ligatures as much as tAvo lines of breadth, and increases their resistance and strength, to a greater or less degree, by drawing them between the nails. Applied upon the artery, these strips (lanieres) do not re- quire to be draAvn tight to efface its calibre ; from whence it hap- pens, that though there is no intermediate foreign body, they pro- duce the same effect as the ligatures of Scarpa, without arresting, like these last, the circulation in the vascular system of the cellular coat. M. Jameson asserts, that after having been draAvn between 70 NEW ELEMENTS OF OPERATIVE SURGERY. the nails, these ligatures may, when tightened with considerable force, partially divide the arterial coats, like the flat ligatures of thread or silk; Avhile in their state of natural suppleness they are incapable of producing this effect. VI. Observing that lead, gold, silver and platina but slightly irritate the parts with which they are placed in contact, Physick at first entertained the idea of constructing ligatures out of these metals. M. Levert (Journal des Progres, t. XVIL, p. 65) availed himself of the suggestion of Dr. Physick, and submitted it to a considerable number of experiments; he made five upon the carotid of a dog, with threads of lead draAvn very tight, then cut very near the knot and left at the bottom of the Avound. The re- union was effected at the expiration of the seventh, eighteenth, nineteenth, twenty-eighth, and forty-second day; the vessel was constantly found obliterated. The small circle of lead occupied a cellular cyst of greater or less density. Three experiments on the carotid, and tAvo on the femoral, with gold threads ; three other ligatures on the femoral, and the two carotids Avith silver threads; and three on the carotid AArith platina, produced the same effects as the threads of lead; finally, M. Levert obtained similar results, by making use of small cords (cordonnets) of Avaxed silk, gum elastic ligature, and even of fibres of grass, (brins d'herbe.) VII. Recapitulation. The result of all these researches, as it appears to me is, that the nature and form of the ligature in the treatment of aneurisms, are not as important as has generally been supposed during the last thirty years, and that French sur- geons have been right in not adopting precipitately, and without re- flection, the conclusions deduced in England from the experiments of Jones. The massive ligatures of Scarpa irritate the wound too much, keep up too abundant a suppuration, and require too great a length of time before they can be extracted, to be deserving of any exclusive preference ; this appears to me to be indisputable; but in flattening the artery, without folding (plisser)it: [i.e., with- out causing the inner tunics to fold upon themselves, as they do when cut through by a small round ligature of silk, &c. T.] they keep its walls in perfect contact, without necessarily dividing the vasa vasorum. In becoming inflamed under such pressure, the cellular coat soon transmits its organic action to the two other arterial tunics, and the whole is soon blended together in such manner as to form an impermeable cord. The objections, therefore, that M. Hodgson makes to them, are far from being founded in truth. When Ave make use of a fine ligature, in order to be more sure of rupturing the internal and middle coats, we strangle at the same time, as M. Jameson main- tains, the small vessels of the external coat; and it is not true as Jones contended, that the obliteration of the artery is mainly effected by an internal effusion of organizable lymph. The ligature it- self is speedily surrounded Avith concretable (concrescible) matter; the continuity of the small ruptured vessels is soon re-established upon the outside of it, and the ligature ultimately finds itself in the TREATMENT OF ARTERIAL LESIONS. 71 centre of an organic ring, (virole,) analogous to that which Duha- mel had supposed in the formation of the callus of fractured bones. This albuminous virole, the formation of Avhich in dogs, has been carefully investigated by M. Pecot, (These No. 155, Paris, 1S22,) becomes, after the extraction of the ligature, gradually harder, retracts upon itself, (revient sur elle-meme) and little by little blends itself with the tAvo obliterated ends of the artery. Scar- pa, and MM. Crampton and Jameson then are Avrong in imputing to fine ligatures a greater tendency to produce secondary hemor- rhages, than to flat and broad ligatures. As to ligatures of animal substances, there can be no question, that by permitting the wound to be immediately closed, they may be of great value in practice. The point to be ascertained is, Avhat should be their form and precise nature. If you Avish to have them very fine, silk only may be used; unfortunately, this substance, we have seen, does not yield to the interstitial action of the parts. The cat-gut has not the same solidity, and moreover is not very easily absorbed. The strips of deer-skin, endoAved Avith a great elasticity, and readily dissolving, offer greater advantages ; but be- fore adopting them surgery requires new experiments ; and also, that the results mentioned by M. Jameson should be confirmed by other practitioners. If Ave admit that these ligatures, Avhen left around the artery do not act the part of foreign bodies, that they may be absorbed by the system, and are not necessarily obliged to be expelled from it at a period sooner or later, there is no person who cannot comprehend at a glance Avhat advantages they Avould give to the patient. With them the plastic ring, (virole,) described by M. Pecot, would be rendered perfect, and protected from all perforation or interruption ; supported by the exact approximation and immediate reunion of the parts, it would run no risk of being destroyed by suppuration, or torn by the removal of the thread. Moreover, Avhether this ligature should possess a little more or less breadth, whether the internal coats Avere or were not ruptured, or the vasa vasorum strangulated to a greater or less extent, the final result, in my opinion, Avould be nearly the same. Experience has noAv indisputably demonstrated that hemorrhage is neither more nor less frequent Avith flat than Avith round ligatures, Avith those of silk than Avith those of thread. The tenuity then and animal com- position of ligatures would possess influence only in the eyes of those Avho would Avish to sacrifice everything to the immediate union of the wound. But even though we should obtain this re- union, Avhat advantage Avould it be in such a case ? In admitting that there was no longer any Avound, where is the surgeon who Avould venture to alloAv his patient to Avalk in ten or fifteen days after an operation for aneurism of the femoral artery ? Since it so happens that even in those cases Avhere Ave have recourse to second- ary union, it is not the wound Avhich retards the definitive cure ; I cannot see, in conclusion, what particular utility there would be'in reviving at present the discussion respecting the form and nature of ligatures. 72 NEW ELEMENTS OF OPERATIVE SURGERY. B.—The Permanent Ligature. Every vegetable ligature, draAvn sufficiently tight to intercept the passage of blood in an artery, is a foreign body Avhich Avill not leave the wound until after having cut through the cord (cordon) Avhich it embraces. In order, therefore, that its separation may not be followed by hemorrhage, it is necessary that the vessel shall have had time to close itself firmly above and below ; otherwise the albuminous virole which surrounds it, possessing too little con- sistence to resist the force of the blood, and having, moreover, been already laid bare in the direction of the skin, will be speedily lace- rated. If it [the ligature] Avere restricted, as is generally supposed, to producing adhesive inflammation in the strangulated portion of the vessel, there would be nothing to dread from its separation; for before the artery Avould alloAV itself to be cut through, it Avould be necessary that it should have become inflamed. But the expe- riments of M. Pecot tend to prove that this is not the case ; the portion of the artery included in the noose of thread, according to this author, almost unavoidably mortifies, a little sooner or later, whatever may be the degree of constriction Avhich it sustains, and it can only be by the steps of an eliminative process, analogous to that Avhich in gangrene separates the dead from the living parts,that the ligature can be detached from the surrounding tissues. When this process is not disturbed, Avhen the organic elements, upon Avhich it acts, continue to remain in the normal state, and nothing prevents them from contracting adhesive inflammation, the ligature is not eliminated until the fifteenth or twentieth day. As the upper end of the arterial canal is no longer permeable on the fourth or fifth day, Ave may, therefore, so far as this is concern- ed, rest perfectly easy. If, on the contrary, the walls of the vessel have unfortunately become softened and steatomatous, yelloAV and inflamed, the ligature will have soon divided them; if the artery shall not have become completely closed, its coats will ulcerate, and there will be no interruption to the course of the blood; finally, if these coats are indurated and encrusted with calcare- ous concretions, as so frequently happens in old men, Ave may un- derstand Avhy their inflammation Avill most usually be too feeble, and too irregular to admit of the effusion of those concretible mat- ters required either externally or internally, and why the ligature, though it come aAvay at a very late period, may give rise to a seri- ous hemorrhage. C.—Precautionary Ligatures (Ligatures d'attente.) To obviate these inconveniences it Avas proposed to use ligatures d'attente, that is to say, ligatures Avhich are useful only Avhen the first that have been applied have cut through the artery before its perfect obliteration ; in a word, Ligatures of Precaution. One of these ligatures Avas pass/ed around the vessel Avithout tightening it, at the distance of a feAV lines below the principal ligature. Another, composed of tAvo threads, was placed a little TREATMENT OF ARTERIAL LESIONS. 73 above the principal ligature ; the lower half of this ligature was to be tied in such manner as to strangulate the artery only to the degree required to deaden the force Avhich the column of blood exercised upon the point we desired to obliterate; a third, also double, Avas placed still higher, and this, in the same way as the upper half of the preceding, was left free. On the supposition that the fixed ligature had failed, force was immediately applied upon the first threads (faisceau) of the upper precautionary ligatures, and successively on all the others, in case of need, in such manner as to arrest the hemorrhage. The same Avas done with the double thread of the loAver liga- ture, which Avas intended only to oppose the reflux of blood from the wound. Such, for a long time were the arguments and the course adopted by A. Monro, Guattani, Hunter, Desault, Deschamps, Pelletan, and even Boyer. At the present time precautionary liga- tures have almost entirely disappeared from practice. Far from being thought useful, they are on the contrary deemed exceedingly dangerous. At first they Avere censured, Avith reason, as irritating the wound too much, keeping up the suppuration, and forming an insuperable obstacle to immediate union. Moreover, Dupuytren and Beclard have shoAvn that the part of the vessel immediately adjacent to them, in proportion as it inflames, undergoes a fatty degeneration, (lardace,) exceedingly susceptible of being cut through, and altogether incapable of sustaining the action of any kind of ligature whatever; from Avhence it happens that their application of itself is sufficient to bring about the ulceration of the artery, which they, in like manner, aftenvards cut through Avith the same facility that they would through a slice of lard or cheese, as soon as we attempt to make the slightest degree of con- striction upon them. D.—Temporary Ligature. Not only have the precautionary ligatures been rejected, but it has even been proposed to ascertain if it Avould not be possible to remove, Avithout endangering the success of the operation, the only ligature which had been employ- ed, and before it should have had time to cut through the vessel. This is a tAvo-sided question. Such practitioners as have occupied themselves Avith this subject have been influenced by two different and even opposite indications. According to some, the temporary ligature should rupture and obliterate the artery in the most prompt and perfect manner possible ; the others, on the contrary, proposed to close the artery by degrees, and not to rupture it by any special means designed for that purpose. I. Sudden (brusque) Obliteration.—It is now more than thirty years since this question has been a subject of discussion in Eng- land. Jones asserted that he had ascertained that by rupturing at three or four different points, at certain distances from each other, the internal and middle coats of an artery, with that number of fine ligatures, an effusion of lymph Avould be effected, Avhich would be sufficient to accomplish the desired obliteration, and to 74 NEW ELEMENTS OF OPERATIVE SURGERY. allow of the ligatures being withdrawn in a few minutes. The results obtained by M. Hutchinson, (Practical Observ. in Surgery, p. 103,) fully confirm those of Jones. But MM. Dalrymple, Hodgson, and Travers have not been so fortunate: their experi- ments Avere made upon horses or sheep, and the artery was never, in any case, obliterated ; they found it only in a slight degree con- tracted, (retrecie) upon killing the animal at the end of thirteen, fifteen, or eighteen days. M. Travers, however, (Observations upon the Lig. of Art., Trans. Medico-Chir., Vol. IX.,) Avas of opinion that he might turn the suggestion to some advantage by modifying it. In the place of removing the ligature immediately after having strangulated the artery, Jie determined not to with- draAV it until after the expiration of a period of time sufficiently protracted to allow of the clot and the effused lymph to acquire a certain degree of solidity, and a consistence capable of resisting the momentum of the blood. His experiments on horses led him to the conclusion that, a ligature kept upon the carotid for the space of six, or two hours, or even for one hour only, generally effected a permanent obliteration of the artery. In 1817 he applied the liga- ture upon the brachial artery of a man, and removed it in fifty hours, Avithout the pulsations in the tumor having returned. M. Roberts (J. Bell, trad. d'Estor, p. 200, en note) Avent still further : a ligature which he left only twenty hours on the femoral artery of a sailor, who had an aneurism in the ham, effected a perfect cure in the space of twelve days. In repeating these experiments the same success, unfortunately, has not always attended them. M. Hutchinson has seen the cir- culation immediately re-establish itself in the femoral artery, though it had been strongly constricted by a ligature for six hours. The same thing happened to M. A. Cooper, (S. Cooper Dictionary, &c, p. 123,) after thirty-two and forty hours. M. Travers himself, after removing a ligature Avhich had been applied to the artery of the thigh for twenty-five hours, noticed that the pulsations gradually returned in the aneurism, that- they would not yield to indirect compression continued for a long time, but required the application of a ligature in the ordinary mode ; so that he ultimately abandoned this prac- tice, which the experiments of Beclard have prevented from being adopted in France. At the moment Avhen the temporary ligature Avas losing its warmest partisans in London, it was seized upon by the surgeons of Italy. Scarpa (Bull, de Ferussac, XXL, p. 115. Arch. Gen. de Med., t. IL, p. 82) made ne\v experiments Avith it, and exerted him- self to procure its adoption. Flat ligatures, tied upon a small cyl- inder of linen, besmeared with cerate, and placed around the carotid of a number of sheep, and AvithdraAvn on the third, fourth, or fifth day, ahvays effected the solid obliteration of the vessels. Repeated on horses, by M. Mislei, a veterinary surgeon, at the school of Milan, these experiments were followed by results pre- cisely similar. The experiments were not less fortunate when TREATMENT OF ARTERIAL LESIONS. 75 used on a man. Paletta, communicated two remarkable cases of this kind to Scarpa, (Arh. Gen. de Med., t. IL, p. 82 a 101.) The first Avas a man forty years of age, Avho had had an aneurism in the ham for two or three months ; the ligature was applied upon the artery on the 8th of January, 1817, and removed on the 12th. The second Avas a patient sixty years of age, and who had an aneu- rism at the bend of the arm. A ligature placed upon the brachial artery Avas removed on the fourth day ; and, as in the first patient, this operation also had a fortunate termination. A popliteal aneu- rism treated in the same manner by M. Morigi, (Valentin, Voyage en Italie, 1826,) terminated equally Avell. The same result took place in a fourth patient Avhose brachial artery had been Avounded, and Avho applied for relief to the hospital at Padua. MM. Molina, Fenini, Maunoir, Graefe, (J. Bell, trad. d'Estor, p, 200,) Dolcini, (Bulletin de Ferussac, t. IL, p. 334,) Medoro, Solera, Falcieri,(/&i'o\, t. XIX., p. 277,) Uccelli, Giutini, Malago and Balestra, (Ibid, t. II.,p. 334,) have also used the temporary ligature Avith success for aneu- risms of the carotid artery, femoral, &c. Vacca, (Reflections sur la Ligat. Tempor., &c., 1823,) hoavever, soon raised the objection, that after having removed the ligature, the artery, nevertheless, a little time after, Avas sooner or later divided, and the experiments of M. Pecot, contrary to those of M. Seiler, tend to confirm this opinion, which however does not in any respect detract from the value of the facts and reasonings adduced by Scarpa. The difficulty in these cases, as is proved by a fact related by Morigi, (PI. Tortal, Clinica Chirurg., t. I., p. 162,) consists in re- moving the ligature without making traction upon the artery and disuniting the lips of the wound. All the modes resorted to in England for this purpose are objectionable. The tAvo single threads Avhich Paletta and Roberts previously place between the vessel, or the small cylinder, and the thread Avhich serves as the ligature, in order to untie this last in draAving the others towards us, effect the object proposed but very imperfectly. The same may be said of the piece of grooved sound which M. Uccelli at first includes in the same ligature Avith the cylinder of linen, and upon which he proposes, at a later period, to divide the ligature. M. Giuntini, in order to extract the foreign body fixed upon the artery, and to fa- cilitate the section of the ligature, makes use only of a waxed thread, which he attaches to the extremity of the small cylinder before ad- justing it. For all these modes Scarpa substitutes the following: a grooved sound, cleft at its extremity, and having tAvo small flattened rings upon one of its lips, one at half a line from the point, the other at near an inch from the plate, (plaque,) serves to guide a very small knife to the thread of the ligature which embraces the artery. The manner of proceeding Avith this small apparatus is perfectly simple. The end of the ligature, which has been left outside, is first passed successively through the tAvo rings Avhich are designed to receive it; and the beak of the sound is then securely guided 76 NEW ELEMENTS OF OPERATIVE SURGERY. to the small cushion of linen Avhich arrests its progress, (Archiv. Gen. de Med., t. II., p. 245.) Then the small knife penetrates with- out difficulty down to the ligature, which it divides transversely, and Avhich may then be Avithdrawn, says the author, without ex- posing the artery to the slightest risk. II. Gradual Obliteration.—Some trials have also been made with the temporary ligature, by combining it with direct compres- sion. From the fear of suddenly interrupting the circulation in the limb, and the dread of hemorrhage after the ordinary ligature, many French surgeons, between the years 1790 and 1815, propos- ed that the constriction of the artery should only be accomplished by degrees. The instruments made use of to effect this object, by alloAving us to augment or diminish the constriction of the vessel at pleasure, and to remove or replace them Avhenever we should desire to do so, may be united very advantageously Avith the pro- cess of a sudden obliteration. a. Process of Deschamps.—In 1793, before the temporary liga- ture Avas thought of in England, and consequently, before it was employed in Italy, Deschamps (Mem. de la Soc. d'Emul., t. VIIL, p. 689) proposed his artery-compressor, (presse-artere) that is, an in- strument composed of a flattened metallic stem, (tige,) about three inches long, cleft at its free extremity, and terminated at the other end by a horizontal plate resembling the flat head of a nail, Avhose length exceeded its breadth, and was pierced Avith two long open- ings near its edges. He first inserted into and conducted through the two openings of the instrument, the tAvo halves of the ligature passed under the artery; then, on drawing upon the one he caused the other to descend ; by Avhich means the vascular trunk Avas flat- tened betAveen the portion of the ligature Avhich compressed it from behind forwards, and the plate of the artery-compressor, the action of which Avas to press against the artery from before back- wards. The operation Avas finished by fastening the extremities of the ligature upon the cleft of the instrument. b. The little rundlet, (barillet) of Assalini, (Bullet, de Ferussac, t. IL, p. 84,) the compressors employed or recommended by Flaja- ni, Buzani, Garnery, Ayzer, (Dissert, etc., Gotting., 1818. Soc. d'Emulat., t. VIIL, p. 692,) and MM. Crampton, (Medico-Chirur- gical Trans., vol. VII., 2d part, p. 341,) Ristelhueber, (Mem. de la Soc. d'Emulat., t. VIIL, p. 685, pi. 7, fig. 9, 10,) Deaze, Jacobson, (Bull, de Ferussac, t. IL, p. 84,) and Chiari, (PI. Portal, Clin. Chirurg., t. p. 154,) though differing in some respects from that of Deschamps, or from the forceps of Schmucker, (Bullet, de Ferussac, t. II, p. 84,) have, nevertheless, all been constructed upon the same principle, that is to say, Avith the intention of flattening in place of strangulating the vessels, and of AvithdraAving the ligature or the compression, at the expiration of a determined period of time. Like that, also, they all have the inconvenience of greatly irritat- ing the Avound, of favoring the ulceration of the artery, and most generally of effecting only an incomplete closure of the vessel. TREATMENT OF ARTERIAL LESIONS. 77 c. New Process.—If it were allowable to deduce conclusions from some experiments made upon dogs, the following process would be as easy as it would be certain to effect the obliteration of the vessels by means of temporary ligatures. We insert under the artery a simple pin, whose two extremities are then to be embrac- ed by a noose of thread, as in the twisted suture, which is to be tightened sufficiently to arrest the current of the blood. A second thread, attached to the head of the pin, allows of our extracting it when we judge it suitable to do so. The ligature being thus left free, offers no farther resistance, and falls out as it were of it- self. This process, which will'be treated of more fully under the article Varixes, (varices,) and which, in certain cases, would enable us to dispense altogether with an external Avound, is of such easy application, and succeeds so well upon veins, that Ave cannot see why it should not procure the same result for arteries. The experi- ments undertaken by M. Franc (Journal des Connoiss. Med.-Chir., 1835, t. III., p. 15, ou, These, Montpellier, 28 Mars, 1835,) fully sus- tain, moreover, Avhat I had written upon this subject in 1831. The process used by M. Malago, (Bullet, de Ferussac, t. XVIIL, p. 82,) and which consists in tAvisting the tAvo heads of the ligature Avith- out tying them, Avould in truth be still more simple, but it does not offer the same degree of certainty. d. Process of Dubois.—The idea Avhich Deschamps had in using his artery-compressor, of obliterating the vessel only by degrees, was adopted by Dubois, (Soc. Med. d'Emulat, t. VIIL, p. 706, pi. 7, fig. 5, 6,) who, in 1810, proposed to found upon this method a neAV process for treating aneurisms. After having placed the ligature of thread (ruban de fil) around the artery, this practitioner passed its tAvo extremities into the knot-tightener (serre-noeud) of Desault, (Bullet, de la Faculte, 6e annee, p. 40,) in such manner as not to intercept the course of the blood except by degrees, and not to effect an entire obliteration until after a period of six or eight days. His object in acting thus Avas to per- mit the collateral vessels (canaux) to dilate themselves gradually, and to prevent the gangrene Avhich was produced at this epoch, also by the sudden strangulation of a large artery. The two for- tunate results Avhich Avere obtained by this process at the clinique of the faculty, at first strongly attracted public attention, but the third attempt having been followed on the fifteenth day by hemorrhage, Avhich rendered amputation necessary, and caused the death of the patient, though the pulsations had ceased to be perceptible in the tumor from the tenth day, soon put an end to such flattering hopes. Since then I Avas not aAvare that any one had again attempted this process, notwithstanding the two fortunate results that MM. Viri- cel and Larrey (Clin. Chir., t. III., p. 246,) say they have obtained from it. Now that Ave knoAV in what light to consider the dangers of suddenly suspending the circulation in the principal artery of a limb, a process like this has necessarily fallen into disrepute ; and what I have said of precautionary ligatures, sIioavs sufficiently that it would be one of the most dangerous that could be proposed. 78 NEW ELEMENTS OF OPERATIVE SURGERY. e. The gradual closing therefore of arteries, ought to be reject- ed from practice, unless it could be effected by one of the modes of indirect compression, as for example, by one of the processes of MM. Viricel, Leroy, or Malgaigne, already related. As to the temporary ligature, properly so called, I am of opinion that it ought still to be made trial of. Could the artery be thus disembar- rassed in four or five days, of every kind of extraneous substance, it would run no risk of becoming altered or divided; the hemor- rhage and purulent collections would by this means become less frequent, and the success of the operation Avould, in every respect be rendered more certain. E.—The Double Ligature with the section of the artery between. Celsus, (De re Med., trad, de Ninnin, t. IL, p. 17,) Galen, (Lib. v. Therapeut., cap. III.,) Aetius, (Tet. 4., Serm. 3, cap. X.,) Guy de Chauliac, (Grande Chirurgie, trad, de Joubert, p. 173,) Rufus, Rhazes, Gouey, Severin, (Med. Efflcace, bibl. de Bouet, p. 98,) and Purman, (Thierry, These 1750, Choix de Hatter, trad. Franc., t. IV., p. 15,) Avere in the habit of applying tAvo ligatures at a cer- tain distance apart, and of then dividing the artery transversely between them. Pelletan (Clin. Chirurg., t. I., p. 192,) follow- ing the advice of Tenon, was upon the point of adopting this pro cess, Avhich was entirely forgotten towards the end of the last century, and strongly censured by Heister, Callisen, and Richter. Abernethey (Dorsey, Elements of Surgery, vol. I., p, 213,) how- ever adopted this method in his first operations of ligatures upon the external iliac artery, without being aware that his countryman, Bell, (Traite des Plaies, trad. Franc., p. 102, 115, 117, 122,) had mentioned it, and considered himself the author of it. With this precaution, says he, the two ends of the artery retract tOAvards the tissues, suffer no traction, and are placed in the same condition as after amputation. M. Maunoir, (TAeseNo. 328, Paris, An XIII.,) in a memoir on this modification, which he also regarded as belong- ing unto him, declared himself its unqualified champion. Like Morand he accords to the arteries a great retractile poAver, consid- ers that the circular ligature, by puckering (en les froncant) them, shortens their length, and exposes them to violent traction by the impulsion of the heart at each throb of the pulse; and that the best means of preventing secondary hemorrhages, must be to alknv the artery which we have just tied, to Avithdraw itself into the soft parts, to an extent proportionate to its natural retractility (retracti- lite.) Some facts related by Abernethey, and Blacke, and MM. A. Cooper, Maunoir, Dalrymple, Post, Guthrie, &c, seemed at first to give a favorable reception to this method, which MM. Roux, Larrey, and Taxil, in France, Avere not opposed to adopting, at least for the large arteries. Having been made trial of, hoAvever, in 1807,by M. Norman, of Bath, it gave rise to an alarming hemor- rhage, and Scarpa, Avho rejects it, arrays against it the cases of Monteggia, Assalini, &c, in which it wa's followed by hemorrhage of a fatal character. The truth is, that the reasons Avhich have been advanced for TREATMENT OF ARTERIAL LESIONS. 79 dividing the artery between the two ligatures are poorly sustained. The retractility imagined by Morand and M. Maunoir, and Avhich has been so much insisted upon since by Bonfils, (These de Stras- bourg,) and Taxil, (Journal Universel des Sciences Medicates, 1816,) and more recently still by M. Guthrie, (Diseases of Arteries, Lon- don, 1830,) can scarcely be said to exist, as has been proved by the experiments of Beclard, (Soc. Med. d'Emulat., t. VIIL,p. 569,) the truth of Avhich I myself have had very frequent opportunities of attesting. If, after amputation of the limbs, the arteries sometimes recede to a great distance, it is because they are draAvn up by the muscles, and not in consequence of a retraction which properly be- longs to them. Moreover, supposing that when strangulated in a ligature, they undergo a certain degree of traction, nothing is more easy than to put a stop to this Avithout affecting the continuity of any tissue. To effect this object Ave have only to adopt the re- commendation of Lyng, (lb., p. 719,) namely, to put the limb in semi-flexion, and all the muscles in a state of relaxation. This section is not only unattended with any decided advantages, but may incur the risk of most serious consequences. Suppose, for example, the ligature upon the upper end of the artery should happen to slip off and become loose, as happened to MM. A. Cooper and Cline, (Dorsey, Elements of Surgery, vol. IL, p. 214,) there would necessarily result from it an alarming hemorrhage, which might speedily prove fatal, if the patient was not instantly relieved. Let a similar accident take place after a ligature upon the carotid artery at the lower part of the neck, or of the subcla- vian, or either iliac, and death will almost inevitably be the result. We must therefore come to the conclusion, that the advice given by Abernethey and M. Maunoir, to apply tAvo ligatures, and to di- vide the vessel in the intervening space, is a method dangerous in its consequences, and insufficient for the end proposed, even though we should place, as M. Petrunti (PL Portal. Clin. Chirurg., t. I. p. 168,) recommends, the little rouleau of Scarpa under each thread. F.—Ligature through the Artery. For sometime past attention has been drawn to a process, already mentioned by Dionis, and which Richter describes in these terms: " The artery being drawn outward, an ordinary ligature, should be passed round it tAvice; this should be made tight by a knot, and Avhen the artery is of con- siderable size, one of the ends of the ligature should be passed through it by means of a needle." This is the plan which Cline thought it proper to recommend, in order to prevent the ligatures in the process of M. Maunoir from becoming loose and escaping from the ends of the artery. M. A. Cooper made trial of it for aneurism in the popliteal space, in a man aged twenty-nine years. The two ligatures were first made tight (serrees) at the bottom of the inguinal space, then the needles Avere passed between them, through the coats of the vessel; the ends of each of the threads were afterAvards fastened on the knots of the first ligatures, Avith the view of opposing an impediment to their slipping. M. S. 80 NEW ELEMENTS OF OPERATIVE SURGERY. Cooper, (Dictionary of Surgery, Art. Aneurism, p. 129,) and all other surgeons, very properly as I think, censured this process, which has neither analogy nor experience in its support, and the employment of Avhich has nothing to justify it. Nevertheless, it might very naturally have suggested the one which M. Jameson appears to have frequently made trial of Avith success upon animals. This physician thought that all that was necessary to obliterate a large artery, or a large vein, was to pass a seton through it of two or three lines in Avidth. Experiments made by him upon the carotid and jugular of horses, Avith ligatures of deer-skin, have alAvays caused an effusion of plastic lymph in the interior of the vessel, a thickening of the perforated tunics, and soon after a complete interruption to the current of blood. I learn from M. Chaumet, of Bordeaux, that these experiments Avere re- peated at the Val-de-Grace, and followed by similar results. M. Carron du Villards, has also made a series of experiments on ani- mals, Avhich demonstrate that the same effect may be produced by piercing the artery with a linen thread, or Avith iron, steel or silver wire, &c.; this, therefore, is a neAV question which, Avithout be- ing a matter of any great importance, nevertheless, in my opinion merits the attention of practitioners. A ligature of deer-skin, or a conical piece of the same substance, passed through an artery, and then left at the bottom of the wound, Avould in no respect interfere with immediate reunion, and Avould render the operation for aneu- rism exceedingly simple, if the cure would as certainly folloAv as after the ligature. G.—Indirect Ligature. The ancients, deficient in the required anatomical knoAvledge, did not take the trouble to lay bare the ar- tery, and confined themselves in some cases to inserting the ligature through the Avhole thickness of the limb, between the vessel and the bones, tying the ends afterwards upon a compress placed be- tAveen the ligature and the skin. This is Avhat Thevenin recom- mended, and Avhat both Le Dran and Garengeot did not think dis- creditable to adopt even at the commencement of the last century, in order to suspend the circulation in the brachial artery Avhile they were disarticulating the shoulder. Though aneurisms may have sometimes been cured by this method, there does not seem to be any necessity for my discussing the subject to any greater length at the present time, in order to demonstrate its inconve- niences and dangers if it should be applied to the deep-seated or large-sized arteries. The superficial arteries, and those of the fourth or fifth order, are the only ones, in fact, to Avhich it could be at all applicable. In the fingers, Avrist, face, and cranium, a pin passed under the artery, then surrounded by a thread crossed in figure of 8, or made tight in circular turns under its extremities, would probably succeed as well as the direct ligature. The thread passed with a curved needle, under the artery, and then tied into a knot upon a small compress, (coussin,) Avould ansAver the same purpose. The operation Avould thus be rendered more simple, easy and prompt, and less painful. TREATMENT OF ARTERIAL LESIONS. 81 H.—The Direct (Immediate) Ligature. When it was the practice to search for the artery at the bottom of the aneurismal sac, it was sometimes so difficult to isolate it from the surrounding tissues, that the question was asked Avhether it might not be alloAvable to include at the same time, in the thread, both the vein and the nerves. Molinelli (Mem. de l'Institut. de Bologne, Clin. Chirurg. de Pelletan, t. I., p. 343,) maintains that it is useless to observe so much precaution, and that the strangulation of the large nervous cords rarely endangers the success of the operation. This was also the opinion of Thibault, (Dionis, edit, de la Faye, p. 703,) Surgeon of the Hotel Dieu. Thierry (These de Haller, trad. Frang., t. IV., p. 16,) arrived at the same conclusions, after having made a num- ber of experiments on dogs, sometimes by tying the axillary and femoral arteries, without touching the nervous plexus; and some- times by including this plexus in the ligature, in none of Avhich cases did gangrene or permanent paralysis take place. The mod- erns nevertheless have rejected his views on this matter, and think unless there should be insurmountable difficulties in the Avay, that the artery alone should be embraced by the ligature. Though even the case' quoted by Pelletan, (Clin. Chirurg., t. L, p. 143,) from a letter of Testa's, in Avhich it is seen that a patient operated upon by Falconnet, Avho had included in the same ligature the pop- liteal nerves, vein, and artery, was seized with frightful pains in the limb, Avhich became gangrenous the very evening of the day of the operation, might not make it imperative to conform to the practice of surgeons in our time, reason alone Avould have sufficed to persuade us to do so. That the section, in fact, of one, or of several of the nerves, does not necessarily cause paralysis, may be conceived; that a ligature upon a large vein should not be constantly folloAved by gangrene, Ave may also understand, Avhatever M. Guthrie may say on this matter ; (Diseases of the Arteries, &c, p. 128,) but let those two kinds of organs be strangulated at one and the same time, Avith the principal artery in the same limb, and it is undeniable that mortification and loss of sensibility Avill take place, if not ahvays, at least in the greater number of cases. In recommending that we should pay no attention to parts so impor- tant, have not surgeons wished to justify the little trouble they took to isolate the artery, and thereby to depreciate the advantages of an opposite course ? At the present time therefore it is the rule not to allow either the vein, or the smallest nervous filament, or any of the surrounding tissue, to be included in the ligature with the artery; and this, Avithout doubt, is one of the reasons why the operation for aneurism, once so formidable, is now so simple and easy. M. Ghidella, (Bullet, de Ferussac, t. XXIV., p. 172,) who, in adopting the advice of Monteggia, included the nerve and the vein in the same ligature, in tying the femoral artery for a hemor- rhage, following amputation of the leg, will not succeed in causing this practice to be revived, notAvithstanding the success he boasts of. M. Grillo also, (Gaz. Med. de Paris, 1834, p. 539,) who asserts 9 82 NEW ELEMENTS OF OPERATIVE SURGERY. that he cured fifteen patients by tying the femoral artery in this manner, places himself beyond the pale of my comprehension. I.—The Double Ligature. Since precautionary ligatures have been rejected, some persons have thought that for greater security, it Avould be well to apply on the large arteries tAvo ligatures, at a certain distance from each other. Vacca says, that by proceeding in this manner we gain nothing, since the intermediate portion of the vessel between the tAvo ligatures, necessarily becomes gangren- ous. But this reasoning of the Professor of Pisa is not valid ; for M. Briquet states, according to Beclard, that a segment of artery continues to retain its vitality, though it may no longer have any connection Avith the trunk from Avhich it is separated; it is there- fore for other reasons that it has been thought advisable to pro- scribe the double ligature. [Ligatures, Compression, Torsion on Arteries, fyc. The revival, by the Irish surgeons, of the ancient pathology by Avhich the consolidation of aneurisms Avas supposed to be most promoted by diminishing only, and not entirely arresting, the cur- rent of blood, gives great additional interest at the present time to every neAV investigation on the subject of the application of com- pression, ligatures, torsion, &c. It Avould seem, in fact, by the ex- periments of M. Manec, that Avhichever be the true doctrine, i. e., whether the inner lining of arteries has absorbents, and can ab- sorb, or so change the clot above the ligature as to prepare it to become organized by fibrinous lymph shooting through it from the coat in question, or Avhether the clot be an impediment or not to agglutination of the parietes of the artery, which common obser- vation on the healing of Avounds Avould seem to authorize us to believe, as is remarked by Mr. Spence, (Cormack's Lond. and Ed. Month. Jour., fyc, June 1843, p. 500, &c.,)it is certain the natural adhesive process for the union of the sides of the artery is often destroyed by the suppuration required to enable the ligature to cut through it. At the first vieAV, therefore, it Avould seem to be the most reasonable course to adopt the most natural method, as that of qualified compression, as used in the Dublin mode of curing aneurisms ; and that this is preferable to torsion, and torsion to ligatures. The base also of the secondary coagulum, and Avhich col- lects or clots above the ligature, Avould also, M. Manec says, be destroyed by the same suppuration, and thereby give rise to imme- diate hemorrhage, if its usual length, and the partial agglutination of the coats Avhich has taken place beloAV did not together have poAver to resist the impulsion of the blood. (Ib., loc. cit., p. 502.) FromAvhence is deduced a rule Avhere ligatures are used,not to apply them, if possible, too near a collateral branch; or, if that cannot be avoided, not to isolate the trunk too much. According to M. Manec, the clot from the sixth to the tenth day, is found to be composed of a homogeneous coagulum and a coagu- able lymph, uniting said mass to the vessel, by means of a clearly TREATMENT OF ARTERIAL LESIONS. 83 discernible filamentous connexion which shortly becomes areolar. All this gradual change of coagulated blood into lamellated tissue, and which organization extends through successive layers of the entire substance of the coagulum, before reaching the centre of which red stria: appear in it in those parts nearest to the artery, are ascribed by M. Manec (loc. cit.) to the impulsion of the blood. The red striae, according to him, seem to be absorbent vessels which slowly take away the colorific principle of the blood and re- turn it to the circulation. The striae, then, after doing this duty, lose their color and consolidate, forming the basis of the fibrinous Aveb, into Avhich the sanguineous coagulum is always changed; each fibrous filament thus appearing to be formed of an oblite- rated vessel. The Avhole of this very plausible explanation, should it turn out to be true, goes still further in favor of qualified com- pression, rather than of ligatures or torsion. M. Spence (Ib.) differs from Manec in respect to the clot being absolutely necessary, as he says lymph, as he has proved, Avill be poured out and unite the arteries firmly without the coagulum. Thus, in the two carotids in the same dog, one had not, and the other had, the coagulum, yet both Avere perfectly obliterated. The great Hunter's success in injecting coagula; and the recent investigation of Dairy mple (Lond. Med.-Chir. Soc, vol. XXIII.) favor Manec's views. MM. Jones, Travers, Guthrie, and others, think reunion depends en- tirely on the cicatrisation of the divided tunics, and that the clot is inci- dental, and may assist, but is not essential. This is the most com- mon opinion, according to Mr. Spence, Avho does not, as Ave per- ceive, coincide with it, but almost entirely Avith that of Manec. All of these investigations, hoAvever, he says, overlook a very uniform and important process, and Avhich is, the changes which take place on the exterior of the vessel, but slightly mentioned by Jones and others, but never as conducing to the obliteration of the vessel. Thus, in examining an artery, forty-eight hours after being tied, (loc. cit., p. 504,) Ave find it, he says, surrounded for a considerable distance above and beloAv the ligature, by a deposition of pretty firm lymph, Avhich presses upon and adheres to the coats of the vessel, completely imbedding the ligature, which is deeply sunk between the ends of the artery. The adhesions of the lymph to the arterial parietes at this time, though distinct, are slight. Ninety- six hours, after ligature, the effused lymph, though diminished in bulk, has become much firmer, and is, as it were, concentrated round the vessel; and Avhen the external portion is dissected off, we see distinct filamentous bands passing from one end of the ves- sel to the other, around its entire circumference. At the ninth day after the operation, that is, Avhen the ligature is separating, Ave find that the thread is enveloped in a tubular sheath of lymph, that the deposit round the vessel itself is iioav very dense and firm, and if the ligature be partially separated, Ave find that the effusion of lymph has kept pace Avith its separation, and united the ends of the vessel at the point Avhence the ligature has separated, immediately behind the thread. On the thirteenth day, that is, when the ligature 84 NEW ELEMENTS OF OPERATIVE SURGERY. has fairly come away, (these Avere the dates in Mr. Spence's expe- riments, the illustrations of Avhich are seen in his series of prepa- rations, in the Anatomical Museum of the University of Edin- burgh) the lymph has assumed the appearance of a firm connect- ing medium, uniting the divided ends of the vessel, not unlike the exuberant callus in a fracture; at the tAventy-eighth day in some, but later in other cases, it has become much absorbed, so that the vessel has noAv the appearance of a firm impervious cord, at that part Avhere the effused lymph formerly existed. (Ib., p. 504, 505.) It is impossible not to be struck with the analogy of the organic process here described, with that already explained and incontesti- bly established in the remarks of our author, (vol. I. of this work above,) on Avhat takes place after the division of tendons. There can be no doubt that nature, so fond of uniformity and harmony in all her Avorks, does, in the obliteration of arterial tubes, so far as their external surface above and beloAV the ligature is concerned, act in the Avay described by M. Spence: and it forms in our mind another argument in favor of qualified compression, which must by its nature be better calcu- lated to bring about to a greater extent, and more equably and gradually this agglutinating organic process, external to the tunics, than a cutting ligature, whose interference is admitted, (see above,) possibly can be. The importance of this process, interfered with, as it certainly is by the ligature, in all that part occupied by the con- striction, is shown in the two simultaneous actions going on in the ligature, viz.,ulcerating its Avay outAvards, and followed up behind it by the reparative process of the effusion of lymph keeping pace Avith the ulceration, as Avas long since seen, says Mr. Spence, in the old operation for fistula, with the gradually tightened wire, the repara- tive process literally following step by step in the track of the ulcera- tion. The effused lymph also is serviceable, M. Spence says, by its pressure diminishing the calibre of the vessel, and thus lessen- ing the impulse of the blood in the neighborhood of the ligature. How much more effectively therefore could, as we think, this great principle, which is the basis of the process; that is to say, pressure from without upon the tunics, be carried out by the new mode of curing aneurism; for it has the double advantage : first, of favoring by its retardation of the blood through the sac, the for- mation of a clot there, Avhere it is certainly of most indispensable importance ; and secondly, after the sac has been enabled to op- pose an insuperable resistance to the impulsion of the blood, while the collateral circulation is at the same time being propor- tionally, gradually, slowly, and securely established and perfected, Ave have it in our power to increase and continue compression along such portions of the tube immediately above the sac as it may be desirable to obliterate by pressure, and external deposit of lymph, in order to give greater strength to the diseased parts, and a better guarantee against the return of the aneurism. Such con- siderations seem to us to be just views. M. Spence is inclined to believe, and in fact admits, that coagula TREATMENT OF ARTERIAL LESIONS. 85 can become organized; but as to their absorption, he thinks proof is wanting to establish that. The labors of M. Spence, as we per- ceive, possess the highest interest. The re-introduction into surgery of the treatment of aneurisms by gentle compression, (see our note, supra,) makes every neAv and well-accredited research on the nature of the fibrine and the coa- gulation of the blood, a subject of deep interest and real value at this moment. M. Polli, in a memoir on the Condition of the Fi- brine in the blood in Inflammatory Diseases (Annali Universali di Medicina, 1844-45 ; and Gaz. Med. de Paris, Avril 26,1845 ; p. 268, 269,) says, the blood in every case, as far as he has seen, coa- gulates in or out of the body before it decomposes. The fibrine is perfectly liquid in the blood during its coagulation. He has effected (hoAV ?) the coagulation of the blood even thirty-six or forty-eight hours after he had taken it from the dead body ! The rigidity, or relaxed condition of the body after death, he imputes to the more or less speedy or tardy formation of the fibrinous clot in the blood-vessels, or its re-solution in the capillaries of the subject. Inflammation, according to this author, gives rise to three differ- ent modifications of the blood : 1. Augmentation of its quantity ; 2. Greater resistance to its coagulation; 3. Its molecular rarefac- tion. But the reasoning advanced by the author to explain these conditions seems to us speculative and contradictory. He supposes thus, that the serum of the blood, (the natural solvent of the fibrine,) though surcharged Avith fibrine, Avhich has greater specific gravity than the serum, (as is proved, he thinks, by its natural precipitation from the serum,) is actually rarefied or attenuated by this super- addition, and is rendered specifically lighter than Avhen defibriniz- ed or deprived of this excess ! This attenuated sero-fibrinous fluid, as contra-distinguished from ordinary dense fibrine, according to him, forms the fibro-gelatinous semi-transparent deposit on the sur- face of blisters, anterior to the organization and excretion of pus, and also forms false membranes. The assumption of this sup- posed tenuity, caused by the commixture of additional fibrine to the serum, does not, in our judgment, explain by the supposed smaller size of the molecules, their capacity of transudation through the capillaries; because it is, on the face of it, at war with established facts, and because, moreover, the capillaries are all dilated by the impulsion of the blood, in acute inflammations and fevers, and therefore fitted to receive and expel the fibrine in its natural state, even supposing that there is then a surplus of this material. But the blood again is most fluid, limpid, and attenuat- ed, in fact, most dissolved in atonic and adynamic fevers, Avhere there is the least degree of inflammatory action, as in typhus, yel- Ioav fever, &c. The high degree of attenuation and rarefaction of the blood, which he supposes to exist in inflammations, (entonic fevers, phlegmasia?, &c, Ave presume he means,) and this too, even after the great superaddition of dense fibrine, is difficult to comprehend, except by the chemico-organic principle of a more perfect solution, or 86 NEW ELEMENTS OF OPERATIVE SURGERY. dissolution of this fluid, by means of the more rapid generation, and consequently greater accumulation, of caloric in acute fevers. The action of the absorbents, hoAvever, is accelerated to the same degree of excess, and hence the rapid transformation of the mus- cular, or fibrinous, and all other tissues, which are pressed or drawn into the vortex of the circulation, as Leibig has so beautifully shoAvn, to furnish additional supplies to the elements of combustion. And hence, too, as a proof of the truth of this fact, familiar to every one, the exhaustion, thirst, and especially the emaciation of patients in protracted fevers; the system receiving no food from without, but consuming itself. It is not necessary to suppose, therefore, an actual accumulation at this time of fibrine in the blood, but a more accelerated transformation, or metamorphosis of this and other materials into that common reservoir. Never- theless, the great accession of caloric may, doubtless, render the blood, during the febrile excitement, far more limpid than in its nor- mal state ; the fibrinous and the other dense products that it throws off from the distended capillaries, however, are no proof that these matters existed then in greater quantity in the blood itself. As Ave deem M. Polli's inferences based in error, we have thought proper to attempt their, refutation; since, in the present rush for experiments and speculations on every subject of science, it is as much our duty in an elementary work like that of M. Vel- peau, to guard against the dissemination of ideas that are purely speculative, as to favor the diffusion of principles that are founded on unquestionable facts and legitimate induction. T.] § IV.—Operative Processes. A. JEtius (Sect. IV., Serm. 3, Cap. X.) says, that in order to cure aneurism, it is necessary to lay bare the artery above the disease, tie it in two places, divide it transversely, then to open and empty the sac, afterAvards to raise up the vessel, tie it above, then below the opening, and to cut it through a second time. B. Paul of Egina (Paulus Mginet., lib. VI., cap. 37,) speaks of a process which consists in passing a needle Avith a double ligature behind the middle of the aneurism, tying one of these ligatures above and the other beloAV the tumor, which is thus strangulated above and below, afterwards opened, and almost the whole of it excised. Thevenin (CEuvres, 1658, in fol., p. 57,) also mentions this process which, as Ave see, is very similar to that which was formerly used in applying a ligature to lupus and many other tumors. It is this, doubtless, Avhich Guyde Chauliac (Grande Chirurgie, etc., p. 173,) has reference to when he asserts after Albucasis, that Ave may cure aneurism by employing the ligature, so as to burst it, (a mode de rompure.) C. Guy de Chauliac points out another mode Avhich, though it approaches that of Paul of Egina, nevertheless differs from it under some points of view, and seems in reality to be more rational. " It is necessary," says he, " that the artery should be laid bare, and TREATMENT OF ARTERIAL LESIONS. 87 tied on both sides, that the part between the tAvo ligatures should be cut through, (tranche) and then treated like common Avounds." The process described at such length by Bertrandi, tOAvards the middle of the last century, being only the repetition of that of Guy de Chauliac, does not require any further mention. It is also so far from being neAV, that Philagrius (JEtius, tet. IV., Serm. 3, cap. X.) had already had recourse to it. D. Guillemeau, ((Euvres Completes, in fol., p. 6 9 9,) rival and disciple of Pare, simplified the method of the ancients ; he contented himself with tying the artery above the tumor, opening this last, emptying it of its clots, and then dressing it as an ordinary Avound ; it is this Avhich forms at the present day the basis of the ancient method of treating aneurisms, a method Avhich up to the last century, no one had the courage to apply except to aneurisms in the bend of the arm. E. Keysleire, (Lettre a Cotugno, Pelletan, Clin. Chir., t. I.,) sur- geon of Lorraine, in the service of Austria, about the year 1774, is the first who asserts that he had many times performed it Avith success for aneurism in the ham. Keysleire, in place of commenc- ing by laying bare the artery above the tumor, proceeded, after having arrested the current of blood in the limb by means of the garrot or tourniquet, to lay open the aneurismal sac in its Avhole length, then carefully cleaned it, sought the opening of ihe ves el, introduced the end of a sound to raise it up, tied its upper end, moderately compressed its loAver end, and treated the Avound after- Avards by the known means. Guattani, Molinelli, Flajani, and al- most all the surgeons of Italy, employed the same method, Avhich soon became generally adopted, in France, Germany, and England, after having undergone, hoAvever, some slight modifications. F. In place of confining themselves to compressing the lower end of the artery, Molinelli, Guattani, &c, found it more prudent to surround that also by a ligature. The tAvo Monros, Hunter, Desault, Pelletan, Deschamps, and Boyer, thought it would be ad- visable also to leave some threads above and beloAV the first ones, in order to make use of them if required, to check consecutive he- morrhages ; from thence came those precautionary ligatures which have been described farther back. G. Anel. A method different from this, and the elements of which are found in the processes of Aetius and Guillemeau, Avas put in practice at the beginning of the last century by Anel. (Observ. sur la Fistule lachrymale, etc., 1714.) Having to treat an aneurism in a missionary of the Levant, Anel applied on the 30th of January, 1710, in the presence of Lancisi, a simple ligature upon the brachial artery, immediately above the tumor, and Avithout touching the sac. On the 5th of March folloAving, the patient had entirely re- covered. Nevertheless, this event, though remarkable, did not at first excite attention, notwithstanding the trial which Leber and V. Hanspel (Verbrugge, De Aneurismate, etc., 1773,) made of it, and was not rescued from oblivion until betAveen 1780 and 1786. De- sault ((Euvres Chirurg., t. IL, p. 568; et Boyer, t. II.) is the first who endeavored to restore it to its honors, in the month of June, 88 NEW ELEMENTS OF OPERATIVE SURGERY. 1785, by tying the popliteal artery Avithout opening the aneurismal sac. On the nineteenth day there escaped from the wound a great quantity of matter mingled Avith blood, and a short time after the cure appeared to be complete ; but the patient ultimately died at the expiration of seven or eight months. The idea, however, of tying the aneurismal arteries at a certain distance from the tumor, dates far back. It is difficult, for example, not to recognize it in this passage of Pare : (ffiuvres, liv. VIIL, Chap. 34, p. 218, in fol.)—" I advise the young surgeon," says this great practitioner, " to be careful hoAv he opens aneurisms, unless they are very small, and in a measure not dangerous ; after incising the skin (le cuir,) over it, and separating it from the artery, we then pass a seton needle, threaded with very strong thread, under the artery on the tAvo sides of the wound, letting the thread fall out of itself, and by proceeding in this manner, nature engenders flesh, Avhich Avill be the means of stopping up the artery." Guillemeau went still farther than his master, for he concludes his article with this remarkable sentence :—" If such an aneurism should present itself to the surgeon in some other external part, he may safely (surement) lay bare the body of the artery at its root and its upper part, and tie it in the same manner Avithout any other ceremony." Is it not evident that Ave here find the parent-thought of the method called that of Anel or Hunter ? In the supposition that it Avas not in the mind of the author, it cannot be denied, at least, that it is deducible from his language. According to the assertion of M. Martin, of Marseille, Professor Spezzani had entertained the design in the year 1781, of tying the femoral artery itself, Avithout touching the sac, for popliteal aneu- rism, a project carried into execution under his eyes by Assalini, (PI. Portal, Clin. Chirurg., 1.1., p. 154.) It was in the month of December, 1785, that Hunter, on his part, carried this suggestion into effect. As his operation was completely successful, it made much noise in the surgical Avorld, and Avas in reality the signal of a revolution in our ideas respecting the trealment of aneurisms. To set out from this epoch, Ave find the method of Anel, de- scribed under the name of the New Method, the Modern Method, and the Method of Desault or of Hunter, all of them inappropri- ate phrases, and Avhich ought to give place to the title of the Method of Anel, its true inventor. In calling it a modern method, Ave make use of an improper expression, Avhich specifies nothing, and which ought to cease to have the least value as soon as another mode of operation should be devised. To-day, for example, the modern method is the method of Brasdor, and no longer that of Anel. In calling it the method of Hunter, as the English surgeons do, and Avhat is more singular, as many persons have been in the habit of doing in France, a double act of injustice is committed tOAvards our nation. In fact, this method devised by Anel, if not by Guillemeau and Pare, Avas by Desault rescued from oblivion. Is it for having applied the ligature at three inches above the point selected by Desault, that Hunter merits the title of inventor in this affair? In that case, this honor Avould in reality redound to an- TREATMENT OF ARTERIAL LESIONS. 89 other, for it is generally in the inguinal space, as Scarpa advised that Ave operate, and not as Hunter did in front of the adductor magnus (troisieme adducteur.) Again, if it is true that Brasdor proposed from the year 17S0, for many years in succession in his course at the schools of Surgery, that Ave should tie the femoral artery in the middle of the thigh, as his panegyrist in the Collec- tions of the Society of Medicine affirms, is it not probable that young Englishmen, Avho then, as at present, Avere always found in con- siderable numbers at Paris, may have carried the suggestion to London, and that in this Avay it had come to the knowledge of Hunter ? It should be the name of Anel, therefore, that ought to be affixed to this process, Avhatever M. Guthrie may say to the con- trary, (On the Diseases of the Arteries, &c., 1830,) and Avho, in order more effectually to oppose Dupuytren on this subject, goes to the extent of calling in question the part accorded in this matter to Desault. H. Method of Brasdor.—Another method has since been intro- duced in science. Embarrassed by the difficulty or impossibility of placing the ligature betAveen the aneurism and the heart, and by the danger of opening the sac Avhen the disease Avas found too near the trunk, and unwilling, nevertheless, to rely upon the method of Valsalva, or upon topical refrigerants, some surgeons in that case supposed that it might be alloAvable to place the ligature beloAV the tumor, between the tumor and the capillary system. According to Boyer, (Malad. Chir., t IL, p. 569,) it is to Vernet, a military surgeon, to Avhom we are to ascribe the first suggestion of this method, since it is to him that Ave are indebted for the attempt to compress the femoral artery below an inguinal aneurism. Brasdor, nevertheless, is the first Avho formally proposed to apply the liga- ture at that place. Desault, ((Euvres Chir., t. II., p. 569,) at a later period, urged the same thing. Deschamps (Ibid., p. 572) carried, it into execution for a very large aneurism in the fold of the groin Avhich threatened to burst. The pulsations immediately be- came much stronger in the tumor, Avhich it became necessary at the end of a feAV days to lay open freely, and the patient died in consequence of this last operation, after having lost a very consid- erable quantity of blood. From that time the proposition of Bras- dor appears to have been definitively adjudged; A. Burns (Sur- gical Anatomy, 1823, p. 186,) qualified it as absurd, and it was generally rejected as dangerous. The attempt of Deschamps seemed fully to comfirm the fears, that reasoning a priori on the subject, had suggested. It had been said that by strangling the ar- tery beloAV the sac, (en dega du kyste,) it is evident that the blood arrested at this point by an insurmountable obstacle, must distend Avith greater violence than ever the aneurismal tumor, and also attenuate its Avails, and ultimately rupture them. M. A. Cooper, (S. Cooper, Dictionary, art. Aneurism?) convinced like Brasdor, that Avhen the circulation is arrested in the artery, beloAV (au-dessous) the aneurism, the blood would soon flow into the collateral vessels, to reach the loAver part of the limb, and that 90 NEW ELEMENTS OF OPERATIVE SURGERY. it would fall into a state of stagnation, and coagulate in the tumor, and in all that portion of the vessel comprised betAveen the liga- ture and the first branch of any considerable size lying tOAvards the heart, did not feel inclined to yield to those reasons. He ven- tured, therefore, in 1818, to reneAV the attempt of Deschamps in a case of aneurism, Avhich raised up (soulevait) Poupart's ligament, and appeared to occupy a great portion of the iliac fossa. The pulsations of the tumor continued, but the progress of the disease Avas arrested. At the expiration of a certain period of time, the tumefaction of the neighboring parts disappeared; the separation of the ligatures was not succeeded by any accident; the Avound cicatrized, and about the sixth Aveek the patient Avas sent to pass his convalescence in the country. It wTas ascertained afterwards that the tumor had ruptured, and that the man died about tAvo months after the operation. The body Avas not examined. NotAvithstanding this unfortunate result, the operation of M. A. Cooper Avas nevertheless of a nature to inspire hopes, and to de- serve neAV trials. M. Marjolin also said (Dictionnaire de Medecine, art. Aneurisme, 1821,) that before abandoning it entirely, it Avould be advisable to make some new trials with it, especially on the primitive carotid. M. Pecot (These No. 155. Paris, 1822,) after- wards distinctly recommended it for certain descriptions of aneu- rism of the primitive iliac, the external iliac, and even the subcla- vian, Avhen the size or situation (disposition) of the tumor pre- vented our laying bare the artery by the method of Anel; provided Ave could at the same time tie the collateral branches which might be found between the principal ligature and the sac. M. Casa- mayor (These No. 151. Paris, 1825,) also, after passing in review all the facts and reasonings that had been adduced in favor of or against the method of Brasdor, asserts that it might perhaps be employed in those cases of aneurism Avhere we should be enabled to suspend by this means the current of blood, or at least reduce its column to such dimensions that it Avould be incapable of pre- venting the contraction of the tumor. Dupuytren, on his part, has declared that the partial success of M. A. Cooper Avas rather cal- culated to encourage than to dampen the zeal of surgeons, and that by restraining the patient to a severe diet, and diminishing the mass of the fluid by repeated bleedings, either before or after the operation, Ave might by this means, probably, by alloAving the blood accumulated in the tumor to become coagulated, promote a favor- able issue. Matters Avere in this state Avhen, in spite of the reasons of A. Burns, and of Hodgson, and many other English authors, M. War- drop, (Archiv. Gen. de Med. t. XX., p. 557,) in 1825, carried into execution the ideas of Brasdor, in the case of an aneurism of the primitive carotid. It was in a woman aged seventy-five years, and in whom the tumor, approximating very close to the sternum, would not have allowed of placing a ligature between it and the heart. On the fourteenth day the aneurism had diminished one half, and the pulsation was no longer felt in it; it terminated by TREATMENT OF ARTERIAL LESIONS. 91 bursting and emptying itself like an abscess; but the ulcer was speedily cicatrized, and the patient perfectly restored. Was it in reality an aneurism ? In the course of the same year, M. Wardrop (The Lancet, Vol. I., 182(i) had to treat another Avoman Avho was fifty-seven years of age, affected Avith an aneurism situated immediately under the sterno-mastoid muscle upon the right side. The carotid, artery Avas tied, Dec. 10th, Avith a ligature made of the intestine of the silk Avorm. On the 13th, the Avound had entirely closed, and on the 21st, the patient believed herself perfectly cured; neArertheless she died on the 21st of March folio Aving, in consequence, ho Ave ver, of symptoms of hypertrophy of the heart, and of accidents which did not seem to have any connection Avith the operation itself. On the 1st of March, 1827, M. J. Lambert, (Ibid., 1827, vol. XII.,) of Wahvorth, had oc- casion to adopt the plan of M. Wardrop in a case of aneurism of the right carotid in a Avoman aged forty-nine years. On the third day the tumor had much diminished in size, and only slight pulsa- tions Avere felt in it. On the tenth day a hemorrhage came on, which did not prevent the Avound from closing. The tumor soon disappeared. On the 17th of April, the cicatrix had become rup- tured, and a red fleshy growth occupied its centre. On the 18th, a new hemorrhage took place, and occurred several times up to the 30th; and on the 1st of May it became so abundant that the patient died at 11 o'clock in the forenoon. On opening the dead body, it Avas found that the carotid artery had ulcerated above the ligature, that the aneurism had become entirely obliterated, and that the hemorrhage had been produced by the reflux of blood from one carotid to the other. M. Bushe (The Lancet, Vol. I., 1828; and Vol. IL, p. 149,) on the 11th of September, 1827, performed the same operation on a Avoman aged thirty-six years, Avith perfect success. M. Wardrop (The Lancet, Vol.'l., 1827; Vol. I., 1828; Vol. IL, 1829. Med. Chir. Rev., No. 21. Bullet, de Ferussac, t. XX., p. 231.) performed it a third time on the 6th of July of the same year, on a Avoman aged forty- fi\re years This time he tied the subclavian artery in place of the carotid, Avhich evinced no pulsation, and appeared to have become obliterated. A month after, the patient quitted London to reside in the country, and tOAvards the latter part of August found her- self perfectly restored. Various symptoms of affections of the chest afterwards occasioned some apprehension. On the 9th of September, 1828, the health of this lady, Avhich Avas the occasion of a suit of slander, (The Lancet, 1828, Vol. I., p. 775,) had never been in a more perfect state; but she, nevertheless, died on the 13th of September, 1829. On the 2d of July, 1828, M. Evans (The Lancet, November, 1828,) also employed the method of Bras- dor in a case of aneurism of the trunk of the carotid, in a man aged thirty years, and on the 28th of October, the patient resumed his usual occupations. Accidents afterAvards supervened, and it be- came necessary to perform a neAV operation, and to tie two tumors, and excise them. The patient was ultimately cured. (Letter of 92 NEW ELEMENTS OF OPERATIVE SURGERY. M. Evans to M. Vilardebo, May, 1831. These No. 158. Paris, 1831, p. 58.) A negro operated upon in the same manner by M. Montgomery, (Guthrie, op. cit., p. 191. The Lancet, 27th of June, 1833,) on the 10th of March, 1828, in the Isle of Mauritius, at first seemed to do well, but died on the 11th of July following. The patient of M. V. Mott (Journal des Progres, 2d ser., t. IL, p, 213, or Ameri- can Journal of Medical Sciences, 1830,) also, whom he had oper- ated upon on the 20th of September, 1829, and Avhom he had sup- posed to be cured, died on the 22d of April, 1830. A Avoman operated upon by M. Key, (London Medical Gazette, July, 1830,) on the 20th of July, 1830, died the same day. An attempt of the same kind Avas made on the 12th of June, 1829, at the Hotel Dieu, by Dupuytren, for an aneurism at the origin of the right subclavian artery ; the patient died on the ninth day after the operation, more perhaps OAving to the great loss of blood than from the operation itself. MM. White (Guthrie, Diseases of the Arteries; Vilardebo, p. 28,) and James, (Med. Chir. Trans., Vol. XVI., 1830,) Avho re- peated the operation of M. A. Cooper, Avere not more fortunate. A patient operated upon by M. Laugier, at the Neckar Hospital, also died ; but a case of M. Fearn, (Arch. Gen. de Med., 3e serie, t. IL, p. 364,) another of M. Morrison, (Ib.,]>. 367,) a third of M. Tilanus, and a fourth of M. Rigen, seem to give support to the first success- ful cases of M. Wardrop. Thus have we three methods of treating aneurism by ligature. It remains noAv to see which is the one Avhich ought generally to be preferred, and in Avhat cases it may be proper to have recourse to the others. § V.—Relative Value of the Principal Methods. A. In the ancient method it is necessary that the seat of the tumor should admit of our making between it and the heart a sufficient degree of pressure temporarily to suspend the entire circulation in the limb. The opening of the sac requires a very extensive Avound, leads to an abundant suppuration, renders the isolation of, and ligature up- on the artery sometimes very difficult—frequently obliges us to place the ligature upon a part of the vessel more or less altered, exposes in a remarkable degree to secondary hemorrhages, and to gangrene from deficiency of circulation, and does not cicatrize but very sloAvly. If the aneurism is deep-seated, this method obliges us to divide the muscles and aponeuroses, and to produce a good deal of destruction in the midst of the tissues; in a Avord, it is a * painful, long, laborious, difficult and dangerous operation. The rea- sons in favor of it are, that it preserves all the important collateral arteries, permits no reflux into the sac, and exposes less than the others to erysipelatous, phlegmonous and purulent inflammations (fusees) in the depth of the muscles. Perhaps, therefore, it Avould still be advisable frequently to give it the preference near the upper part of the limbs, and to adopt it generally in traumatic aneurisms, TREATMENT OF ARTERIAL LESIONS. 93 whether primitive or consecutive, (constitutifs.) M. Guthrie, (Oper. cit., p. 270, 283,) who will allow of no other in such cases, no doubt goes too far ; but in rejecting it altogether from practice, modern surgeons have gone to the other extreme, which is equally as objectionable. B. By the method of Anel, Ave act on tissues in the normal state, and Avhose relations have not been disturbed. It is easy to include only the arterial trunk in the noose of the ligature, and to avoid the nerves, veins and all other tissues whose strangulation might compromise the success of the operation; the previous compres- sion of the vessel is not indispensable ; and we may look for it in the place Avhere it is most easy to lay it bare, or where it is most superficially situated. The Avound which is smooth, (nette,) and of little extent, cicatrizes promptly and Avith facility ; the operation • is simple, easy, and infinitely less painful and not so long as by the other method; and Avhen the artery is tied upon a portion of it which is perfectly sound, the secondary hemorrhages must be less formidable and less frequent. The continuity of the tissues not ' being so much disturbed, (interessee,) the circulation below the liga- ture is more easily re-established; and the constitutional reaction is necessarily less intense, (vive,) and the gangrene of the limb less to be apprehended. I. To those Avho say :—By opening the sac; 1, we may apply the ligature as low as possible, and the tumor is immediately emp- tied ; 2, Ave do not add another lesion to the first; 3, that tumors placed too near the trunk, (i. e., of the artery. T.,) to treat them by the method of Ariel, will, by the process in question, alloAv of the two ends of the artery being tied; 4, that Avhen an arterial trunk has been Avounded, and Ave knoAV the place that the opening occu- pies, it appears more rational at first sight to lay it bare in this place than to proceed by means of a neAV Avound to search for it higher up ; the partisans of the method of Anel reply :—1, After a liga- ture upon an artery, the circulation ceases, not only in the part Avhich is nearest approximated to the ligature, but moreover also as high up as the first collateral of any considerable size Avhich is met with in the direction tOAvards the heart; 2, in placing a liga- ture upon the popliteal artery, the femoral itself, for example, becomes obliterated as high as to the origin of the profunda, for Avhich reason there is in this respect no advantage in cutting down to the vessel at the loAver third of the thigh; 3, that in respect to tumors situated very near the upper part of the limbs, there are none of them at the present day to which the method of Anel Avould not apply, so long as they admit of being operated upon by opening into the sac; 4, that in diffused aneurisms it cannot be de- nied that the embarrassments caused by the effusion of blood, the displacement and disorganization of the tissues, the difficulty of cut- ting doAvn (tomber) exactly upon the point Avounded, and of finding the vessel itself at the bottom of a wound more or les irregular in its shape, and the depth to which it Avould sometimes be necessary to penetrate, are inconveniences calculated to justify the practice of 94 NEW ELEMENTS OF OPERATIVE SURGERY. those who, even under such circumstances, operate upon a part of the limb higher up; so much the more so because hemorrhage which might return by the loAver end of the artery, could easily be arrested by pressure properly applied. II. The opponents of the method of Anel might however rejoin, that in placing the ligature at a certain distance from the disease, Ave incur the risk of seeing the blood and pulsations return in the sac, and of having thus performed, to no purpose Avhatever, an operation of a dangerous nature. The blood by means of the anastomosing branches (arcades) may return into the arterial trunk betAveen the tumor and the ligature, re-enter the aneurismal sac by its loAver opening, or arrive there directly by some secondary branch. Though experience may have shoAvn that these pulsa- tions soon cease, and that they are generally easily overcome by a moderate compression, the contrary also is equally possible. Rea- son, moreover, perfectly explains this result. The blood Avhich arrives to the aneurism, under such circumstances, cannot do so but after having traversed the capillary system, until after having passed from very small channels into branches of greater and greater calibre, and consequently not until after having lost in a great degree its natural force, (vitesse habituelle ;) but if it be suffi- cient in order to effect its coagulation that it should remain in a state of oscillation or stagnation, and that it should cease to cir- culate in any given point Avhatever of the vascular system, Ave may also conceive that in certain cases it might remain liquid, keep up the disease to an indefinite period of time, and bring on inflamma- tion of the sac; and that if the inconvenience in question is fai from meriting the importance that was at first given to it, we should do wrong on the other hand to pay no attention to it. As to the subsequent opening (ouverture consecutive) of the sac, and its inflammation and suppuration, both of which have, with good reason, been deemed of a nature calculated to jeopardize the success of the method of Anel, they are inconveniences which, when they do happen, render the operation still less formidable than that of Keysleire. They are, moreover, rarely met with but in cases Avhere the disease is far advanced, or where the aneurism is contained within Avails that are greatly attenuated and more or less disposed to mortification. III. In reality the method of Anel has numerous and indisputa- ble advantages over the ancient method. Nevertheless this last should not be entirely rejected; we should give it the preference, for example, in diffused superficial aneurisms, in those Avhich are situated upon the brachial artery very near the axilla, and even in those of the axillary artery, when the shoulder is infiltrated or so altered (deformee.) that it Avouldbe dangerous to attempt the ope- ration in front of or above the clavicle ; also in all aneurisms of very large size that are in danger of becoming gangrenous, or that are in the vicinity of a large and important collateral vessel; in fine, in a varicose aneurism (aneurisme variqueux) which requires that the artery should be tied above and below its opening. This doctrine, zealously advocated by M. Guthrie, seems to me to be exceedingly TREATMENT OF ARTERIAL LESIONS. 95 sensible, and altogether conformable to the principles of sound sur- gery ; many facts Avhich will find their # place elseAvhere, have satisfied me that it is correct. C. The method of Brasdor, being a mere modification of that of Anel, has consequently as an operation, all its general advantages and inconveniences. It is in fact nothing more than a substitute or dernier resort Avhich is applicable only to cases which do not' admit of the two other methods. The cures that are obtained - by it are explained in the following manner:—the blood circu- lates with less force in the aneurism than above and below it, and this in consequence of a physical or hydraulic cause which is easily understood. From this condition of things, the first effect of a ligature when applied upon the distal (excentrique) por- tion of an artery, should be to completely arrest its circulation first in the tumor, which from that moment is converted into a bar- rier, (transformee en impasse ;) and secondly, as far as to the supplemental branches, through Avhich the blood, may obtain egress, and be diverted from its accustomed channels. Let, for example, the carotid be tied near its bifurcation, and it Avill become obliterated gradually doAvn to its origin, that is to say, doAvn to the point where it separates itself from the aorta, or the subclavian ; it Avill be the same respectively Avith the tibial, radial, ulnar, popliteal, brachial and femoral arteries, &c. But if by constricting an artery near its distal (peripherique) extremity, Ave are enabled to obliterate its canal down to its origin, it is evident that an aneurismal tumor ex- isting between those two points, ought to be made to disappear with almost as much ease and certainty Avhen Ave placed the ligature upon the distal as upon the cardial side of the disease. It is, in fact, to be presumed that by the method of Brasdor the pulsations Avould be leys apt to return or to be kept up in the sac than by the process of Anel, unless there should happen to be found a number of large sized collaterals betAveen the ligature and the aperture of the artery. In this last case, Avithout doubt, the operation would present fewer chances of success, but it nevertheless would, in my opinion, often succeed; provided the supplemental branches should be only one half or a third of the size of the principal trunk; that they should not furnish to the blood a circuitous route, (voie de detour,) which would prevent its stagnation in the aneurismal sac, and that the walls of this last should have sufficient thickness or density to resist the violent efforts and pulsations Avhich they are ordinarily obliged to sustain immediately after the operation. WTe must not, hoAvever, exaggerate the value of this neAV method. Out of about twenty subjects Avho have hitherto been submitted to it, at least fourteen have died, Avhile a fifteenth Avas exposed to the most imminent danger. A great number of facts here and there to be met Avith in scientific Avorks prove that the arteries are far from always becoming obliterated to a great extent on the cardial side of the ligature. Warner cites the case of an aneurism of the brachial which succeeded to an amputation above the elbow, and in Avhich it became necessary to tie the vessel near the axilla. An amputation 96 NEW ELEMENTS OF OPERATIVE SURGERY. of the leg presented the same difficulty to M. Roche at Tarragona, in 1813, so that it was found necessary to tie the posterior tibial between the aneurism and popliteal artery. We find in M. Hodg- son two examples of aneurism, closed on their distal side, and Avhich, nevertheless, ultimately ruptured or became gangrenous. M. Guthrie says that many specimens in the collection of Hunter shoAV a complete obliteration of the artery on the distal side (au- dessous*) of the sac, Avithout a cure of the disease having been thereby effected. In his ligature upon the external iliac by the method of Brasdor, M. White found the artery impermeable, and yet the aneurism continued to increase. In a Avoman on whom I performed amputation at the knee, a month before, strong pulsa- tions of the popliteal artery were still perceptible at the bottom of the Avound. And Avho has not been Avitness to the same phenome- non after amputations of every kind? But if the arterial trunk (kyste) continues pervious on the distal side (au-dessous) of the col- lateral branches, at an inch or tAvo from the suppurating surface of an amputation, or from a spontaneous obliteration of the vessel, we can scarcely comprehend why the same difficulty would not exist after a methodical application of the ligature. To understand ourselves on this subject, and to appreciate the method of Brasdor, it is necessary, after the example of M. H. Berard, (Diet, de Med., 2d edit., t. III., p. 59 a 72) to divide the facts which relate to it into two classes. 1, If there is no collateral branch remaining betAveen the ligature and the sac, we have every possible chance of success; the aneurism is then converted into a cul de sac, where the blood is concreted and closes the upper end of the artery. 2, If collaterals exist between the tumor and the ligature they serve to divert and keep up the circulation to that point, and hinder the blood from concreting in the sac. 3, And even supposing that there should be no collaterals beyond the tu- mor, Ave should still have to fear the presence of arteries Avhich take their origin from the sac itself, or from the immediate neigh- borhood of its upper orifice. M. Berard (Jour. Hebd.; et Archiv. Gen de Med., 1830) it is true, has shoAvn that the roots of these ar- teries raised up and displaced from the line of (transporters hors) the principal arterial axis, soon lose their permeability, by becoming like the aneurism, filled with bloody concretions; but this fact, or this process must be subject to exceptions, and we cannot, in my opinion, fully rely upon it. It is very obvious from these facts, why the operation of Brasdor upon the femoral artery and the axillary ar- tery has not succeeded, while in the primitive carotid it has been attended with very advantageous results. We should do Avrong, however, at present to receive this opinion as conclusive ; I shall, when speaking of arteries in particular, shoAV that though the ca- rotid and subclavian give off enormous collaterals, this has not al- t * In most places when the author, on this part of the subject of aneurisms, speaks of the artery above (au-dessus) the ligature or sac, he means the cardiac side, or nearer to the heart; and so au-dessous, or under the ligature or sac, is the distal side in the opera- tion of Brasdor, i. e., farther from the heart. T. TREATMENT OF ARTERIAL LESIONS. 97 Avays prevented the patients from recovering, and that it remains to be proved that the establishment of the circulation through these collaterals has been the cause of failure in other cases. The ques- tion whether death or the cure in these cases depends, as M. Guth- rie (Oper. cit., p. 207-208] maintains, upon an inflammation which is transmitted from the interior of the sac to the heart, will be discussed in treating of the arteria innominata. § VI. Operative Process. Is it requisite before applying a ligature to an artery that the pa- tient should undergo a preparative course of treatment ? Should we wait until a very advanced period of the aneurism, or is it bet- ter to operate as soon as Ave are perfectly satisfied of its existence ? The previous compression recommended Avith the vieAV of favoring the development of the supplementary vessels, is, comparatively speaking, useless. Latterly, in our times, it has generally been re- jected ; in fact, it Avould be idle to make trial of it, except in cases Avhere it might possibly offer some prospect of aiding in the cure. By the ancient method there was no risk incurred by deferring the operation ; the interruption to the course of the blood, caused by the development of the tumor, favored to the same extent the es- tablishment of the collateral circulation, and the prospect therefore of obtainingin a number of cases a spontaneous cure. At present we attach no importance to those feeble reliances, and by the neAv pro- cesses more especially Ave undertake the operation as soon as pos- sible. Some persons go to the extent, but erroneously, as I conceive, at least in formidable cases, of rejecting all precautions of regimen or general treatment. One or tAvo bleedings if the patient is robust or of the sanguine temperament; a diminution to a greater or less extent in the quantity of aliments, with drinks slightly bitter and diluent, and anodynes (calmants,) tepid baths and anti-spasmodics if there are nervous symptoms and a great deal of irritability; preparations of digitalis to weaken the impulsion of the heart; a mild purgative Avhen the . bowels are costive ; and leeches if any local inflammation should supervene, Avill not be omitted by the practitioner Avho knoAvs hoAV to unite the principles of sound me- dicinal treatment to the rules of judicious surgery. A. The ancient method.—I. Instruments (appareil.) In the an- cient method the instruments employed are a convex, a straight, and a blunt-pointed bistoury, a female sound, (algalie de femme,) blunt probes, a spatula, needles of different forms, ligatures, a tour- niquet, a garrot, agaric, lint, compresses, bandages, sponges, scis- sors, &c. The skin upon the aneurism and surrounding parts should be carefully shaved. II. Position of the Patient and the Assistants.—The patient being placed upon a bed properly prepared, or upon a table, an assistant Avho can be relied upon, is charged with the duty of com- pressing the artery between the tumor and the heart, by means of his fingers, a rolled bandage, a bureau seal provided Avith a pelote, 98 NEW ELEMENTS OF OPERATIVE SURGERY. the garrot of Morel, the tourniquet of Petit, or some other similar- instrument ; a second assistant grasps the sound limb, or places himself in front of the operator; a third, hands or receives (re- prenne) the instruments as they are required or no longer needed; a fourth and a fifth, Avhen there is room for them, attend to holding in proper position the head or any other part of the body whose movements might produce some disturbance. III. Operation.—The course of the artery being Avell ascertained, the surgeon divides Avith the convex bistoury, first the skin and the adipose tissue, then Avith a second incision the Avhole thickness of the sac, commencing his incision a little above and not terminating it until he has reached an inch beloAV the tumor. After having re- moved the clots of blood and sponged and wiped the bottom of the wound, he seeks for the opening of the vessel, slackens the compres- sion a little, if necessary, in order to discover the artery with more certainty, introduces into this opening a blunt probe, or a female or a grooved sound, then raises the upper end of the artery, assures himself again that it is this Avhich he has under his eyes, isolates it from the vein, nerves and other tissues Avhich it is im- portant to avoid, passes the ligature under it as if Avith the intention of including the sound at the same time with it, seizes immediately the two heads of this ligature Avhich he draAvs tOAvards him Avith one hand, Avhile he applies the forefinger of the other upon the raised trunk in order to identify its pulsations, and to be certain that the artery is properly secured, and that the ligature Avhich is about to be placed around it Avill effectually constrict its calibre; afterwards there remains nothing more to do than to tighten the ligature by a simple knot, Avhile, at the same time, the sound is AvithdraAvn, then to secure this first knot by another, after Avhich one of the threads of the ligature is to be divided by the scissors very close to the artery. We proceed in the same manner for the lower end of the artery ; the bottom of the wound is then to be filled with agaric, or better still, with balls of soft lint, Avhich are covered with the perforated linen and large plumasseaux of lint spread Avith cerate, and Avhich are kept on by the aid of a feAV compresses and a simple containing bandage which completes the operation and dressing. B. Method of Anel.—When Ave operate Avithout opening the sac, certain precautions required in the ancient method, become useless. The position of the patient and the assistants is not materially different, but there can be no longer any object in making compres- sion of the artery above the tumor, (i. e., on the cardial side,) except as a matter of prudence. The place at which the ligature should be applied upon it, not being determined by the presence of the aneurism, requires somewhat more attention on the part of the sur- geon. I. The place of choice.—In spontaneous aneurisms we should cut as far as possible from the tumor, because the nearer Ave approach to it the more danger is there that the coats in this part of the artery are diseased. In traumatic aneurism Ave must adopt a contrary rule, TREATMENT OF ARTERIAL LESIONS. 99 because in addition to the certainty that in placing the ligature very low doAvn Ave shall find the artery as sound there as anyAvhere else, we have the advantage, also, of preserving intact collaterals of greater or less importance. Nevertheless, if it should be con- sidered that the operation Avould be much more difficult near the aneurism, Ave should, unless Ave are obliged to sacrifice a large sized supplemental branch, proceed to seek for the vessel Avhere it is most easy and least dangerous to cut down to it. The more dis- tant we are from the sac the less danger is there of causing its rup- ture, inflammation and suppuration. We must not, hoAvever, in order to avoid one extreme, fall into the other; that is to say, place the ligature immediately beyond, (i. e., on the distal side of,) a large secondary arterial branch. In fact the consequences of such an operation rarely fail to become alarming, not because, as has been too frequently asserted, the bloody clot, Avhich Jones has dAvelt upon so much, cannot be formed, but because the blood, finding a free and very Avide passage immediately above (i. e., on the cardial side of) the ligature, does not alloAV the Avails of the artery to ap- proach each other and to contract adhesions between them. II.—Incision. The Surgeon placed on the side of the aneurism commences by stretching the integuments either cross-wise by means of the thumb, fore-finger and ulnar border of the hand, or by applying the extremities of the four fingers upon the track of the vessel parallel to its direction, and then makes an incision into the skin of from tAvo to four inches in length. This incision should be made Avith a bistoury convex upon its cutting edge rather than with a straight bistoury ; it is better that it should be rather long than otherAvise. An incision, moreover, of from two to three inches in extent, so long as Ave are not obliged to go deep, will be found to answer in the greatest number of cases. Most frequently we make it correspond with the direction of the artery, but sometimes Ave go in the direction of the muscular fibres,in which case it crosses the vessel more or less obliquely. We must take care not to go too deeply at the first cut ; and it is much better to make two cuts in dividing through the skin than to come down to the artery Avith the first incision. After the integuments we divide the aponeurosis in the same manner, if the artery is still at a certain depth. In the contrary case or Avhen the operator is not very sure of his hand he inserts under the aponeurosis a grooved sound Avhich serves as a conductor and guide to the bistoury. The other laminae should be divided suc- cessively Avith the same precautions and to the same extent. Ill-—To isolate the Artery. Having reached the vascular and nervous fascia^, Ave must now attend to the opening of the common sheath. The grooved sound is then of the greatest importance. We insinuate the sound (?*. «?., director) from above downwards, or from beloAV upAvards in the interior of the sheath, taking care to raise up this only, and not to let any of the parts Avhich it Avould be danger- ous to Avound, slip in between the sound and the instrument. To separate the parts afterwards, Ave also make use of the same direc- tor, Avhich should be slightly flexible, or slightly conical in shape 100 NEW ELEMENTS OF OPERATIVE SURGERY. without any cul de sac, and not so blunt, (moins obtuse) as the ordinary grooved sound; holding it in the hand as a Avriting pen, we pass its extremity betAveen the vein and the artery, then making gentle movements Avith it backwards and fonvards, Avith a moder- ate but steady pressure, we detach and separate the two vessels from one another to the extent of a few lines. In proportion as this separation is effected, we incline the sound more and more backAvard, in order that its point making its Avay by degrees under the posterior surface of the artery, may as it reaches around it show itself on the opposite side ; then use the fore and middle finger of the other hand to separate the nervous trunks from it, or to push backAvards and outwards all the parts that we Avish to avoid. It is important therefore to manage the sound Avith a great deal of address, otherwise instead of going round it Ave might run the risk of plunging it into the vein or the artery, as M. Rienzi, (Med. Oper., trad. Ital., t. I., p. 105,) accuses a skilful surgeon of Italy of having done. IV.—To apply the Ligature. Before AvithdraAving it the sound is to perform another duty ; for it is on this that Ave pass doAvn the ligature, Avhether for this purpose we use a simple silver probe, having an eye at one of its extremities, or prefer for deep ligatures the curved needle, attached to a forceps, as figured in the Avork of Dorsey, (Elements of Surgery, Vol. IL, pi. 23,) or the needle of J. L. Petit, or that of Deschamps, &c. Desault ((Euv. Chir., t. IL, p. 555,) contrived for those cases Avhere we are obliged to manipulate at the bottom of a narrow and deep cavity, a spring needle much resembling the sound of Bellocque, and Avhich has been modified in England, by MM. Ramsden, Earle and Brenner, (S. Cooper, Dict.,"p. 151.) M. A. Cooper in these difficult cases makes use of a steel stem, supported by a han- dle, and strongly curved backAvards at its free extremity, and ter- minated by an olive bit (une olive") in the thickness of Avhich is situ- ated the opening destined to receive the thread. M. Mott has fre- quently employed an instrument of the same kind, and the needle of M. Causse (Rev. Med., 1828, t. III., p. 388) is but a modification of that of Petit. Scarpa has greatly extolled, a small spatula of pure silver, very thin, and so flexible that it can adapt itself to all the parts we wish to include. But the grooved sound, aided by the probe such as I have pointed out, will generally be found to answer in the hands of a skilful surgeon; it has besides, in preference to all special instruments and the numerous needles whose forms have been so carefully delineated by M. Holz, (Trait, des Ligat. Ar- terielles, Berlin, 1827,) the immense advantage of enabling us to de- nude (depouiller) the artery in the neatest manner possible, and al- most without any laceration of the surrounding tissues. As soon as it has reached the other side of the vessel we cannot see Avhy it would be impracticable to slide along upon its groove the head of a flexible probe and in this manner pass the ligature; so much the better could this be done as there is nothing to prevent our having an eye near its point, to conduct the ligature at the same time that TREATMENT OF ARTERIAL LESIONS. 101 the point detaches and lays bare the circumference of the artery. HoAvever every one understands then nature of these instruments, and can make up his own judgment Avhich to give the preference to. It is not only improper but also dangerous to attempt, as Scarpa has advised, to raise up and separate the vessel from the surround- ing parts by means of the fingers. By this means Ave tear the tis- sues and make a contused wound, Avhich Avill almost inevitably proceed on to suppuration ; Avhen in fact it is important to make this wound as neat and as regular as possible. Those avIio recom- mend shaving Avith the bistoury flat-Avise (en dedolant) all the layers of cellular tissue that envelop the artery, run the risk of Avounding it in spite of the most minute precautions, or even in the most fa- vorable cases, of unnecessarily prolonging the operation. The sound (i. e., director) protects us from these inconveniences, enables us to act Avith greater security and promptitude, and to pass the thread around the artery, so to speak Avithout displacing it, or disturbing its natural relations or laying it bare more than to the very smallest extent possible. V.—To Tighten the Ligature. It is not possible to determine what degree of force should be employed to strangulate the artery. The ligature should be drawn so tight as to hermetically shut up the artery to the passage of the blood not only at the moment of the operation but also afterAvards ; this is the only rule that Ave may be permitted to lay doAvn upon this subject ! When it in- cludes Aviththe artery some portion of muscular tendinous, aponeu- rotic, or even cellular tissue, the object in vieAV may be defeat- ed, because those fibres in Avasting aAvay soon cause the ligature to become loose, and thus render it almost useless, at the same time that they prevent it from coming aAvay at a proper time. To obtain this last result Ave must also avoid passing the ligature twice round upon itself so as to form Avhat Avas called in other times the surgeon's knot. Even Avith this knot, notAvithstanding the greatest degree of constriction employed, the centre of the circle remains sometimes gaping open, or permeable. This it is said (Pelletan, Clin. Chir., t. I., p. 122) happened to Chopart, when among the first in France he proposed in 1781, to apply a ligature on the popliteal artery. Many ligatures Avere successively used without hoAvever succeed- ing in effecting the entire suspension of the circulation in the limb; (can that be true ?) when it became necessary to have recourse to im- mediate amputation,and an examination of the parts afforded an op- portunity of ascertaining that not one of the ligatures had complete- ly effaced the cavity of the vessel. We confine ourselves therefore to tAvo simple knots. If the ligature is of animal tissue Ave cut off the two ends in order to enclose the remainder in the Avound; in the contrary case Ave reserve one of the extremities which is to be left hanging outside. If after having laid bare the artery, we discover that it is diseased, and that its walls are yellow, friable (fragiles) and encrusted Avith calcareous lamellae, (plaques,) it Avould perhaps be prudent to flatten it as Scarpa recommends, instead of strangu- lating it as in the other processes; for that purpose we place upon 102 NEW ELEMENTS OF OPERATIVE SURGERY. its anterior surface, betAveen that and the ligature, a small compress (rouleau) of linen, cork, gum elastic, or adhesive plaster, from four to six lines long, from one to three in thickness, and about the same in Avidth. MM. LaAvrence, A. Cooper, and Briot, however, have obtained satisfactory results in pursuing an opposite course, and in venturing to use only a simple thread upon arteries that were obliterated, and brittle, and entirely altered from their natural state. It is in such cases especially that the ligatures of M. Jameson (vid. supra,) might be of great advantage, Avhen we have no chance of doing better, by making a new incision in order to perform the operation higher up. VI.—Dressing. The Avound being cleaned and freed of all the foreign bodies that may be contained in it, should be partially brought into union immediately. Nothing is more formidable than the suppuration that folloAvs ligatures upon arteries; immediate union on the contrary Avould almost always ensure us success ; but it is from the bottom tOAvards the borders that this union is desir- able, and not from the skin tOAvards the deep seated parts, as the tendency is, from the manner in which the stitches of the su- ture are arranged by some surgeons. The presence of the ligature around the vessel and of a foreign body betAveen the lips of the wound, is moreover under these circumstances an obstacle almost insuperable to an immediate agglutination. The consequence is that we limit ourselves to keeping the sides of the wound correctly approximated by means of graduated compresses, adhesive plasters and the position. After having wrapped up the ligature Avhich hangs outside, Ave turn it back toAvardsthe most dependent or near- est angle of the Avound, or merely place it crossAvise between two strips of adhesive plaster. The perforated linen is then applied, or we make use of the fringed linen bandelettes, (bandelettes de linge decoupees,) (vid. supra. Vol. I.) A plumasseau of soft lint, and one or tAvo long or square-shaped compresses, cover over the pre- ceding portions of the dressing, and Ave terminate as in the ancient method by some turns of bandage to support the Avhole. C.—Method of Brasdor. The manual of the operation is precise- ly the same in the method of Brasdor as in that of Anel. D.—Subsequent Treatment. The patient is carried back to his bed and placed in such a position that the muscles of the part upon which we have been operating may be in a state of relaxa- tion. I.—The limb supported upon cushions, ought, according to some, to be surrounded Avith bladders containing hot aromatic substances, (entoure de vessies aromatiques chaudes) sachels (sachets) filled with sand, ashes or bran, at the temperature of 30 degrees; (Reaumur;) according to others, it should be merely supported with soft pilloAvs sufficiently Avarmed; there are also others Avho, indifferent to all special precautions, add nothing to the natural furniture of the bed unless the sensation of cold which comes on at that time should be very uncomfortable. This last mode is the one which should be adopted as obviously the most rational. One LESIONS OF THE ARTERIAL SYSTEM. 103 of two things takes place, either the circulation is restored to the parts which have been momentarily deprived of it by the opera- tion, and their temperature by this means is raised to the proper elevation ; or it is not re-established, in which event the artificial heat can scarcely be otherwise than calculated to hasten the development of the gangrene. On the supposition then that the sensation of cold does not incommode the patient, Ave may dispense with heated cushions. In the contrary cas eAve may, during the tAvo or three first days, place in contact with the parts that are suffer- ing from cold, cushions of sand kept constantly Avarmed. II.—In other respects we may proceed as we do after all serious operations. Diet, repose, and the most perfect tranquillity, and mild acidulous drinks slightly anodyne or anti-spasmodic, are necessary at first. General bleeding may also become necessary Avith the view of preventing or relieving the congestion (refoulement) of the blood in the viscera. Most frequently it is found advantageous in the first tAventy hours to administer some spoonfuls of a drink, blended Avith slightly aromatic mixtures, as the tincture or ex- tract of opium, or occasionally Avith a little ether or the liquor of Hoffman, in order to calm the nervous state of excitement and agitation Avhich the patient frequently falls into. In such cases the most suitable drink is linden (tilleul) water tepid. On the morning after I alloAv the patient light broths, (bouillons,) and soon after soups, (potages,) eggs, and diluted Avine and Avater; then meat if no general re-action should supervene; a rigorous diet Avould jeopardize the success of the operation. [This sanction of a rather generous course is perfectly in accordance Avith, and in anticipation of, the hoav recently adopted and certainly most rational views of the consecutive treatment of aneurisms; for by this it is truly said as in the cure by compression, (vid. notes, supra et infra,) Ave thus favour the deposition of plastic lymph in the aneuris- mal sac, &c. T.] HI.—The first dressing is not made until the third or fourth day at the earliest. The greatest care should be taken not to disturb the limb by any movement, and to make no traction upon the liga- tures, nor Avhen removing the portions of the dressing to derange the position of the lips of the Avound,at least in those cases Avhere we are attempting immediate re-union. The same attentions are also necessary afterwards, until the ligatures come aAvay, Avhich they do from the tenth to the tAventieth or thirtieth day, but which also may not happen until the fortieth or even the fiftieth; and we may promote this separation as soon as the obliteration of the artery appears to be complete, by pulling from time to time gently upon the threads, if they are slow in becoming detached. When the time of reaction is passed by and the first symptoms are subdued, and the limb has regained its natural temperature and sensibility, the patient should from that time be considered as convalescent. Nevertheless, even after the cicatrization of the Avound is complete, he ought not for a considerable length of time, to be permitted to make any other than very slight or trivial movements, if he does not wish to run 104 NEW ELEMENTS OF OPERATIVE SURGERY. the risk of losing his life by a secondary hemorrhage, and of having his wound reopen afresh, as happened in a case cited by Beclard. § VII.—Consequences and accidents of the operation. The results produced by the operation for aneurism are some- times complicated with accidents or symptoms that require par- ticular attention. A.—In general the limb during the first tAventy-four hours be- comes cold to a greater or less degree, as has been already said, then it afterAvards by degrees re-acquires its usual temperature; but it is not uncommon to see too great a degree of heat succeed to this state of things, causing by this means so much irritation in the part as to result in gangrene. Vacca and some modern Avriters have given examples of this kind; in such cases the limb should be wrapped in flannel, Avet with emollient liquid, or covered Avith cata- plasms of the same emollient nature; perhaps even it would be found useful to apply leeches upon those points Avhich were most pain- ful or Avhich Avere most likely to become inflamed. For certain reasons also, 1 am induced to believe that a roller bandage applied moderately tight would overcome this difficulty better than any other means; cold water of itself would also be another resource that we might make trial of. B.—Gangrene, the too common consequences of ligature upon arteries, is not always preceded by this excess of heat; it is often caused by the circulation not being re-established. Then the lower part of the limb remains cold and insensible and becomes dis- colored, and the seat of phlyctense, and soon after of all the other characters of mortification. The patients who are about to be affected with it are ordinarily seized Avith violent pains, which nothing can assuage, throughout the whole extent and especially towards the loAver extremity of the limb. In one case it will not show itself until the eighth day, in another not until the tAvelfth, though the pain from the arteritis (inflammation of the arteries. T.) may have continued incessantly from the day of the operation. This gangrene, as M. Laugier has remarked, (Archiv. Gen. de Med., t. XXX., p. 162,) is announced by a livid, violet, greenish, milky yellow, (jaune lacte) color, rather than by the signs of ordina- ry gangrene ; it seems more like an organic decomposition (decom- position cadaverique) than a disease. If the gangrene has not ex- tended to a great degree, or seems disposed to become circum- scribed, we proceed as in those cases where it is produced by any other cause. We wait until the escars are detached, and the ulcers which result from them are cicatized; but if it invades the whole thickness of the limb there is nothing but amputation that can save the life of the patient,though that also is a resource which often fails. C—The sudden interruption of the course of the blood through an artery of large size, sometimes occasions so great a disturbance in the general circulation as to excite an intense fever, with symp- toms of plethora and congestion, and a strong'tendency on the LESIONS OF THE ARTERIAL SYSTEM. 105 part of the principal organs to become the seat of severe inflamma- tions. It is under such circumstances that the antiphlogistic regi- men should be adopted in all its rigour, and that we should have recourse to bleeding, general or local, and even to be repeated fre- quently, while the strength of the patient, or the severity of the disease, seem to justify it. D.—In other cases, it is the nervous symptoms which make their appearance and create alarm ; the pulse becomes irregular, small and frequent; delirium supervenes, convulsive movements take place, and most of the symptoms of ataxic (ataxique) fever may become developed. Experience has shoAvn that anti-spasmodics in general, and especially opiates, are the best remedies for this kind of accident. It would appear from a case that occurred at the Val de Grace, that in order to subdue the symptoms M. Gama was obliged to administer laudanum to a very great extent, and that the delirium which takes place in such patients has some analogy to that with Avhich drunkards are so often affected, in other Avords, delirium tremens. E.—Ordinarily the tumor shrinks, (s'affaisse,) or at least dimin- ishes, and ceases to pulsate immediately after the ligature ; at a later period, it hardens and retracts ; the blood contained in it con- cretes and is gradually absorbed, and the Avhole terminates after the expiration of a greater or less period of time, by disappearing altogether, or leaving only a small tumor or simple hard, moveable kernel, (noyau,) without any pain. In the place of these phe- nomena, others sometimes supervene ; the pulsations, Avhich had temporarily ceased, reappear at the end of some hours or days; the tumor retakes its original volume, and the operation appears to have had no effect upon the disease. This is owing sometimes to large collaterals, which open either directly into the tumor, or be- tween the tumor and the ligature, and Avhich bring the blood there in too great quantity ; sometimes to this fluid returning to the sac by the loAver end of the artery. It is, hoAvever, a less serious acci- dent than it was first thought to be. Observation has proved that, in a majority of cases, the system succeeds in triumphing over it. Nevertheless, if topical refrigerants, the methodical application of the roller bandage, or any kind of compression Avhatever, continued for some Aveeks, should not bring about any favorable change in this respect, it Avould be advisable to ascertain if there Avould not be more security, in case the thing were possible, in applying a new ligature very near the tumor, either above or below it, or, in fact, in operating by the ancient method. F.—In place of shrinking or becoming hardened, or ending in fact in resolution, the aneurismal sac becomes heated, and some- times even inflamed, Avith a tendency to become converted into an abscess. If cold topical applications, astringents, and compression do not produce at first the benefit that we had a right to expect from them, leeches and emollient cataplasms should be promptly substituted in their place. Also, if suppuration, or an actual puru- lent fluctuation take place, it will be necessary to treat the aneu- 106 NEW ELEMENTS OF OPERATIVE SURGERY. rism, as a simple abscess, (depot,) to open it freely with the bis- toury without Avaiting too long a time, and to empty it of the mat- ters that it contains, and afterwards to dress it as any other sup- purating Avound. G.—Immediate union is not effected always, though we may have done everything to obtain it. Pus sometimes stagnates at the bot- tom of the Avound, extends itself to a great distance, and separates (decolle) the tissues; the muscular sheath and that of the artery, in their turn, become inflamed, and soon end in suppuration; it is then that the patient is exposed to the most imminent dangers. From thence come erysipelas, diffused, phlegmons, angioleucitis, phle- bitis, and purulent infections, Avhose danger it is difficult to estimate. It is important, therefore, to resist this unfortunate tendency as soon as it is ascertained, to dilate the integuments freely, and all other tis- sues Avhich oppose a free and easy exit to the pus or other effused matters—to lay bare the bottom of the Avound throughout its Avhole extent—and to give up every idea of union by the first intention. H.—When, in spite of his efforts, the surgeon finds that suppura- tion takes place, and is diffused and protracted to so great a length of time as to enfeeble the Avhole organism and lead to the appre- hension of adynamia or exhaustion, it behoves us to* look to the arrestation of this drain by general medication, and to sustain the strength of the patient by administering the extract, syrup, decoc- tion, and other preparations of cinchona, (kina,) also an allowance of good Avine, and light, but substantial aliments, &c.; at the same time, to take care to cleanse the condition of the ulcer and abscesses by proper topical applications or incisions. I.—The accident resulting from the application of a ligature upon arteries, Avhich has more especially interested the attention of prac- titioners, is hemorrhage; fortunately, the perfection Avhich opera- tive processes have attained makes this accident more rare now than it formerly Avas. It occurs more particularly when, in tying a trunk very near (fort rapproche) the heart, Ave have been obliged to place the ligature close up to a large collateral trunk; or Avhen the ligature has been badly applied, or become displaced, or not been draAvn sufficiently tight, or fixed upon a diseased portion of the vessel; or when, from any cause Avhatever, the vessel becomes diseased either above or even in some cases below the ligature. Hemorrhage may also be produced by the rupture of the sac, and may occur after the first feAV days of, or not until a consider- able time after, the operation, or it may depend upon the irritation which exists in the wound, or be only a simple exudation, (simple exhalation.) Without admitting that, in the process of Anel, it will occur in one out of every six cases, (as a surgeon in our times, by an erroneous statistical computation, has attempted to prove,) Ave must nevertheless concede that it happens sufficiently often to claim all the solicitude of practitioners. It is from the lower end of the artery that this most frequently takes place, and observations prove that it may thus occur on the seventh day as well as on the fifteenth, thirtieth or fortieth. Pressure, made upon the artery on TREATMENT OF ARTERIAL LESIONS. 107 the side of the heart, or on the opposite side—compresses and lint, saturated Avith cold Avater, or impregnated Avith bonafoux powder, or the lotions of Binelli, Talrich and Halmagrand, or Avith any other hemostatic substance, applied upon the place from Avhich the blood appears to issue, are the first means to be made use of. When they are not sufficient, we are obliged to remove the dress- ing and all the effused blood, and to have recourse to tamponing (tamponner) and indirect compression. If these last measures should still prove insufficient, there will be nothing left to be done but to choose betAveen the application of a ligature upon each of the two ends of the artery at the bot- tom of the wound, or at a point higher up on the limb. But, fortunately, Ave may in most cases dispense Avith proceeding to such extremities, and arrest the hemorrhage Avithout recourse to a neAV operation. [A Hemorrhagic Diathesis is to be taken into the account in all wounds of, or operations upon, the arteries. It Avould appear, from a case related by Dr. Alph. Guepratte, (Journal des Connaiss., &c, Paris, Juin, 1844, p. 239, &c.,) that the remarkable tendency, in some constitutions, to excessive hemorrhage upon receiving the slightest Avounds or punctures, is not, as has been supposed, always hereditary, but sometimes acquired. This case was a West India boy, aged nine years, at Guadaloupe, of respectable, healthy, Avhite parents. This disposition to hemorrhage is imputed, by M. Gue- pratte, to the defective nourishment afforded by the milk of the black nurse Avhen the patient was a child, and his constantly per- sisting in living with her in a damp, unhealthy situation, and in- dulging in too much fruit. The patient Avas pale, emaciated, hag- gard, the superficial veins on the skin clearly visible and of violet color, and Avhen the hemorrhage occurred, the blood Avas exceed- ingly attenuated, Avithout scarcely any fibrine or red color—all of which appear to be naturally explained by the patient's course of life and the food used. A radical cure was effected, after some years, by change of residence, food, &c, time, tonics, meat, exer- cise, pure air, in order to give health and force and color to the blood, together Avith other judicious means. We have, hoAvever, known this remarkable peculiarity to exist in three children of the same parents, not any of v/hom nor any of their relatives Avere ever knoAvn to have exhibited any indications of it. They were the grand-children of the present venerable Peleg Almy, Esq., of Portsmouth, Rhode Island—a family of the highest respectability,-Avealth and rank, and noted for their sound, healthy and robust constitutions—having, from the first settlement of NeAV England, constantly resided on their patrimonial estates, from the year 1640 to the present time. Therefore, had such a pre- disposition been hereditary, it Avould certainly have been recorded. We have not the details of these cases, but they all died under the age of 16 years—one Avhile an infant, from the physician having punctured a small abscess, while another bled to death from hav- ing knocked out a tooth in a fall. Mr. Almy informed me, (1844,) while I was at his residence, that these children had all been in the 108 NEW ELEMENTS OF OPERATIVE SURGERY. enjoyment of excellent health, and that there Avas no circumstance Avithin the knoAvledge of the family to account for the fatal results, either from hereditary or acquired causes. There are, hoAvever, it must be recollected, hemorrhages Avhich are of a salutary or useful character to the organization, carrying out the great law of the vis medicatrix naturce. These do not re- quire suppression by surgical means—in fact, should not be med- dled with, except to control them Avhen excessive. These hemor- rhagic discharges are common in Avomen, Avhere there is dysmenor- rhoea and obstruction to, or diminution in, the normal quantity of menstrual blood that ought to be evacuated. They take place as a vicarious efflux, but most usually synchronously Avith the cata- menia, being more or less abundant as the latter are more or less restricted, or altogether absent. They come from the lungs, throat, nares, &c.; and a case is related by Professor D'Outrepont, (Neue Zeitschrift Fiir Geburtskunde; see also Gaz. Med de Paris, Janv. 4, 1845, p. 13,) in Avhich a similar discharge took place from near the insertion of the deltoid on the right arm; an incrustation of the size of an egg in diameter, which had formed there on the skin, falling off at each menstruation, and discharging freely of blood, Avhich afforded great relief, and was either less or more in quan- tity, according to the quantity discharged from the genital parts. Similar discharges from the hemorrhoidal vessels are familiarly known at intervals of tAvo months or more after the natural cessa- tion of the menses ; and I have knoAvn a case ofan old man, who had a menstrua], hemorrhoidal flux of this kind, Avhile his daughter inva- riably had a sanguineous discharge in the form of a passive hemor- rhage, apparently from the branches of the bronchial arteries, and Avhich she threAV out by mouthfuls, without effort or pain, or paying any attention to it, as it always made up for any deficiency of the ca- tamenia. So, as is familiarly known, these hemorrhoidal evacua- tions, so common in men also in the decline of life, become abso- lutely necessary to their existence when they live luxuriously, or are subject to more or less sanguineous plethora and congestion in the head, liver, chest, &c. All the peculiarities of constitution ap- pertaining to a hemorrhagic diathesis, vicarious hemorrhages, &c., are to be duly weighed before and after operating for aneurism. T.] § VIIL—Changes which are effected in the vessels of a limb after the obliteration of an artery. When an artery ceases to become permeable to the blood, there are certain changes produced in the neighborhood of the wounded part which it is proper to notice. Among these alterations, there are some that are generally conceded; others that are as yet ques- tionable, or very imperfectly understood. A. Collateral Arteries.—The blood, compelled to take another route in order to reach the loAver part of the limb, enters the col- laterals, by degrees dilates them, and soon produces anastomosing arcs of such large size, that branches Avhich Avere scarcely visible in their natural state sometimes acquire the dimensions of a crow-quill, TREATMENT OF ARTERIAL LESIONS. 109 while other branches, of a little larger volume, ultimately ac- quire a third of, or even half the size of, the primitive trunk. It is where such supplemental channels are readily formed, es- tablished, or developed, that operations for aneurism are at- tended Avith a prompt and successful issue, and that the pul- sations, Avhich had been momentarily suspended, soon re- appear beloAV the ligature. Though this point be universally conceded, it is not so on the question Avhether or not neAV arteries are created to re-establish the current of the blood after the division of the diseased trunk, (tronc altere.) B. New arteries. Parry (An Experiment on the Art. puis., 1819) was one of the first who conjectured that neAV vessels Avere gene- rated, a fact Avhich he considers indisputable. He has seen, he says, the tAvo ends of the carotid communicate with each other by numerous small vascular branches, a long time after it had been tied or divided. It Avas Avith difficulty at first that this statement was believed, in consequence of which his assertions did not attract as much attention as one would have supposed. At the same time, or a short time after, M. Ebel, a physician belonging to the military service, had arrived, according to M. Foerster, at results nearly similar, by means of experiments repeated upon more than thirty different animals. M. Salemi, M. Seiler, and M. Zuber obtained similar results. More recently, M. Schoensberg, (Christiani, Jour- nal des Progres, t. XII., p. 70,) has reneAved the experiments of the English physician upon the carotid of goats and rams. He affirms that he has seen in these animals neAV branches of very consider- able size, forming a very complicated net Avork between the tAvo ends of the divided tube. If the delineation given by M. Foerster, (Jour, des Prog., le serie, t. XII.,) accurately represents what the Surgeon of Copenhagen professes to have ascertained, nothing can be conceived more beautiful than the process which the organiza- tion establishes under such circumstances. It appears to me, hoAvever, that we are under an error in respect to the importance of this reproduction of vessels, and that it is a result also Avhich we imagine to take place much more frequently than it in reality does. In contradiction to the facts related by M. Schoensberg, though it Avere even alloAvable to accord to them an entire faith, we may oppose the observations now almost Avithout number, which have been made upon man. If neAV arteries re- united the two ends of that which had been divided, they Avould have been met with in the dead body in subjects Avho have died at the expiration of a greater or less period of time after the operation for aneurism; but never have the finest injections or the most care- ful and delicate dissections been enabled to demonstrate their exist- ence. M. Maunoir (Oper. cit., 1802, et These, an XIII.) alone says he has found in a carotid which he had divided betAveen two liga- tures, a holloAV filament (filament creux) going from the upper to the loAver end of the artery. In place of this complicated net-Avork (reseau) spoken of by the authors whom I have quoted, I have found nothing but a cellular cord, pliant and impermeable to fluids, 110 NEW ELEMENTS OF OPERATIVE SURGERY. and which blended imperceptibly with the cellular tissue of the neighborhood, but no new arteries to reestablish the continuity of the principal trunk. If I do not deceive myself, the assertions of Parry, Bell, and MM. Meyer, (Arch. Gen. de Med., 1838, t. XIX., p. 567,) Foerster, Seiler, Zuber, and Schoensberg, are founded upon a phenomenon which has hitherto been but imperfectly examined, but which will readily furnish an explanation to the results which those authors imagine they have established. The albuminous effusion Avhich takes place and coagulates (se concrete) about a ligature to form the virole of which M. Pecot speaks, (vid. supra, vol. I.,) may, as has been remarked, become the seat, Avhen it is organized, of a vascular net-work of new formation, in conformity to a very general law, observed in a great number of accidental organic productions; these small vessels Avhich at first present themselves under the aspect of tortuous capillaries, or simple canals excavated in the midst of an amorphous substance, and in which the fluids and blood cir- culate rather under the influence of the laws of chemistry than by the impulsion of the heart, continue while the virole remains iso- lated and does, not make part of the surrounding tissues; but as this groAvth (renflement) shrinks little by little, and gradually assumes the appearances and nature of cellular tissue properly so called, the small canals in question contract (se reserrent) in the same proportion, and ultimately in their turn present no longer any differences from the capillaries Avhich pervade the lamellar system in general. These vessels being susceptible of distension, by injec- tions, may be recognized and possess even a certain degree of mag- nitude during the first and second Aveek after the operation, Avhile at a period more advanced it will scarcely be possible to identify them any longer, as their purpose is not that of reestablishing the general circulation of the limb. Numerous experiments instituted by M. Manec, (De la Ligature des Arteres, &c, Paris, 1833,) have illustrated this fact, and seem to me confirmative of the opinion I have just given. C. Remote Capillaries. (Capillaires eloignes.)—A result of the same kind but more important takes place, where the capillary branches of the upper collaterals communicate with the capillaries of the loAver branches of the obliterated artery ; circulating canals of every variety (de toutes pieces) are formed at this point, and what takes place is quite a different result from the mere dilatation of the natural capillaries. According to the experiments of MM. Kaltenbrunner, (Exper. con. stat. sang., etc., 1826,) Wedmeyer, (Jour, de Prog., le serie,) Doelinger, (Ibid., t. IX.,) and Blain- ville, (Cours de Physiol, compl., t. I.,) the arteries pour out the blood they contain into the amorphous or parenchymatous cellular tissue, before it is taken up (repris) by other vessels; in this or- ganic Avoof (trame) the fluids oscillate rather than circulate, and act so to speak like Avater which has escaped and overflown from a river, while excavating for itself a thousand channels, through a plain of sand; that is to say, that at every instant new conduits TREATMENT OF ARTERIAL LESIONS. Ill are being formed, while others are disappearing. The blood not being enabled any longer to pass by its central primitive canal, creates for itself a number of passages, Avhich afterAvards become organized by degrees in order to transmit it from the upper into the loAver portion of the closed vessel; and it is without doubt to this process that Ave must impute the heat, sensibility and even redness which manifest themselves under the skin in some patients, at the expiration of one, tAvo or three days after the operation for aneu- rism. [Pathology of Aneurism.—Dr. Thomas B. Peacock of Edinburgh in his post mortem examinations of aneurism of the ascending as Avell as arched portion of the aorta, is led to believe (Cormack's Lond. and Edinb. Month. Jour, of Med. Sc, January, 1845, p. 16, &c.) Avith Dr. Hope (Diseases of the Heart, &c, 3d edition, 1839, p. 421,) that almost all of this description are originally of the true species. He has found that their dilatations and pouches, unless Avhen very large and of long standing, all partook of the exact character of the general texture of the artery, the tunics being all readily separable by maceration, and each tunic when separated retaining its corresponding dilatation, Avhile the continuity of the internal membrane Avith that of the sound portion of the tube was perfect. It rarely occurs, he says, in the larger tumors, that the internal tumors can be traced throughout the sacs, and it is ex- tremely improbable, this physician says, as he had also shoAvn by experiments on the formation of dissecting aneurisms, (Lond. and Edinb. Month. Jour, for October, 1843,) that Scarpa's idea can be correct, that the external coat of the aorta can alone sustain a column of blood extravasated betAveen it and the middle tunic. A peculiarity of these aneurisms is their intercommunication through reguhrly formed apertures, betAveen their sacs and the right ventri- cle of the heart, as was observed by Mr. Thurman, in eight out of ten of the interesting cases noticed by him in these situations, (see his Memoir on aneurisms, and especially spontaneous varicose aneu* risms of the ascending aorta and sinuses of Valsalva—Medico-chir. Transact., Vol. XXIII., 1840,) Avhile in the tAvo others the com munication Avas Avith the right auricle. The greater frequency of communications with the right ventricle is OAving to the situation of that cavity,—in close contact with the left and right sinuses of Valsalva, and the points of attachment of the corresponding valves -—exposing it to the pressure of aneurisms in each of these situa tions, Avhile the auricle is in contact Avith a much smaller portion of the origin of the aorta. As illustrative of another remarkable peculiarity in the pathology of aneurism, or of Avhat may be called perhaps, Avhen the disease in- vades these primary trunks, the aneurismal diathesis, is the gene- ral fatty degeneration which takes place in the muscular tissues of the heart—which is generally found also to exist simultaneously in the liver and kidneys. Occasionally this fatty deposition will take place on the external surface of the heart and between it and the pericardium, Avith adhesion of the latter. In such cases Dr. Peacock 112 NEW ELEMENTS OF OPERATIVE SURGERY. found the muscular coats of the heart attenuated. But in general it commences from Avithin and proceeds outwardly. Rupture of the Heart. Rupture of the Heart and Ossification of the Veins of the Brain.— Dr. Claudi of Budweis (Germany) relates (Schmidt's Jarbucherand Jour, des Connaiss., &c, Paris, Jan., 1844, p. 32) the case of a woman aged 56, robust and the mother of several children, who being suddenly seized Avith illness, fell and immediately expired. The largest veins of the pia mater were found of a whitish blue color as if distended Avith milk ; they Avere indurated and in part ossified, especially near the sella turcica, Avhere they exhibited here and there spindle-shaped dilatations. A circular cavity of the size of a small nut Avas found in the medullary substance above the right ventricle. The cortical substance on the anterior surface of the anterior lobe, exhibited an ulceration of 12 millimetres in length. The surface of the brain was every where covered Avith a layer of broAvnish and granular like matters. The pericardium was of a darkish blue, greatly distended and contained 12 to 1300 grammes of coagulated blood. The heart was fatty (adipeux) and at the loAver part of the intra-ventricular septum there was a zig-zag rupture of 13 to 14 millimetres in length; and a little above that an- other to Avhich clots of blood were adherent. The right ventricle contained nearly 15 grammes of blood; that of the left side was much larger. T.] As closely connected with this subject we here insert a remark- able case of rupture of the heart, in the practice of Dr. Mott, many years ago :— (A Case of Sudden Death, from a Rupture of the Left Ventricle of the Heart, with Remarks, by Valentine Mott, M. D. Trans, of the Physico-Medical Society of NeAV York, vol. L,p. 150-160, year 1817.)' $' Instances of rupture of the heart, from violence or disease, are seldom met with in practice and less frequently recorded in medi- cal Avritings. The following case of rupture of the parietes of the left ventricle, from an abscess, Avith a view of the parts, is respect- fully presented to the society; as an interesting specimen of mor- bid anatomy. The subject of this case, was a young Avoman, about twenty-two years of age; of a robust and plethoric habit: She had led an irregular and dissolute life; and from appearance and from what could be learnt, had been addicted to the liberal use of ardent spirits. For some time previous to her death, she had made no complaint which could be considered as amounting to indisposi- tion. Her friends recollected to have heard her mention some slight pains, which she called rheumatism. They state, also, that she had entered into a marriage contract Avith a gentleman, who had broken it off a day or tAvo before her death. Since which time, they say, she appeared dejected, and had been seen sobbing and in tears. TREATMENT OF ARTERIAL LESIONS. 113 She took supper as usual, appeared someAArhat dejected, and re- tired to bed at the ordinary time. As she remained longer in her chamber than common in the morning, some person was sent to awake her; but to the terror of the family she could not be roused —she Avas dead. From the posture in Avhich she Avas found lying on the left side, Avith the knees draAvn up, she Avas thought to be in a profound sleep ; but, it Avas the sleep of death. Examination and Dissection of the Body. No marks of violence Avere to be seen on any part of the body. The lips Avere purple, one side of the face appeared also someAvhat livid. The Avhole countenance, Avith the integuments of the neck, and upper part of the chest, Avere suffused Avith a deep red colour. The features of her face Avere not the least distorted; nor Avas there any apparent contortion of the limbs. It may be said that she slept through death ; for she did not appear to have suffered any of its agonies. The dissection Avas commenced by cutting through the parietes of the abdomen in the direction of the linea alba. The contents of this cavity upon a general inspection, appeared to be in a natural and healthy state, excepting the liver, Avhich seemed larger than natural, and of a pale white color. In continuing the examination more particularly, the liver Avas the only viscus in this great cavity, which Avas found in an unhealthy state. It had contracted strong adhesions to the peritonaeum where it lines the parietes of the chest, abdomen, and lower surface of the diaphragm. The connecting organized coagulable lymph, was very beautifully arranged, and appeared like small delicate shreds ; some were an inch long, others of a greater length, and from one to two inches in width. The thorax was next examined. On raising the sternum from the diaphragm, there was nothing preternatural to be seen. The lungs on each side were free from adhesions; but the pericardium was, to the feel, perhaps more tense than common. On opening the pericardium, a large coagulum of blood presented itself, cover- ing the heart on all sides, and completely filling the cavity of the pericardium. This, Avhen removed, amounted to eight or ten ounces, with an ounce or tAvo of serum. The heart was of the usual size and very fat. Upon lifting its apex, it was immediately discovered that the blood proceeded from an opening in the upper part of the left ventricle, about half an inch in diameter, of an irregular lacerated appearance. The parietes of the ventricle, around the opening, were considerably thinner than natural; and, upon attentive examination Avith the fingers, a fluc- tuation could be distinctly discovered, to the extent of an inch on one side of the opening; and upon pressure, flakes of a cheese-like substance were discharged. The pericardium Avas generally of a natural appearance ; ex- cepting a portion of it, about the size of a dollar, or a little larger opposite the opening, Avhich shoAved strong marks of inflammation • 8 114 NEAV ELEMENTS OF OPERATIVE SURGERY. an adhesion, about the size of a six-pence, had also taken place a little above the opening, betAveen it and the surface of the ventri- cle. The external surface of that part of the aorta, Avhich is gene- rally said to be Avithin the pericardium, likeAvise exhibited, on one side, some traces of inflammation. In order to give an opportunity for a more minute examination, the heart, pericardium, and large vessels about it, Avere taken out of the body. On .opening the right auricle from the inferior cava, nothing unnatural Avas to be seen. The dissection Avas continued from the auricle into the right ventricle ; and this also exhibited a natural appearance. The left auricle Avas next opened from one of the pulmonary veins, and then the left ventricle; both of which, in general, appeared natural. On more minute inspection, hoAV- ever, of the left ventricle, an opening of an elliptical form Avas dis- covered, sufficiently large to admit the little finger, about an inch from the origin of the aorta, on the left side, and immediately under the left columna carnea. It Avas considerably smaller than the ex- ternal opening, to Avhich it Avas almost directly opposite. Both openings communicated Avith an abscess in the parietes of the ven- tricle, about the size of a pigeon's egg. It Avas to the upper sur- face of the thin covering of this abscess, Avhich was more promi- nent than other parts of the heart, that the pericardium Avas adhering. The aortal, pulmonary, and ventrical valves, were all in a natu- ral state. From this case may be deduced, a very important fact in Patho- logy, though perhaps of little practical utility. It teaches us that considerable disease may exist in so essential an organ as the heart, and yet be unknown, or even unsuspected, from there not being a single symptom present by Avhich it can be characterized. Authors and practitioners concur in opinion, as to the intricacy of most of the diseases of this highly important organ. In their commence- ment, they are so exceedingly obscure and insidious, that the most attentive and sagacious physicians are perplexed and embarrassed. Some are abruptly and suddenly fatal, as in the present instance; others, continuing for a considerable time, are mistaken for affec- tions of some other part, but ultimately prove fatal. This is the general result of all diseases of the heart, as dissection confirms. Though the ravages of disease are extensive, there are often no predominant symptoms which can be considered as pathognomo- nic ; the nature and seat of the diseases are guessed at, until an opportunity after death is afforded for dissection to develope them. Every fact Avhich morbid anatomy furnishes, is important, as it tends to elucidate an obscure part of pathology, and must regulate our prognosis. It is a curious and an interesting fact, that the left ventricle more frequently gives way, than any other part of the heart. At first sight, it appears strange, that the aortic or systemic side (Avhich all anatomists knoAV to be much stronger than the right or pulmonic side) should actually give Avay, or burst by its OAvn action. This TREATMENT OF ARTERIAL LESIONS. 115 fact is confirmed by the experience of the celebrated Portal, (Cours d'Anatomie Medicale,) Avho informs us, that he has found the heart burst by its OAvn action; the left more often than the right side ; and the left ventricle more frequently than the auricle. Verbrugge, in his Dissertation on Aneurism, makes a similar remark, that though the left ventricle, from its organization, might be considered less subject to rupture, it is hoAvever the most fre- quent seat of it. Morgagni also mentions one or two facts of a similar nature. Professor Chaussier communicated to Portal, a case of rupture of the left auricle from a carriage Avheel passing over the arch of the aorta. When organic lesion of the heart occurs, in the sound state, it has most generally been induced by some violent and sudden effort, or by a burst of anger. We see an analogous effect produced upon other powerful muscles of the body, and particularly the strong fibres of the gastrocnemius Avhich are lacerated by their OAvn strong and sudden contractions. The present case cannot be considered a fair specimen of organic lesion of the heart, in a sound state ; but an example of abscess or ulceration in the parietes of the left ventricle, Avhich, upon burst- ing, proved suddenly fatal. The habit of our patient, no doubt, very much accelerated the fatal termination, " for Ave uniformly find, (says the late much lamented Allan Burns,) that in almost every organic lesion of the heart, stimuli are the bane of the pa- tient." As extreme grief has been anciently said to break the heart, the disappointment in love which this unfortunate young Avoman experienced, ought not perhaps to be Avholly overlooked in an investigation of the cause of her fatal disease. The existence of rupture of the heart, where the muscular pari- etes have been diseased, is additionally confirmed by this case. In most of the examples, it would appear, that hectic, and other symp- toms of decay, have been the attendants. This appears to have been the condition of a man whose case is related by Marchettis. This patient, after lingering for some time, died suddenly, and dis- section shoAved an ulcer, Avhich had destroyed, not only the peri- cardium, but also a large portion of the heart; and the ulceration had ultimately penetrated into the left ventricle, and sudden death Avas the consequence. Other observers have recorded similar cases. (Morgagni.) Morgagni found on dissection, in a spleeny old man, who died on the third day after a slight indisposition, that blood Avas effused into the cavity of the pericardium, through three holes, which communicated Avith the left ventricle. Organic lesions of the heart, and spontaneous rupture, from ab- scess, or ulceration, or the bursting of an aneurism of the aorta within the pericardium,* are uniformly and quickly fatal. In each * Whilst a pupil in Guy's Hospital (London) I saw an instance of instantaneous death, from the rupture of an aneurism of the aorta, within the pericardium, about the size of half a nutmeg. The man was on the operating table, undergoing the operation for pop liteal aneurism ; and just as A. Cooper was about to raise the lower edge of the sartorius muscle, he suddenly expired. 116 NEW ELEMENTS OF OPERATIVE SURGERY. of these instances, the pericardium becomes filled with blood, and the heart is oppressed, and no longer able to act. Perforations of the heart from wounds, are observed to be less suddenly mortal than the lacerations just referred to. We are informed by Fanton, that he saw a man live till the twenty-third day, Avho had been wounded in the heart. The left ventricle Avas pierced, and, as he states, the internal fibres corroded and destroyed. Though but feAV will be Avilling to give credit to a case so astonishing, we have, nevertheless, a number of very remarkable examples of Avounds of the heart, by Morgagni and others, where it has been pierced through and through, Avithout being followed by instant death. Charles Bell has seen a man Avho Avas wounded during the em- barkation of Sir John Moore's army at Corunna, in Avhom the right ventricle of the heart Avas penetrated by a ball; and he lived for fourteen days. In the 2d vol. of the Medico-Chirurgical Transac- tions, we find a case related, in Avhich a bayonet had Avounded the heart. It extended about three quarters of an inch into the mus- cular substance of the left ventricle, about two inches from the apex. The bayonet penetrated the substance of the ventricle, and divided one of the fleshy columns of the mitral valve. This man lived forty-nine hours after receiving the injury. He expired sud- denly in the night, experiencing just before his death, a chilly sen- sation, which admonished him of his approaching dissolution. EXPLANATION OF THE PLATES. Figure 1st. Represents the heart unopened: the whole extent of the left Ventricle is seen; at the upper part of which is the hole, or rupture, and the diseased appearance around it. Likewise the pericardium adhering a little above and reflected Dack to show the diseased part more completely. 1. The left ventricle unopened. 2. The hole or rupture, large enough to admit the end of the little finger. 3. Diseased part, showing a prominence of the abscess, and a dark coloured inflammation surrounding it: at this point the fluctuation was plainly to be felt. 4. A portion of the pericardium folded and thrown back. 5. Point of adhesion with the ventricle. 6. Left auricle. 7. Pulmonary artery. 8-8. Division of the pulmonary artery into right and left. 9. Ascending aorta. 10. Superior cava. Figure 2d. Shows the left Ventricle cut open through the middle, and reflected back to expose the internal opening through which a bougie is passed. 1. The aorta. 2. Pulmonary artery. 3-3. Right and left pulmonary arteries. 4. Superior cava. 5. Divided edge of the left ventricle as turned up. 6. Lower edge of the same with the external surface of the ventricle. 7. One of the mitral valves. 8-8. Cordae tendinea. 9-9. Divided edges of the left columna carnea. a. The internal pectinated surface of the left ventricle. b. Internal opening with a bougie introduced. TREATMENT OF ARTERIAL LESIONS. 117 RUPjjTURE OF THE HEART. (Fig. 2.) as-Jlb &H^-'&~ 118 HEW ELEMENTS OF OPERATIVE SURGERY. SECTION V. ARTERIES IN PARTICULAR. CHAPTER I. ARTERIES OF THE ABDOMINAL LIMB. The arteries of the loAver extremity being exposed more than any Avhere else to the action of external agents, and being at the same time numerous, and for the most part of considerable magni- tude, are naturally subject and more liable in fact than any others to all the diseases of the arterial system. The surgeon therefore is frequently called upon to perform serious operations upon this member ; nevertheless the trunks and their principal branches are the only ones upon which these operations can be practised with advantage; consequently there are scarcely any others in this point of vieAV that ever require our attention, except the dor- salis pedis, anterior tibial, posterior tibial, peroneal, popliteal, and femoral, and the circumflex and iliac arteries. Article I.—The Dorsalis Pedis. § I.—Anatomy. The Dorsalis Pedis artery, being a mere continuation of the ante- rior tibial, takes its origin under the annular ligament of the tarsus, a little nearer to the internal than the external malleolus ; thence it passes obliquely inwards to Avards the first inter-osseous space of the metatarsus, which it traverses from above downwards, to reach the plantar surface of the foot, and to form the plantar arch, in anasto- mosing Avith the external branch of the posterior tibial. Separated from the bones and from their ligaments by a simple cellulo-adi- pose layer, and accompanied (cotoyee) on the inner side, some- times on the outer, by the internal branch of the deep dorsal nerve of the foot, and by its accompanying vein on the opposite side, this artery is covered as Ave proceed from the deep-seated parts towards the skin : 1st, by a thin fibro-cellular lamella Avhich separates it from the surrounding tendons; 2nd, by a cellulo-adipose layer Avhich is not constant ; 3rd, by the dorsal aponeurosis of the foot; 4th, by the sub-cutaneous fascia, upon Avhich moreover are distri- buted the superficial dorsal veins and nerves ; and 5th, by the skin. The first tendon of the extensor longus digitorum pedis, is found up- on its outer side ; that of the extensor proprius pollicis pedis, upon ARTERIES OP THE ARDOMINAL LIMH. 119 its inner side, Avhile the first bundle of the extensor brevis digito- rum pedis muscle crosses it very obliquely from Avithout imvards, and from behind forAvards, on its anterior portion. Though the tarsal and metatarsal branches Avhich the dorsalis pedis artery furnishes, may be of too little importance to require any description here, it is quite otherAvise with its anomalies : I have once met with it directly under the skin ; but it happens more fre- quently that it is entirely wanting ; and a branch of the fibular ar- tery sometimes takes its place; at other times it is replaced by a very large branch of the posterior tibial. Though it be true that these varieties are of a nature to cause much embarrassment to young surgeons Avho practise on the dead subject, I do not see hoAV this can be so on the living body. In fact if the vessel does not exist, no lesion can make it necessary to look for it; if it is given off by the posterior arteries of the leg, its position at one of the borders of the foot, supposing it becomes necessary to tie it in consequence of a Avound, Avill preclude the idea of our searching for it in its custo- mary situation. § II.—Indications. Boyer asks the question if an aneurism of the dorsalis pedis artery has ever been seen. Neither Pelletan, Scarpa, nor Dupuytren appear to have met with it ; from Avhence Ave may conclude that it is at least very rare. Nevertheless, Guattani says he has seen an example of this kind caused by venesection, (une saignee,) and M. Roux mentions tAvo cases of Avounds of this artery, which Avere the source of alarming hemorrhages. M. Vidal has published in the Cliniqne, a similar case observed in the Hospital of Beaujon. M Champion informs me of another, and the only one perhaps in Avhich there has been a false consecutive aneurism of this artery. It is evident moreover, if such a thing should be met with, that the compression Avhich succeeded imthe case of M. Champion, Avould generally ansAver, and that if Ave operated according to the modern method, it would be the anterior tibial and not the dorsalis pedis, Avhich it Avould be necessary to tie; [See note of Dr. Mott, above,] but as it may be required to obliterate the vessel in front and behind the lesion, in consequence of the plantar arch, that is, to operate after the ancient method, the surgeon ought consequently to knoAV where to find the artery itself. § HI.—Operative Process. The patient should be laid upon a bed, Avith the limb slightly flexed and the foot moderately extended ; an assistant holds the limb steady by grasping it above the ankle-bones. With a straight or convex bistoury, the surgeon makes an incision into the skin of about two inches, in the direction of an oblique line carried from the middle of the instep to the first inter-osseous space ; and divides the sub-cutaneous layer, Avhile he endeavours to avoid the principal 120 NEW ELEMENTS OF OPERATIVE SURGERY. venous and nervous branches which it contains ; he then comes down in succession to the aponeurosis, then betAveen the tendons of the tAvo first toes, then upon the second fibrous layer, and finally upon the artery itself, which he isolates by means of a grooved sound from the veins and from the collateral nerve and cellular tis- sue, before applying the ligature, which he ties, after having per- fectly assured himself that he has included nothing in it but the artery. Tavo strips of adhesive plaster bring the lips of the wound together, and the operation is terminated. Article II.—Anterior Tibial Artery. § I.—Anatomy. The anterior tibial artery, after taking its rise from the popliteal, and after having pierced almost at a right angle the upper part of the inter-osseous ligament, folloAvs as it descends to the middle of the instep, the direction of an oblique line drawn from the middle of the space betAveen the head of the fibula and the spine of the tibia. Resting almost denuded upon the inter-osseous ligament in its two upper thirds, then upon the outer side and front part of the tibia; it is consequently situated at so much the greater depth, the higher up Ave seek for it upon the leg. The two veins Avhich accompany it repeatedly communicate Avith each other in front of the artery by small transverse branches ; the nerve of the same name crosses its anterior surface very obliquely from above doAvmvards, and from without inwards ; sometimes however it continues outside as far doAvn as the instep. A thin (peu abondant) pliant cellular tissue, envelopes and unites these different parts, but does not furnish them a true sheath. The anterior tibial being situated betAveen the exten- sor longus digitorum pedis, and tibialis anticus muscles above, and the tibialis anticus, and extensor proprius pollicis pedis in the middle portion, and the extensor proprius pollicis pedis, and the extensor longus digitorum pedis far beloAV, but rarely presents anomalies of sufficient importance to require the attention of the surgeon ; nor are the branches that proceed from it with the exception of the an- terior tibial recurrent, of any importance in surgical operations. Anomalies. I have tAvice seen the anterior tibial artery lying superficial at the middle of the leg. In one of these cases it origin- ated as usual from the popliteal. In the other, in the place of pierc- ing the inter-osseous ligament, it turned around outside of the fibula and folioAved the course of the musculo-cutaneous nerve. It is to one of these peculiarities that we ought doubtless to attribute the pulsations observed on the fore-part of the legs in a patient of Pel- letan's, (Clin. Chir., t. II.,) and Avhich misled this practitioner so far as almost to induce him to believe in the existence of an aneurism. Fortunately we have only to recal the possibility of such an ano- maly, to understand how we are to avoid the mistakes or errors that might arise from it. ARTERIES OF THE ABDOMINAL LIMB. 121 § II.—Indications Supported by the inter-osseous ligament behind, by the bones of the leg upon its sides, and by muscles in front, which are firmly held doAvn by a strong aponeurosis, the anterior tibial must rarely be the seat of a spontaneous aneurism. For myself, I do not knoAV a single instance of it, unless Ave may regard as such the case of a bloody tumor described by Pelletan, Avhich had destroyed by erosion a great portion of the upper extremity of the tibia. Traumatic aneurisms on the other hand, are observed here quite frequently ; these Avhich are sometimes circumscribed, but more frequently diffused, are produced by pointed and cutting instruments, balls and all sorts of projectiles, fragments of bones in fractures, &c. J. L. Petit, (Malad. des Os, t. II., p. 46,) Desault, ((Euvres Chir., t. II.,)Deschamps, (JournaldeFourcroy, t. III., p. 85,) Dupuytren, (Repert. d'Anat. et de Ph.ys., &c. t. V., p. 217,) Pelletan, (Ctin. Chir., t. II., p. 266,) Boyer, MM. Roux, (Med. Oper.,\. I.,) and Cowan, (The Lancet, 1829, Vol. I., p. 719,) relate examples of them, and sIioav that they may occur at all the different points (hauteurs) of the leg. Deschamps in the case mentioned by him of false consecutive aneurism, operated by the ancient method. This also is the method Avhich M. Guthrie exclusively adopts in such cases. If the blood should still be floAving, if the accident should have existed only for a short time, and the wound of the artery appear easy of access Ave might, and ought in fact, to adopt the course of these tAvo authors ; but othenvise the method of Anel is preferable. It does not ap- pear at all necessary to place a second ligature under the tumor or wound, as some surgeons have recommended, inasmuch as a mode- rate degree of compression will answer that purpose advantage- ously. If however, the disease should be situated in the upper third of the leg it Avould be difficult to tie the artery above, without encoun- tering the tumor, and consequently Ave should not have it in our power to avoid adopting the ancient method. In that and in all cases where it would be attended Avith too much difficulty to per- form the operation on the leg, there remains as a last resource, the ligature upon the popliteal or the femoral itself. Dupuytren first employed this practice Avith success in 1S09, in conformity to the recommendation of Pelletan, (Clin. Chir., 1.1., p. 178,) upon a Avo- man aged sixty years, who Avas brought to the Hotel Dieu, Avith a fracture complicated Avith a diffused aneurism of considerable size in the leg. M. Roux derived the same advantage from it in a case of hemorrhage folloAving amputation below the knee, and Delpech has frequently obtained similar fortunate results. M. Guthrie how- ever (Injuries of Arteries, fyc, p. 283,) who avers that he has seen this operation performed at Albufera and Salamanca, long before our countrymen thought of it, condemns it in most energetic terms. In a soldier operated upon in May 1814, the hemorrhage returned to 122 NEW ELEMENTS OF OPERATIVE SURGERY. the wound: it became necessary to amputate and the patient died. The same thing took place in another soldier wounded at Sala- manca. According to M. Guthrie it is infinitely better to lay open the tissues freely at the risk of dividing the muscles ; here is a proof of it: a young man let the point of a sabre fall upon the fore-part of the leg and Avounded the anterior tibial artery. A false circum- scribed aneurism Avas formed. M. Josse, (Melanges de Chir., p. 247,) ties the femoral artery ; the ligature comes away ; hemor- rhages take place ; the pulsations in the tumor are uninterrupted. The operation by the ancient method is performed, and the patient recovers. Though it may be true as a general rule that the opera- tion by the ancient method is more certain, Somme (Jour. Hebdom. Univ., t. II., p. 242,) has shown, and M. Neve, (Communique par M. Champion, 1838,) of Bar-le-duc, has also recently proved that the advice of Dupuytren may be followed Avith advantage. § III.—Operative Process. The patient placed as for the dorsalis pedis ought to have the leg in slight pronation, and arranged in such manner that the muscles of its anterior portion may be stretched or relaxed at pleasure by the assistant Avhen he acts on the foot. To arrive upon the ar- tery it is necessary to divide the skin, the subcutaneous layer and the aponeurosis, to the extent of about two inches upon the line mentioned above ; then Avith the fore-finger or the extremity of a grooved sound, we separate if we are above the extensor longus pollicis pedis from the tibialis anticus, pushing it outAvards; and from the extensor longus digitorum pedis, on the contrary, and pushing the latter inwards, if Ave are far beloAV. This being done, there is nothing left but to isolate the artery from its accompanying veins and collateral nerve, in order to tie it, then to unite the lips of the wound and apply a suitable bandage. In its middle part, or its two upper thirds the artery may be cut doAvn upon in many different Avays. A. Process of M. Lisfranc.—In the process attributed to M. Lisfranc, by MM. Coster (Manuel des Op. etc., 3e edit.,) and Taxil, (These No. 142, Paris, 1822,) the incision of the skin is oblique from beloAV upwards, from the crest of the tibia towards the fibula, and distant about an inch or tAvo from the horizontal line. After hav- ing divided the aponeurosis transversely, Ave seek for the interstice Avhich separates the tibialis anticus from the extensors, and as it is the first Ave meet with outside the tibia, nothing is more easy than to distinguish it. B. The Ordinary Process.—In the common process Ave cut pa- rallel to the directionof and upon the trackof the artery,taking forour guide the line mentioned above, or the middle of the space which separates the fibula from the crest of the tibia; or the slight de- pression Avhich naturally exists opposite to the interval of the muscles that Ave intend to separate apart (ecarler,) or Avhat in fact is as well we carry the bistoury directly to about an inch outside the anterior ARTERIES OF THE ABDOMINAL LIMB. 123 border of the leg ; the aponeurosis like the skin should be divided to the extent of three to four inches ; the muscular interstice where Ave should use the fore-finger, in order to separate the muscles and to come perpendicularly upon the inter-osseous ligament, is indicated by a yellowish line. At the bottom of this interstice is seen the vessel which Ave endeavour to isolate and raise up, but this is the most difficult part of the operation. C. After having flexed the foot and properly separated the mus- cles apart, the best mode of managing with the artery is to pass under it a grooved sound, very obliquely from beloAV upAvards and from the fibula towards the tibia, in place of passing it tranversely or from the anterior to the outer border of the leg. To appreciate the utility of this remark, Ave have only to recal to mind, that the fibula is almost always on the same plane Avith that of the vessels, while the crest of the tibia is much above their level. We may moreover apply the ligature by means of the needle of Deschamps, or any other of the numerous porte-ligatures [ligature-holders, i. e., with handles to hold the needles. T.] Avhich have been contrived for this purpose. D. Appreciation.—It is needless to remark that no one Avill ven- ture at the present time to imitate Hey (Estor dans Bell., trad., Franc., p. 205,) or Logan, (Hey's Practical Observations, 1814,) by cutting out a portion of the fibula to arrive Avith more ease upon the tibial artery, as these Surgeons declare they have once done Avith success, and asGooch (Bell, Op. cit.,]}. 199,) has the boldness to recommend. The oblique incision, it is asserted, enables us to come down Avith more ease than the parallel incision, upon the guiding interstice (interstice directeur) and the trunk of the artery. The remark is true for the first point, but not .for the second, and experiments frequently repeated shoAV that Ave should give the pre - ference to the ancient method at least in ordinary cases, and Avhen- ever there are no special indications to fulfil. Article III.—Posterior Tibial Artery. § I.—Anatomy. From its origin a little below the popliteus muscle doAvn to its di- vision into the internal and external plantars, the posterior tibial artery follows almost exactly the direction of a line very little convex inwardly, Avhich Avould extend from the middle of the upper part, (racine) of the calf, to half an inch behind the internal malleolus. Tavo veins of considerable size ordinarily accompany it, and by their frequent anastomoses sometimes form around it a complete network. Upon its fibular side is found the posterior tibial nerve Avhich is rarely distant from it more than three or four lines. Supported throughout its Avhole extent by deep seated muscles, it is covered over by the aponeurosis which is situated between the tAvo fleshy layers of this region; also by muscles, or cellular tissue, and other fibrous lamellae, 124 NEW ELEMENTS OF OPERATIVE SURGERY. afterwards by the common integuments, but with peculiarities in certain parts of its track Avhich it is important to note. A. In the Tibio-calcanean Groove, (la gouttiere tibio-calcanienne,) the posterior tibial artery rests against the fibrous sheath of the flexor longus digitorum pedis, at about three lines from the poste- rior border of the malleolus ; the nerve is behind and the veins are on the inside ; a lamellar or adipose tissue envelops it ; the inter- nal ligament of the tarsus, a kind of fibrous layer Avhich is conti- nuous Avith the aponeurosis of the leg covers the artery and binds it doAvn (la bride) where this ligament blends Avith the dense and filamentous tissue which separates it from the skin. B. Between the Malleolus and the termination of the calf, the pos- terior tibial artery is a little farther distant from the tibia. The nerve is rather outside than behind. The lamellae Avhich immedi- ately surround it are very pliant, and frequently covered Avith fat. The deep aponeurosis Avhich is quite thin in this place, holds it firm, (la tient appliquee) against the tibialis posticius muscle, the flexor longus digitorum pedis, and the flexor longus pollicis pedis; out- side of this lamella is seen the tissue which forms (remplit) the sheath of the tendo Achillis, then the tibial aponeurosis properly so called, before Ave arrive at the skin. C. At the Calf, the tibial artery is situated very deep, and almost on the same plane Avith the posterior surface, and much nearer to the external or fibular than to the internal border of the bone which has given its name to it. The aponeurosis Avhich covers it and Avhich in some sort it lies in naked contact Avith, and which is ribbon-like in appearance, (rubanne) and silvery (argentine) Avith longitudinal and very strong fibres is concealed by the tibial portion of the soleus muscle, the gastrocnemius internus, the tibial aponeurosis (aponeu- rose jambiere,) and the sub-cutaneous tissue, in Avhich are found situated the great saphena vein and the internal saphena nerve. D. It is an unusual thing to find the posterior tibial artery wanting, but it may happen that it is of very small size, and that the fibular artery takes its place on the surface of the foot. More frequently it continues upon the median line until it reaches near the mal- leolus ; in that case, (alors,) the nerve is on its inner border. I have on one occasion seen it proceed along side of the fibular artery for two thirds of its extent, and pass under the arch of the os calcis at near an inch behind the malleolus. § II.—Indications. Like the anterior tibial, and for the same reasons, the posterior tibia] artery is very rarely the seat of spontaneous aneurisms, or even of false circumscribed aneurisms ; Ruysch, nevertheless, cites a case of aneurism near the heel, Avhich could only belong to this artery, and Avhich was opened by mistake for an abscess. M. Dorsey (Elements of Surgery, Vol. II., p. 271,) gives an example of varicose dilatation and hypertrophy of this artery in a case of aneurismal varix. Guattani also speaks of pulsating tumors, which, ARTERIES OF THE ABDOMINAL LIMB. 125 without doubt, were the result of certain lesions of the posterior tibial. Wounds, in fact, accompanied with hemorrhages or diffused aneurisms, have in latter times been noticed in this artery by Scar- pa, Dupuytren, MM. Hodgson, Marjolin, Earle, and Vincent. (The Lancet, 1829, Vol. I., p. 719.) The ancient method, according to Boyer, is the only one Avhich should be applied to these affections, since, by the method of Anel the blood would soon be brought back to the inferior end, by means' of the plantar arch and the anterior tibial. Others, influenced by the same fears, but not Avishing to act upon the diseased point, have proposed an intermediate method; that is, to place one ligature above and one below the aneurism, without touching the tumor. I confess I do not see the necessity of proceeding in this manner. On the supposition that the return of the blood would be an obstacle to the cure, as in the patient of Alancon, Man. Prat, de I'Amput., p. 164,) all that would be necessary probably to prevent it Avould be to make methodical compression upon the course of the dorsalis pedis artery, as M. Marjolin has done, or even beloAV (that is, on the distal side of) the wound, if its position permitted. On the other hand, when the seat of the difficulty is in the sole of the foot, and compression does not succeed, the ligature upon the trunk of the tibial evidently cannot be applied, except by the modern method. The only case where the ancient operation might strictly be admis- sible, or at least be preferable, if Ave should not be inclined to tie the popliteal or femoral artery, is that where the aneurism occupies the upper half of the leg. Nevertheless, diffused traumatic aneurisms do not come under this rule, and should I think be treated as Boyer and M. Guthrie recommended; that is, by the method of Keysleire. Though Pel- letan, (Clin. Chir., t. IL, p. 266,) unable to tie a wounded posterior tibial, succeeded by an incision and by tamponing, (tamponnant,) and by compressing the artery upon the inter-osseous ligament; and Colomb, already quoted, confined himself to simple compression in a case of this kind; and though Gelee put a stop to the hemor- rhage, by cutting down and introducing a thread in order to pass a piece of agaric against the artery, we see that compression was fol- lowed by gangrene in the cases of Bourienne, (Journal de Horn, t. VII., p. 281—282,) by convulsions and death in two patients that Boyer speaks of, (Malad. Chir., t. I., p. 262,) and proved ineffectual in the cases of Wiseman, Deschamps, Briot, and a great number of other surgeons. The ligature which was placed upon the anterior tibial artery by Ginies, (Anc. Journ. de Med., t. LXXVL, p. 71 ) and on one of the other arteries of the leg by M. Ouvrard, (Obs.de Med. et de Chir., 1828, p. 245,) had entire success, and is therefore in every respect to be preferred. § HI.—Operative Process. Whatever may be the point where Ave Avish to lay bare the pos- terior tibial artery, the leg should be flexed and laid upon its ex- 126 NEW ELEMENTS OF OPERATIVE SURGERY. ternal side; and in the same Avay as for the anterior tibial, if com- pression is to be made, it is to be made upon the thigh or upon the body of the pubis. A. Behind the Malleolus. a. Process of the Author.—I make an incision slightly curved, with its concavity forwards, which, commencing an inch above, finishes an inch below, and passes at three or four lines behind the posterior border of this projection. When Ave arrive at the begin- ning of the groove of the os calcis, it is of importance to proceed Avith caution, and to cut the tissues layer by layer, and pass the grooved sound under the aponeurosis, before dividing it Avith the bistoury, if Ave do not wish to incur the risk of Avounding the ar- tery, Avhich is sometimes very superficial; in making the incision nearer the malleolus, Ave might readily penetrate into one of the fibro-synovial grooves Avhich it assists in forming, and nothing would be more dangerous than such a mistake, because of the inflamma- tion Avhich might result from it. Farther back, the artery Avould be difficult to find, and the operation much more laborious. b. Process of M. Robert.—M. Robert proceeds in another man- ner. Here is the method Avhich he has communicated to me: The incision extending and directed from the posterior angle of the malleolus to the upper border of the os calcis, should be perpen- dicular to the course of the vessel. " Thus placed, it enables us," says M. Robert, " to isolate the artery Avithout difficulty, as soon as the aponeurosis, Avhich is very thick in this place, has been divided." In a case of a recent opening into the tibial artery in this region, M. H. Berard, (Arch. Gen. de Med., 2e series, t. VII., p. 453,) hav- ing secured its tAvo ends, found that the hemorrhage continued, but that it proceeded from a vein which it Avas unnecessary to tie. B. Below the Calf, I make a straight incision, from tAvo to three inches long, at an equal distance from the inner border of the tibia and the tendo Achillis. The skin, the adipose tissue, and the superficial layer (feuillet) of the aponeurosis having been divided, Ave endeavor, by means of the sound, to denude the deep-seated aponeurosis; and then divide this tissue to the same extent as the skin, being careful always to guide the bistoury upon the groove of a director. In that case, Ave are cer- tain to encounter the artery, especially Avhen Ave have taken the precaution to divide the tissues perpendicularly; that is to say, by carrying the bistoury from behind forAvards, and from the inner tOAvards the outer border of the leg, as though Ave were going to prolong it to the fibular side of the tibia. It is important to recol- lect, that if the integuments are attacked nearer the bone than the place mentioned, Ave should have but one instead of tAvo aponeu- rotic layers to divide ; but that, in thus coming down upon the mus- cles at a great distance from the vessel, Ave should run a much greater risk of being led astray, than by proceeding in the man- ner I have indicated. ARTERIES OF THE ABDOMINAL LIMB. 127 C. In the thick part of the Leg, (au gras de la Jambe.) M. Guthrie, on one occasion, undertook to cut doAvn upon the posterior tibial, by cutting through the Avhole thickness of the calf. Gelee, in the case described by him, made a counter opening, passed a ligature betAveen the two muscular layers, and then tied it upon compresses on the front part of the limb, after having inserted into the depth of the Avound several pieces of linen between the mus- cles and the artery, in order to act upon this last with a sufficient degree of pressure : his patient recovered. b. Most authors, on the contrary, recommend that we should penetrate on the inner side of the leg, and dissect and turn back the corresponding portion of the soleus muscle from the posterior surface of the tibia. But then the operator would run the risk of denuding the bone, of not reaching the vessels Avithout much diffi- culty, and of meeting Avith such interference from the muscles as to oblige him, after the operation, to divide their fibres transversely upon the posterior lip of the Avound, as happened to M. Bouchet, of Lyon. In proceeding in the folloAving manner, Ave are protected from all such inconveniences. c. The Author.—Placed on the outside of the limb, the surgeon makes an incision of about four inches long, in the direction, and at the distance of, considerably more than the Avidth of a finger from the inner border of the tibia, then separates the saphena vein, divides the aponeurosis, and falls perpendicularly upon the fibres of the soleus muscle, Avhich he divides, layer by layer, as though he Avere cutting for the posterior surface of the tibia very near its outer border ; in a short time he perceives a fibrous, thick, pearl-colored layer, upon which the muscular fibres are inserted ; this is the deep aponeurosis which is traversed by many vascular branches. We divide it upon a grooved sound to a sufficient extent, and the artery being situated immediately above, and surrounded by its satellite A^eins and accompanied by the nerve Avhich is distinguish- able from it by its rounded form, size, and yelloAV color, is then easily raised up and tied. Article IV.—The Fibular Artery. It is seldom, except at its upper portion, that the fibular artery can require the interposition of operative surgery. Below it is too small and too deep-seated to make it necessary to pay any regard to its Avounds. On the supposition that aneurisms might be de- veloped on some part of its track, an example of which Avas seen in the Hotel Dieu in 1830, sound practice perhaps Avould suggest that we should proceed to tie the popliteal or the femoral, rather than the diseased trunk itself. If, hoAvever, we should, OAving to any particular circumstance, feel ourselves obliged to pursue a con- trary course, as occurred to Ouvrard, (Oper. Cital., p. 251,) the fol- lowing is the process which it would be necessary to adopt:— 128 new elements of operative surgery. § I.—Operative Process. Since it Avould be necessary, if in the calf, to look for the fibular artery at the depth of several inches, Avhether Ave adopted the pro- cess of M. Guthrie or proceeded according to the rules indicated for the posterior tibial; and inasmuch as it is a vessel of no import- ance in its lower fourth, there is no other point in fact Avhere it is allowable to attempt to tie it, except at the place Avhere the soleus is separated from the gastrocnemii. A wound three inches long, parallel with the posterior border of the fibula, and inclined tOAvards the axis of the limb, and comprising the skin, adipose tissue, super- ficial aponeurosis,the outer root (racine) of the soleus, and the deep- seated aponeurosis, would in fact put it in our poAver to lay it bare, and to isolate it in the midst of the fibres, or upon the posterior and inner side of the flexor longus pollicis pedis. M. Guthrie, (Oper. Cit., p. 298,) Avho is a declared enemy of the method of Anel in traumatic aneurisms, preferred, in order to reach this vessel in a case in Avhich it had been wounded by a ball, to cut into the calf vertically to the extent of seven inches; then to divide transversely the outer border of the Avound, and afterwards to constrict the artery indirectly by means of a ligature introduced in a suture needle, rather than lay it bare above. We should in fact, in my opinion, in a case of this kind, folioav his mode rather than decide upon tying the trunk of the femoral. §11. The rule Avhich recommends that for all these ligatures the in- cision through the integuments should cross the track of the artery at an angle of thirty-five degrees, instead of being made parallel to it, might Avithout doubt be adopted, and in fact should not, perhaps, in some cases be disregarded; but in the majority of cases it does not appear to me to possess such advantages over the ordinary method, as to require any special recommendation. Article V.—The Popliteal Artery. § I.—Anatomy. The ham, Avhich has acquired importance in surgery for a cen- tury past, in consequence of its principal artery, is a holloAV of a rhomboidal form, (en forme de losange,) composed of tAvo triangles united at their base, and having its broadest part situated above the condyles of the femur. A. The popliteal artery courses through it from above down- wards, keeping a little nearer to its inner border, which conceals the vessel at its origin, than to its outer border, until it reaches the point where it enters into the notch between the condyles. In its arteries of the abdominal limb. 129 femoral portion, the vein is closely united to it upon its posterior and outer side ; the internal branch of the sciatic nerve is still more superficial; from three to five lymphatic ganglions and cellular and adipose tissue surround it, and separate the whole of this portion of it from the aponeurosis. In the leg it is not so deeply situated • mute frequently the vein and nerve are found on the inner side of it; at other times the first is found upon its fibular aspect, Avhile the second is placed upon its tibial side. On its posterior surface it is concealed, first by adipose cellular tissue, and afterwards, a lit- tle farther down,by the origin of the gastrocnemii, Avhile its 'ante- rior surface rests against the posterior ligament of the articulation and the popliteal muscle. This artery, moreover, has been wounded by a necrosed fragment of the tibia in a patient Avhose case is men- tioned by M. Porter, (Journ. des Conn. Med. Chir., t. I., p. 27.) It is proper to add that the external saphena vein is no longer su- perficial after it enters into this region, and Avhere it is generally found upon the median line ; and that, after having received from the thigh its descending branch, it empties into the popliteal vein a little above the condyles. In a specimen Avhich M. Manec ex- hibited to me, it Avas given off by the ischiatic artery, but was Avanting in the case mentioned by M. Caillard, (These No. 307, Pans, 1833.) The five articular arteries, and the two surales which arise from it, serve to re-establish the circulation of the leg and thigh in cases of aneurism of the ham. § H.—Mechanism. In no part are aneurisms more common than in the ham. Spon- taneous aneurism is that Avhich is more especially met with here • traumatic aneurism is not unfrequent; varicose aneurism (aneu- risme vanqueux) has also been sometimes met with in this artery (J. lerry, Encyclograph. Med., 1836, p. 100. Larrey de Toulouse! Press. Med., t. I., p. 25. Lassus, Pathol. Chir. Ribes, Bullet, de la J acuite, t. V., p. 284.) The great frequency of the first has specially occupied the attention of surgeons; some have imputed it to he efforts of extension of the leg upon the thigh; Scarpa and Delpech have taken ground against this opinion, by maintaining that an aneurism, which is not directly occasioned by a Avound is always produced by a disease of the internal or middle coats of the fr!fyu , , Rlcherand considered the first opinion conclusively es- tablished ; but M. Hodgson speaks of facts which have given oppo- site results, and the majority of the moderns adopt the opinion ot N-arpa. May it not be possible to reconcile these two modes of treating this question? While the artery continues perfectly sound, no extension of the leg, it is true, appears capable of rup- turing its coats; but if its interior is encrusted with calcareous plates (plaques,) or is the seat of any ulceration ; if one of its coats (membranes) has lost its flexibility and become brittle, hoAV can we reject the cause assigned by the ancients? It is certain that laboring men and those who are habitually in the erect posture 130 NEW ELEMENTS OF OPERATIVE SURGERY. postilions, (jockeys) for example, are those who are most frequent- ly the subjects of this disease. The form and the accidents of popliteal aneurism, and every- thing that concerns its development, find a natural explanation in the anatomical arrangement above-mentioned. Restricted by the bones in front, and the aponeurosis behind, the tumor first increases in breadth, or from above downAvards, and remains a long time be- fore it makes any prominence outAvardly. Most frequently, how- ever, the aponeurosis yields, and soon after becomes attenuated, so that the aneurism ultimately makes a projection under the skin. Anatomy also teaches us that Ave must not judge of the seat of the arterial opening by the position Avhich the tumor occupies outward- ly. The resistance presented by the soft parts of the popliteal re- gion being less in its middle portion than anywhere else, is the rea- son Avhy the sac always has a tendency to make its Avay towards that part. This, moreover, is a peculiarity Avhich Ave must not lose sight of Avhen Ave decide upon operating by the ancient method. § III.—Circulation. The anastomoses Avhich enable the arteries of the leg to commu- nicate Avith each other, are too numerous and too large for the sur- geon to have the least inquietude about the re-establishment of the circulation in this part of the limb, after the operation for aneu- rism; but in the holloAV of the ham we no longer operate with the same confidence. Here the artery is solitary, (unique,) and the supplemental branches are but of small size. Thus the ancients, being persuaded that the obliteration of a trunk like this could not fail to bring on mortification of the parts that derive their nourish- ment from it, had, in order to cure aneurism and external Avounds in the popliteal space, no other resource after compression and de- pleting means, than that of amputation of the thigh. J. L. Petit and Pott Avere tortured Avith these apprehensions. N. Gufinaud (These de Haller, t. V., p. 153 ; trad., t. III., p. 389) vainly endea- vored to dispel them, and Bromfield (Mem. de Chir. Etrang.,t. III., p. 354) still qualified as extravagant the proposition to tie the femo- ral artery. If some more fortunate results were announced, they ex- plained them by saying that an abnormal division of the vessel Avas the cause. It required nothing less than the operations performed by Guattani, Pelletan, Desault and Hunter, and especially the splen- did researches of the indefatigable Scarpa, towards the beginning of the present century, to give predominance to an opposite opin- ion. To-day there is no longer any uncertainty in this matter; going from one extreme to the other, an aneurism in the ham is at- tacked almost with the same boldness as that of one of the tibial arteries. ARTERIES OF THE ABDOMINAL LIMB. 131 § IV.—Treatment. Nevertheless, Ave should do Avrong to dissemble that this opera- tion is a serious one, and should not be performed for slight grounds, (legerement;) so much so, that for aneurisms in the upper third of the leg, for example, I should decidedly give the prefer- ence to the ancient method, or even that of Brasdor. A. The depleting regimen, applied to aneurisms of the popliteal artery, is a resource too uncertain and too dangerous to be seriously recommended. B. Neither cold applications nor ice, to Avhich all the patients at the Hospital of Incurables, at Naples, are still submitted, (De Renzi, trad. Ital. de ce traite,p.71,) and which, M.Zaviziano informs me, he has often seen succeed in this establishment; nor potter's clay, Avith Avhich, as a topical application, M. Kanelski has obtained complete success, have been followed by any considerable number of cures, unless in the practice of MM. Guerin and Dutrouilh, of Bordeaux. C. Indirect compression either upon the tumor or above it, (i. e., on the cardial side,) or upon the whole limb, has been more fre- quently followed by advantageous results than have the preceding methods. Guattani, Boyer, (t. II., p. 308—324,) Pelletan, (Clin. Chirurg., t. I., p. 121,) Desgranges, Dupuytren, (Bulletin de la Facultc, t. VI., p. 242,) MM. Richerand, Ribes, (Ibid., le annee, p. 87,) and Viricel, (Ibid., 6e annee, p. 132,) relate examples of cures obtained by this means; but in the patient of Eschard, (Pel- letan, Clin. Chir., t. I., p. 115,) it required eleven months of treat- ment and absolute rest. M. Roux mentions a case Avhere com- pression, applied successively upon different parts of the thigh, Avas followed by accidents of the most alarming character, and this without arresting the progress of the aneurism. Nevertheless, Ave may in timid, young, and feeble persons, Avho have a great repug- nance to an operation properly so called, have recourse to it, either alone or combined Avith the refrigerants and the treatment of Valsalva. A patient treated in that manner by M. Fabris, (Bullet, de Ferus- sac, t. I., p. 346,) Avas perfectly cured. M. Chiari (Renzi, Med. Oper., trad., p. 346) thinks that his compressor above the tumor succeeds as well as the ligature by the method of Anel. Cumano (Bullet, de Ferussac, t. XXL,p. 121) also says he has cured a pop- liteal aneurism by the compressor of Dupuytren. A. Dubois (Bul- letins dela Fac. de Mid., 6e annee, p. 40) obtained a similar success- ful result at the beginning of this century. Upon the supposition that the patient may not bear it Avell, or that it aggravates instead of ameliorating the symptoms, it is easy to lay it aside and come to the last resource. When the disease has a tendency to disappear spontaneously, it cannot be denied that compression*is calculated powerfully to aid the salutary efforts of nature. In such cases at least, it may be folloAved by success. ' 132 NEW ELEMENTS OF OPERATIVE SURGERY. D. In some cases also, Ave must add, the tumor has disappeared without any assistance. A man from the country came to the Hospital of Tours to be treated for an aneurism in the ham. The principal surgeons of the town were called in consultation. The necessity of the operation was unanimously conceded. But on the day after, the pulsations in the tumor had in great part ceased, so much so that in three days more they could not be perceived at all, and in two months the patient found himself perfectly cured, without having undergone an operation. Rest and regimen ef- fected a similar result in a case cited by E. Ford ; examined at a later period on the dead body, the popliteal artery Avas found a lit- tle dilated, and of about the size of a hazel-nut. We tried, says the author, to introduce a probe into its canal; it was obliterated, and it Avas not possible to penetrate it, even in using some force. This part of the artery Avas shut up by a firm and solid substance. The same patient had a femoral aneurism, which had terminated by gangrene of the tumor, Avhich had caused his death, Avithout producing either hemorrhage or effusion under the skin, though there was a crevice on its anterior part; a very thick clot by its strong adhesion to the gangrened integuments, presented an obsta- cle to the exit of the blood. Blizzard and Salmade have each re- lated a similar case, and scientific collections afford a number of others that are not less remarkable. Moi'nichen (Bonet, Corps de Med., t. IV., p. 56) saw a popliteal aneurism burst and recover without an operation. E.—As to the ligature, it would seem from a letter of Testa to Cotugno, (Pelletan, Clin. Chir., t. I., p. 137,) that Keisler or Keys- lere, had used it a great number of times before it Avas spoken of in Italy. Lochman, another surgeon of Lorraine, operated in the same manner Avith success upon a patient at Florence in 1752, while Birchell (Guthrie, Op. Cit., p. 144) ventured to do the same at the infirmary of Manchester in 1757. It Avas these facts, no doubt, which aAvakened the attention of Mazotti and Guattani. In his two operations Mazotti placed a second ligature below the arterial perforation; and it is Avith this modification that the method of Keisler Avas for the first time made trial of among us in 1780 by Pelletan. In fact the ligature upon the popliteal artery might be performed by the three knoAvn methods. It has been performed a great num- ber of times in France by Pelletan, Desault, Deschamps and Boyer, by the ancient method; but by this mode, it has appeared to present so many difficulties and dangers, that it has generally been renounced since the last ten or fifteen years. It is rare also, that the process of Anel taken literally, is had recourse to in aneurisms of the ham. Desault is the only one who has made use of it, and his case tends to prove that under such circumstances it is better to tie the femoral itself. Though the method of Brasdor has not yet been tried on this artery, I have not considered it right to pass it over in silence. If the tumour in fact should not have displaced (deforme) the parts to too great an extent, or should not be too ARTERIES OF THE ABDOMINAL LIMB. 133 voluminous, or should occupy the femoral portion of the popliteal space, it has appeared to me probable, that we might some- times succeed by placing the ligature beloAV the disease, (i. e., on the distal side of the tumor, or by the method of Brasdor;) at the present day especially when we have the process of M. Marchal, I should not hesitate to attempt it. In conclusion then, it is only for aneurismal affections of the upper third of the leg that if may be advantageous to tie the popliteal artery, and consequently after the method of Anel only. We may after all, succeed with it without any great difficulty ; perhaps also, we ought to prefer.it when the subject is thin, and Avhen every thing leads us to believe that the disease does not extend to the ham itself. § V.—Operative Process. A.— The ordinary process. The patient is laid upon his belly and the leg held moderately extended. I.—To reach the portion of the artery in the leg by the common method, Ave incise upon the median line, parallel Avith the axis of the limb and to the extent of three or four inches, both the skin and the sub-cutaneous tissue, taking care to push the external sa- phena vein to the outside, if it presents itself under the edge of the bistoury. The aponeurosis being once divided the instrument is no longer required; Ave tear apart (dechire) with caution the cel- lular and adipose tissue; then separate the attachment of the gastrocnemii muscles, and isolate the vessel from the nerves and the vein or veins Avhich surround it, by means of the grooved sound. 11.—Above the condyles, it is easier to avoid the saphena, and the incision should be longer, and a little nearer to the internal than the external border of the ham, at least at its upper part, and follow- ing a direction slightly oblique in descending upon the inter-condy- loid notch; under the aponeurosis are found the nerves, the vein soon after, and the artery quite at the bottom, and generally difficult to be detached from it, (the vein,) and ahvays more deeply situated than in its loAver half. B.—Process of Jobert and Ashmead. In place of incising upon the posterior surface of the popliteal region, M. Jobert (Bibliot. Med., 1827, t. I., p. 229,) advises to cut doAvn upon the artery by pene- trating into the depression which is observed above the inner con- dyle of the femur, between the vastus internus and the internal border of the ham, Avhen the leg is semi-flexed. In acting in this manner difficulties are created which do not exist in the ordinary method, and I do not think that the modification of M. Jobert ought to be adopted, notwithstanding the very precise rules Avhich M. Ashmead, Avho believed himself the inventor of it, laid doAvn for this method in 1829. C.—Process of Marchal. Maintaining Avith reason that the ligature upon the popliteal artery, is, all other things being equal, less serious than that upon the femoral, M. Marchal (These No. 156 134 NEW ELEMENTS OF OPERATIVE SURGERY. Paris, 1837,) proposes a neAV mode of proceeding. The patient is laid upon his back, having the leg turned outwardly, and moderate- ly flexed. The surgeon keeping along the outer side of the semi- tendinosus, divides the integuments to the extent of about three inches upon an oblique line Avhich extends from the holloAV of the ham to the internal border of the tibia, taking care to avoid the saphena. After having cut through the aponeurosis a little farther behind, he inserts his finger between the inner portion of the gas- trocnemius internus and the popliteus muscle, in order to separate the cellulo-adipose tissue. A greater degree of flexion of the leg then allows him to distinguish the vascular bundle (faisceau,) and to pass the ligature around the artery. This process, Avhich could take the title of the method of Brasdor, if it Avas applied to aneurisms in the popliteal space, (creux,) and that of the method of Ariel, in cases of disease of the arteries in the calf or upper part of the leg, is evidently preferable to the ancient, and Avhile it does not alloAv of our attacking the femoral artery for Avounds of the arteries of the leg, relieves us from the necessity of folloAving the precepts of M. Guthrie, (vid. supra.) D.— Consequences of the operation. Whatever may be the mode, method or process, Avhich has brought about the cure, Avhen the popliteal artery is in question, the resources which nature employs to re-establish the course of the blood are always the same. The obliteration of the vessel is prolonged to a certain extent above and beloAV the wound or the part included in the ligature ; the branches Avhich allow the perforating arteries to communicate with the su- perior articular arteries, and these latter and some branches of the superficial femoral Avith the inferior articular arteries, surales, and the tibial recurrent of the knee, gradually augment in volume, and ultimately form a very beautiful net-work about the articula- tion. The blood then passes Avith sufficient ease from the thigh to the arterial canals of the leg. There exists in the Museum of the Faculty an anatomical speci- men, prepared by Ribes, and taken from a subject who had been a long time before cured by Sabatier, which gives the proof of this arrangement. We find a sketch of a similar preparation in the first volume of the Clinique of Pelletan. MM. A. Cooper, Hodgson, Dupuytren, &c, have observed the same fact in a num- ber of dead subjects; and I had an opportunity of corroborating the truth of it in 1823, upon the dead body of the first patient operated upon at Paris, by the ligature, for popliteal aneurism. It was in 1780 that this man came to receive the advice of Pel- letan ; he Avas then thirty-two years of age, and died consequently at the age of eighty-four. The trunk of the popliteal artery Avas transformed into a fibro-cellular cord, quite small and of little resist- ance throughout its Avhole extent; the superior articular arteries, internal and external, the anastomotic and a branch of the super- ficial muscular supplied by the femoral, had acquired the size of huge crow's quills, and formed large tortuous (flexueuses) arcades upon the sides of the patella and the condyles, becoming continuous with the recurrent of the anterior tibial, the inferior ARTERIES OF THE ABDOMINAL LIMB. 135 articular arteries, &c.; the limb moreover Avas exceedingly Avell nourished, and did not differ in other respects from that of the opposite side. Article VI.—Femoral Artery. § I —Anatomy. Reaching from the crural arch to the loAver third of the thigh, the femoral artery follows the direction of a line slightly spiroidal (spiroide) Avhich from the middle of Poupart's ligament, Avould de- scend obliquely inwards, and folloAving also the track of the pop- liteal, terminate betAveen the tAvo condyles. The vein attached to its inner and posterior surface, is united to it by dense cellular tissue, Avhich forms a species of common sheath for both. The principal branch of the crural nerve, lying first on its outer side, gradually gets upon its anterior surface and sometimes even to its inner border in proportion as it descends, but far beloAV leaves it altogether in order to pass betAveen the muscles which form the border of the ham. Another nerve of not less size, sometimes crosses its upper portion, and continues before it and the vein down to near the middle of the thigh. A.-—Relations. A fibrous sheath, formed out of substance (epaisseur) of the deep layer of the fascia lata, envelopes the Avhole of it, and presents an arrangement Avhich it is important to notice. The anterior wall of this sheath gradually increases in thickness in proportion as it descends, so that in the groin Ave can easily tear it Avith the sound, Avhile beloAV it often opposes a great de- gree of resistance ; beloAV it is continuous Avith the fibrous expan- sion, or more properly Avith' the terminating aponeurosis of the second and third adductor muscles. The artery is afterAvards covered by the sartorius muscle Avhich crosses it very obliquely from Avithout inAvard, and Avhich does not in reality conceal but its tAvo loAver thirds, leaving it free above to the extent of some inches. In the last mentioned portion, it is covered by the deep lymphatic ganglions and by pelotons of filamentous cellular tissue. It is only when it approaches the gracilis muscle, to form the apex of the inguinal triangle, that its inner border begins to separate itself from the superficial layer of the aponeurosis of the thigh, which lies in almost naked contact with it in the fold of the groin. In proceeding toward the skin, after leaving the sartorius, Ave find the first layer of the facia lata, then the sub-cutaneous fascia enclosing the branches of the saphena, Avhich latter is almost ahvays situated within the line of the course of the artery. Among the branches of the femoral, there are several which the surgeon should not forget; these are:—1, the profunda, Avhich is given off from it at about two inches from Poupart's' ligament, in order to penetrate down to the level of the little tro- chanter, under the aponeurosis, and to furnish as it divides the three 136 NEW ELEMENTS OF OPERATIVE SURGERY. perforating ; 2, the circumflex arteries, which ordinarily rise a little higher up or some lines beloAV, and more frequently still from the profunda itself; 3, the superficial muscular, which gives off the external circumflex and Avhich descends down to the knee to anastomose Avith the branches of the popliteal; 4, the great anas- tomotic, Avhich has its origin near the commencement of the pop- liteal, and proceeds to the inner side of the knee while continuing by the side of the upper surface of the third adductor muscle. B.—Anomalies. The secondary branches of the femoral are subject to numerous anomalies ; but they are very seldom found on the trunk itself. Morgagni, who thinks it is often double, had imagined it so, but had never seen it; the same may be said of Haller ; nevertheless, Gooch gives three instances of it; M. Casa- mayor points out a fourth, and I have met Avith a fifth. In that of my OAvn the supernumerary artery was evidently only a con- tinuation of the profunda, which, after having furnished the per- forating, retained sufficient size to descend to beloAV the knee. In a subject affected with aneurism in the ham, M. Bell found the fe- moral divided into two trunks of equal volume, Avhich did not unite until they formed the popliteal. M. J. Houston, Conservator of the Anatomical Museum at Dublin, cites a similar fact. MM. Bronson and CroniAvell pointed out to me, in 1825, in the rooms of the School of Practice, a different variety. In place of remaining contiguous to the artery, the crural vein had, on the contrary separated itself from it at its origin, so as not to rejoin it, until at its entrance into the popliteal space, after having formed a long arch, whose con- vexity Avas turned tOAvards the internal border of the thigh. I have since met, in one instance, Avith the same arrangement, Avhich moreover it is only necessary to point out that each one may estimate the value that is to be attached to it in operative surgery. In a subject of Avhich M. Manec has shoAvn me the specimen, the femoral artery, Avhich was wanting in front, Avas replaced behind by the descending branch of the ischiatic. In a dead body dissect- ed by M. Caillard, it lost itself at the lower part of the thigh, with- out giving off the popliteal. (These No. 307, Paris.) § II.—The Different Kinds of Aneurism, and the Indications. If traumatic aneurism is quite rare in the popliteal space, it is not the same in the thigh, Avhere the artery badly protected in front is obliged to follow the movements of the hip joint. M. Champion writes me, that though engaged in a very extensive practice of more than thirty years, in a circuit of tAventy-five leagues, he and M. Moreau, of Bar-le-duc, have never met Avith a spontaneous aneurism in the thigh. I have, hoAvever, myself already seen seven examples of it. We often meet, in this part, with diffused, and also Avith false circumscribed aneurism; nor is it any more protected from varicose aneurism, (aneurisme variqueux,) as is proved by a case of M. Larrey. MM. Fleischer, (Bulletin de Fe- russac, t. VI., p. 343,) Guersent, the son, Perry, (Rev. Med., 1836, ARTERIES OF THE ABDOMINAL LIMB. 137 t. II., p. 421,) Venturoli, (Gaz. Med. de Paris, 1736, p. 200,) and before them Bourguet, (Sur un Aneur., &c, an IV., in 8vo,) have also published examples of it: and I have myself seen two cases, (Diet, de Med., 2d edit., art. Femorale.) Inferiorly, the sartorius tends in general to make the tumor glide forward; superiorly it would push it rather inwards; which, with the slight degree of density of the aponeurosis near Poupart's ligament, sufficiently explains a remark made by a number of practitioners, to wit, that in the groin the opening of the vessel corresponds almost ahvays to the lower third of the aneurismal sac. Surrounded with parts having but little solidity, aneurisms of the femoral artery may rapidly acquire a very great degree of development; never- theless, as they neither involve nerves of large size, nor any im- portant articulation, they are, all other things being equal, accom- panied Avith accidents less numerous than those of the popliteal artery. A.—Spontaneous Cure. Notwithstanding the size of the artery which has given origin to them, aneurisms of the thigh, left to themselves, are not ahvays fatal. In a case, cited by M. A. Seve- rin, the inguinal tumor was attacked Avith gangrene ; after the fall of the escars the wound cicatrized little by little ; there Avas no he- morrhage, and the limb returned to its natural state. Lancisi has seen an aneurism of the same kind, though very large, diminish by degrees, and ultimately disappear under the treatment of simple fomentations, warm baths, and diluents. . Guattani, at Rome, in 1765, saw in a cook the same thing occur, as in the case of M. A. Severin. In 17S4, Clarke noticed a similar case. Ford has seen an aneurism in the thigh get well Avithout any other assistance than diet and rest. In 1808, M. Spalding, after having opened and cleaned an enormous crural aneurism, Avas astonished to find the artery obliterated above and beloAV its laceration, and that not a drop of blood flowed from it. M. Hodgson has met, in the dead body, in the loAver third of the thigh, Avith an aneurismal sac, whose coagulum, of remarkably solid texture, completely obli- terated the artery, to the origin of the profunda in one direction, and down to the commencement of the leg in the other. M. Mar- jolin makes mention of an aneurism in the middle of the femoral, in a man aged sixty years, and which became transformed into an abscess, and ultimately got Avell after a long suppuration. M. Guthrie [Oper. Cit., p. 97) mentions a similar case, noticed in the hospital at York. The varicose aneurism, noticed by Bourguet, also recovered Avithout an operation. The autopsy of the dead body, at a later period, allowed of an opportunity of verifying the state of the parts. B.—The Refrigerating Method. Antiphlogistics, regimen and compression have also procured some fortunate results in the thigh. Hodgson gives many cases of this kind. At Bordeaux, M. Trey- ran succeeded in curing a femoral aneurism by bleedings, cold ap- plications, &c, in a patient Avho had another in the opposite leg. M. Larrey speaks of a sergeant of the guard, who, in April, 1817, 138 NEW ELEMENTS OF OPERATIVE SURGERY. received a sabre wound in the upper part of the right thigh. A false circumscribed aneurism Avas the result, but the treatment of Valsalva, aided by cold topical applications, soon succeeded in curing the disease. The successful case cited by M. A rid rein i, also has reference to an aneurism in the thigh. According to M. Ribes, Sabatier succeeded in the same manner in a patient Avho had two aneurisms in the same limb, one in the thigh, the other in the ham. A patient of M. Lyford (Bulletin de Ferussac, t. XVII., p. 394) Avas also cured Avithout an operation. * The aneurism, in the case of M. Faulcon (Gaz. Med. de Paris, 1837, p. 313) did not shrink (s'affaissa) until after all compression had been suspended. C.— Compression. The observations of Arnaud, Mayer, King- lake, Albert, [London Medical Gazette, t. IX., p. 28,) Dubois, (Bul- let, de la Fac, 6e annee, p. 40,) Dupuytren, and M. Pigeaux, prove that compression alone is capable of producing the same results; it is for this purpose that Guattani and Theden have so Avarmly urged their mode of bandaging. If such means enabled us, as Avas thought up to the end of the last century, to cure aneurism, Avithout obliterating the artery, Ave ought assuredly ahvays to make trial of them before coming to the ligature ; but the contrary having been demonstrated, it is ahvays .found infinitely more simple to recur immediately to the last. It is, nevertheless, true, that Professor Chiari (Velpeau, Med. Oper. trad, de M. Renzi, p. 118) asserts, that he has, Avithin a few years past, eight or ten times obliterated large arteries, the carotid and femoral especially, by means of a compressor of his invention. E. Ford (Mem. Cit., p. 115) says, that after having intermitted, in a patient who could not bear it, the compression attempted in the fold of the groin for an aneu- rism of the femoral artery, he afterwards saAV that the tumor ceased to pulsate, and that the cure took place. (See note on Compression, supra.) § III.—The Operation. The ligature upon the femoral artery is at the present time an operation very frequently performed. It is this Avhich is preferred for most of the lesions of the popliteal artery, and even for aneu- risms of the leg, as we have seen above. Nevertheless, many centuries elapsed before this operation was hazarded. Severin and Trullus had made trial of it successfully for an aneurism situ- ated at eight fingers' breadth below the groin ; Bottentuit (Saviard, Observat. Chirurg., p. 277, Obs. 63,) did the same, and Avith a si- milar fortunate result, at the Hotel Dieu, of Paris, in 168S ; Guat- tani had subtituted for it, with the like complete success, indirect compression made upon the trunk of the artery, under Poupart's ligament; but nothing, then, inspired surgeons Avith confidence. It was not until after having reflected upon the numerous anasto- mosing branches pointed out by Winslow and Haller, that Heister ventured to propose the ligature of the artery for certain cases of aneurism in the thigh. A short time after, Hamilton, Burchall, ARTERIES OF THE ABDOMINAL LIMB. 139 Leber, and Jussy, made it apparent, that after this ligature the cir- culation is re-established Avith facility in the loAver part of the limb, and that it Avasan error to entertain any fears of such an operation. As the trials, according to Pott, Wilmer, and Kirkland, that Avere made of it in England, from 1760 to 1780, Avere much less en- couraging than they had been in Italy for twenty years preceding, it required nothing short of the successful results of Desault, Hun- ter, and Pelletan, to give to it ultimately its proper rank, and to cause it to be generally adopted. Laugier, (Ann. de Marseille, t. I., p. 135,) Avho had the boldness to place the ligature at tAvo inches below Poupart's ligament, also obtained a fortunate result. A recent Avound obliged M. Fardeau (Communication de M. Bar- thelemy,) to operate in the same place, or above the great mus- cular, and this patient also recovered. Applying it, in tAvo cases, on the Avound itself, near the middle of the thigh, M. Champion (Communique par l'Auteur) was equally successful. M. PI. Portal (IlSeverino, 1834, vol. III., p. 101) Avas not less fortunate in ap- plying it immediately after the Avound occurred, in the case of a priest aged seventy years. It is, therefore, at present, a question definitively adjudged. We may, in fact, for wounds, as for aneu- risms, tie this artery, at all the different points of the thigh, but not everywhere, hoAveA'er, Avith the same chances of success. So long as the profunda of the femoral is avoided, the danger is not ex- treme, though greater than Avhen the ligature is appied upon the popliteal artery. When, on the contrary, Ave have been forced to sacrifice the great muscular, it is evident that the blood cannot any longer arrive at the limb, but by the secondary »branches, Avhich are distributed to the pelvis. A. Of the three essential methods, that of Anel is almost the only one noAv in use for the thigh. That of Keisler so frequently prac- tised by Desault, Pelletan, Deschamps, and M. Roux, and which has so long prevailed in France, is no longer recommended by Boyer himself, in the second edition of his Avork, except in a small number of cases. Nevertheless some persons have continued to accord to it the preference in varicose aneurism and diffused trau- matic aneurism, and especially Avhere the tumor is too nearly ap- proximated to the fold of the groin to alloAV of our placing a ligaT ture between it and the profunda Avithout Avounding it. In 1826, I saAv M. Roux operate by this method for an aneurism in the upper third of the thigh, and the result Avas perfectly satisfactory. It is true, as Boyer says, if the tumor extends up to the fold of the groin, we may by opening into it, easily preserve the deep mus- cular; Avhich would be impossible by the new method. It remains to be seen if this advantage is sufficiently important to compensate for the inconveniences to Avhich Ave are exposed. The ligatures upon the iliac have proved that in such cases, the artery in question is not indispensable to the maintenance of life in the limb. But Avhat regrets we should have if after having voided the aneurismal sac, Ave should find that the femoral artery Avas perfo- rated higher up than we supposed, or that the walls of its upper 140 NEW ELEMENTS OF OPERATIVE SURGERY. end were too diseased to sustain the pressure of the ligature ! Would it not be better in such cases to follow the method of Brasdor ? B. Consequently we cannot see that there can hardly ever be any absolute necessity of opening the sac to tie the crural artery, except in aneurisms produced by external causes, or in those that are dif- fused, or of very large size, or situated very high up. In employing the method of Anel in the treatment of aneurisms in the lower limb, Desault applied his ligature at the apex of the popliteal space, and not upon the femoral, properly so called. M. Martin says that Spezanni had performed it on the thigh four years before, Avith the intention of disarticulating the limb Avhen the gangrene should be arrested, and that the patient's limb was saved. As I have already said, it is asserted on the other hand that for a long time before it was spoken of in England, Brasdor had pub- licly recommended it in his lectures at the schools of surgery, Avhile Tissot (Trad, de Bilguer, Sur VAmputat., p. 115) had proposed in the year 1778 to tie the femoral artery very high up. It cannot nevertheless be denied that it is to Hunter the merit belongs of having ultimately aAvakened the attention of European surgeons to this fortunate improvement. He made his incision a little beloAV the middle of the thigh upon the inner border of the sartorius mus- cle, laid the artery bare to the extent of three inches, and passed four ligatures around it. Scarpa recommends that Ave should operate at only four fingers' width frorn Poupart's ligament, justifying himself upon the fact that there is nothing more easy than to find the vessel in this place, that there is no important collateral to avoid, and that being also as remote as possible from the aneurism, we have much more chance of meeting Avith a sound part of the tube to sustain the ligature. The reasoning of Scarpa has not convinced every one; most French surgeons think, and with reason in my opinion, that it is useless to go up to the inguinal space, even for aneurisms of the thigh, unless Ave are forced to do so by the situation of the dis- ease. They rarely go as far from fear of approaching the pro- funda, of sacrificing too many of the collaterals, and of thus inter- fering Avith the formation of the clot. It is therefore proper to make known also the manner of tying the femoral artery in the two prin- cipal regions of its track, that is to say, above and beloAV its middle portion. C. The temporary ligature also has been often made trial of in the thigh. M. Canella (Bulletin de Ferussac, t. XVIII., p. 431) withdreAV his ligature on the fifth day, but the patient died. M Falcieri (Ibid.,t. XIX.,p. 277) did not leave it on even as long as four days, yet his patient recovered. It was removed from the artery upon the third day in the case of M. Balestra, (Bulletin de Ferussac, t. II., p. 334,) and the aneurism disappeared. M. Morigi, (Valen- tin, Voyage en Italie, 2d edit., p. 317,) who removed his two liga- tures on the fourth day, also succeeded. In France the different ARTERIES OF THE ABDOMINAL LIMB. 141 kinds of artery compressors are no longer spoken of. [A different state of things since M. Velpeau published this work in the year 1839, exists now. See our note on compression, supra. T.] D. It is surprising, to say the least of it, that the precept to include the vein and nerve in the ligature with the artery has been renewed in our days, and principally upon the femoral. M. Grillo (Gazette Med. de Paris, 1834, p. 539) Avho extols this method, says he has practised it fifteen times, and that all his patients were cured! It is also upon the femoral artery that M. Ghidella (Bulletin de Ferussac, t, XXIV., p. 172) has applied this rule Avith success. To tie it upon tAvo places Avith the interposition of a rouleau of adhe- sive plaster, and to cut it between the two ligatures, is a method which M. Petrunti (II filiatre Sebezzio, Avril, 1836, p. 244) still prefers, and of Avhich he gives tAvo examples, one of which reco- vered and the other died. § III.—Operative Process. A. Lower half.—It is in this place that it Avould be prudent to seek the vessel, Avhen Ave are treating Avounds or aneurisms either of the leg or ham by the method of Anel, in the same way as for those of the inguinal region Ave Avould use the method of Brasdor. The limb is slightly flexed and turned outAvardly. An incision of about three inches is then made into the soft parts, so that half of it extends upon the middle third and half on the loAver third of the thigh. LoAver down, at some three or four fingers Avidth only above the knee, as some persons have doubtless inadvertently advised, Ave should not find the artery, because it has entered then into the hollow of the ham; higher up Ave should come into the process of Scarpa. I. In the operations of Hunter, this incision being obliquely from without inwards, fell upon the inner border of the sartorius, which Avas turned fonvard in order to lay bare the sheath of the vessels. Then Ave encounter successively the skin, which is generally quite thin, afterAvards the adipose layer and the saphena vein, which it is important not to Avound, and the superficial layer of the aponeurosis or sheath of the sartorius muscle ; and under this last quite deep down and near the femur, and in the groove (gouttiere) which separates the vastus internus from the adductors, we have a second fibrous layer to divide. II. M. Roux on the contrary recommends that the incision should be made on the outer edge of the sartorius, which is to be pushed inwardly in order to reach the artery. It is also the advice which M. Hutchison gave in 1811, seeing, says he, that in this manner we are sure to avoid the great saphena vein; we have here also the same number of layers to divide as in the process of Hunter. III. Seeing that by one mode as Avell as by the other, Ave are obliged to displace the muscle Avhich conceals the vessels, and to turn it aside either Avithin or outAvards, M. Hodgson thought it would be better to divide (decouvrir) the middle portion of it a 142 NEW ELEMENTS OF OPERATIVE SURGERY. suggestion in fact which had already been made by Desault, who asserts besides, and with reason, that we may Avithout inconve- nience make a transverse section of this fleshy bundle, Avhen it em- barrasses the operation by its presence or by its contractions. [The division of the sartorius since the discoveries of tenotomy and my- otomy must now be a consideration of the least degree of moment, as its ready reunion Avould soon restore to it all its functions. This remark will apply to the division of muscles of far greater magni- tude, and to all operations Avhere they present serious impedi- ments. T.] IV. In the process of Hunter the Avound is not so deep; being made near the inner border of the thigh, it is easy after the opera- tion to give it a depending position (une position declive ;) never- theless it may be objected that a Avound of the saphena without being dangerous in itself may have a tendency to cause gangrene, if the crural vein should be found included in the ligature or oblite- rated in any manner Avhatever, as is seen for example in a case mentioned by M. Begin; also, it is remarked, that if in the place of coming doAvn upon the sheath of the sartorius Ave should lay bare the gracilis muscle, Ave might readily be deceived, and that the depending" position urged Avith so much zeal in theory, may be neglected here Avithout any great inconvenience. The process of M. Hutchison also may lead to some mistakes. In carrying the bistoury too much outAvardly, it happens sometimes that we fall upon the triceps muscle, and that if the error is not immediately perceived the operation becomes very laborious. To avoid this inconvenience, it is sufficient fortunately to recollect that the fibres of the sartorius, parallel to each other and to the axis of the mus- cle or to that of the limb, are Avithout any admixture of fat; Avhile those of the vastus internus, fasciculated or intermingled Avith cellular or adipose lamellae, are all oblique from above dowmvards, from behind fonvards, and from the internal border of the femur towards the anterior median line of the thigh. V. The most prudent course therefore is to conform to the ad- vice of Desault or of M. Hodgson, Avhich alloAvs us, as soon as the first aponeurosis is divided, to arrive almost Avith equal facility at the internal or external border of the sartorius. As to the section practised by Desault, though it may be less dangerous than was thought formerly, it is better not to have recourse to it Avithout there is an absolute necessity. In theory it is difficult to conceive how it can ever become indispensable except in the ancient method. B. Upper Half. —Above the middle of the thigh an incision of two to three inches suffices to lay bare the trunk of the femoral artery. The middle part of this incision should be found at the distance of four fingers' Avidth from Poupart's ligament, unless Ave should be obliged to make it immediately under the crural arch, and to go down between the profunda artery and the epigastric. In all cases we carry the bistoury in the direction of the line Avhich represents the track of the vessel, and in consequence of the saphena vein, rather a little outAvard than too much inwardly. After pass- ARTERIES OF THE ABDOMINAL LIMB. 143 ing the skin and the adipose tissue, the aponeurosis presents itself to the eye of the operator ; before dividing it, it is Avell to recollect that, below, the internal edge of the sartorius ordinarily separates it from the artery, Avhich is no longer the case in the upper part of the inguinal triangle. This sheath being opened, and the muscle pushed outwardly as much as is necessary, Ave pass a grooved sound to serve as a conductor to the bistoury, under the superfi- cial layer of the arterial sheath, in order to cut it Avithout danger and to the same extent as the rest of the Avound. Finally Ave iso- late the vessel, seizing it by its inner border and with the usual pre- cautions so as not to Avound either the crural vein or the nerves in the neighborhood. C. Consequences of the Operation.—After this operation, Avhether it has been performed higher up or loAver down, the vessels charged Avith re-establishing the course of the blood are nearly the same. The branches of the superficial muscular pour out this fluid into the great anastomosing artery, the external articular arteries or the tibial recurrent, and those of the profunda, or the perforating arte- ries, into the internal articular arteries. It returns sometimes by the intermediate muscular arteries betAveen the ligature and the tu- mor, Avhose pulsations may thus be kept up, and interfere Avith the resolution during a variable period of time. This inconvenience which had at first been deemed very serious, no longer at the pre- sent day causes the same inquietude. Cold and resolvent applica- tions, aided by slight compression, in general, causes it promptly to disappear, Avhen Ave do not think proper to leave it to itself. The facts opposed to this statement, hoAvever, are less rare and more authentic than is generally thought. I. Monteith has seen the pulsations return in the tumor many months after the cure ; an aneurism operated upon in 1S21, by M. Cumming, reappeared in 1825 to such extent as to make it neces- sary to amputate the thigh. In a patient in Avhom I had tied the femoral artery at three inches below the profunda, a hemorrhage from the lower end took place after the fall of the ligature on the thirteenth day. A new ligature above did not arrest the blood; it was necessary to unite compression Avith it below the wound. M. Smith, (Journ. des Conn. Med. Chir., t. II., p. 192,) Avho had operat- ed in the same way, saw the hemorrhage supervene on the tAvelfth day. A ligature upon the femoral above the profunda did not pre- vent the hemorrhage from returning eight days after. Direct com- pression arrested it completely. An aneurism Avhich existed in the other thigh Avas cured at the same time. It is then an accident quite frequent. Bromfield cites an instance of it from J. Hunter, and M. Guthrie also enumerates several. II. When it has not been possible to preserve the deep-seated muscular artery, it is by the branches of the epigastric that the cir- culation is re-established; the gluteal, the ischiatic, the internal pu- dic, and obturator inosculate Avith*the circumflex and perforating arteries, and these disgorge themselves, as has been said above, into the arteries in the neighborhood of the knee. 144 NEW ELEMENTS OF OPERATIVE SURGERY. III. Not only has the femoral artery been tied for its OAvn aneu- risms and for those of the popliteal space, but also for certain dis- eases of the leg. If those aneurismal tumors Avhich develop them- selves in the substance (epaisseur) of the bones, tumors Avhich Pott and Scarpa Avere the first to mention, of which Pelletan cites many cases, and Avhich have been three times seen at the Hotel Dieu by Dupuytren, (Repert. d'Anat., de Phys., et de Path., etc.,) should again be met with under the knee, as has been seen by M. Lallemand, (Archiv. Gen. de Med., t. XIII., p. 544,) in the canal of the tibia, for example, as has been noticed by Rossi, (t. II., p. 66, en note,) or in the thigh, (Lallemand, Bulletin de Ferussac, t. XV., p. 73,) it would no longer be necessary in order to effect a cure in any of those cases, as was formerly thought, to amputate the limb ; the ligature upon the femoral, by the method of Anel suffices; it succeeded completely with M. Lallemand and Pearson. IV. NotAvithstanding all this, the ligature upon the femoral artery is an operation much more dangerous than the observations of modern surgeons might induce us to believe. It is true that in an enume- ration of fifty cases, I do not find but eight instances of death; that M. Mott has told me that he has lost but one patient out of that number; that M. Roux also declares that he has cured almost all his cases; that everyAvhere successes are spoken of, and that no one mentions failures; but I deem it just to declare that out of seven persons, who, to my knowledge, Avere submitted to the liga- ture upon the femoral artery for aneurisms, in 1837 and 1838, in the hospitals of Paris, three are dead ; that a patient operated upon at Naples (De Renzi, Oper., t. I., p. 109,) and another of whom M. Lauchlan, (Gaz. Med., 1838, p. 487,) speaks, both succumbed ; that gangrene made it necessary to amputate the thigh in that of M. S. Cooper, (Arch. Gen. de Med., 2e serie, t. I., p. 281,) that at the Hotel Dieu, in the department of Dupuytren, a great number died, and that all the cases of this kind are not knoAvn. Though now they are scarcely ever any more spoken of, yet I find in about sixty cases of this operation, tAvelve examples of gangrene, and thirteen of hemorrhage, without counting abscesses. The hemor- rhage moreover supervened on the 3d,4th, 9th, and 15th days; twice on the 16th, 21st, 22d, 12th and 8th days, and tAvice on the 40th day. It is enough I think to induce practitioners not to tie the femoral artery Avithout the necessity for it is fully established. The gravity of this operation being well ascertained, Avould it not suffice, iioav that the process of M. Marchal is knoAvn, to induce us in cases of Avounds or aneurisms of the leg, to tie rather the ter- mination of the popliteal artery than the femoral itself? We may, moreover, do this Avith much less danger for the arrest of hemor- rhages which sometimes supervene after amputation, (Arnal, Journ. Hebdom., t. VII., p. 209,) or Avhich are complicated Avith fractures of the thigh. Patients thus operated upon by MM. Roux, (Ibid., p. 209-10,) Gerdy, (Arch. Gen. de Med., 1834, Beaugrand,) Jobert, (Journ. Hebdom., t. VII., p. 210,) and Ch. Bell, (J. Bell, Trait, des PI, p. 200,) have recovered perfectly. Nevertheless M. Roux, ARTERIES OF THE ABDOMINAL LIMB. 145 (Dubourg, Journ. Hebd. Universel, t. I., p. 45,) Avas less fortunate in 1830, in two patients who had had the crural artery opened. Article VII.—Branches of the Femoral Artery. Wounds of the thigh sometimes give rise to serious hemorrhages, and even to aneurisms, though the trunk of the femoral artery may remain intact. In a patient of Abernethey, who met Avith a fall, hemorrhage ensued from a soft cancer; a ligature at the groin proved insufficient, but compression with the fingers effected a cure, (Abernethey, Melang. de Chir., t. II., p. 469.) We find the following case in Hevin, (Cours de Pathol, et de Therapeut., t. II., p. 48.) A Avound upon the middle and inner part of the thigh, from a sabre-cut, hemorrhage, application of vitriol, (bouton de vitriol,) compression, tourniquet, and tumefac- tion to a very considerable extent in the lower part of the thigh as well as in the leg, Avhere there Avere already phlyctenae. Foubert, Petit, Morand, Ledran and Faget decide Avith Hevin that amputa- tion should be performed. Though the femoral artery in this case remained intact, a considerable branch Avas Avounded at four or five lines distant from its origin in the trunk. This probably is the same case that M. Arbey (Coup d'ozilsur I'Amput., 1815, p. 7) says he had heard of, from a professor of Strasbourg. M. Champion writes me :—I Avas called to apply a ligature upon the femoral, in consequence of a hemorrhage from the middle and inner part of the thigh, produced by a wound from an iron pitch-fork. The blood had ceased to Aoav under the compressive dressing ; it had effused itself throughout the Avhole thigh; but as the engorgement did not increase, I resolved to Avait, and the patient recovered. A young man Avho received a wound above and outside of the patella, died at La Charite (Medec. Operat.,t. I., p. 283) in 1838, from repeated hemorrhages. The blood came from an articular branch. Another patient, who had a similar wound above and inside the patella, presented a short time after similar accidents ; but a free dilatation, Avith compression, finally arrested the flow of blood. The point of a knife, striking perpendicularly upon the fore part of the femur above the knee has tAvice occasioned me similar trouble. A case has also been stated (Seance Publique de I'Academie de Chirurgie, 1748) of an aneurism of the superficial muscular artery, cured by compression ; and M. Mauban, (Bullet, de la Soc. Med. d'Final., t. VI., p. 238,) making use of the same means, professes to have cured one in the circumflex of the knee. If one of the circumflex arteries or the profunda should be divid- ed, or become the seat of an aneurism, it Avould not in general be very difficult to apply a ligature to it. The essential point would be to verify (reconnoitre) such a lesion. In laying bare the trunk of the femoral at its exit from the crural arch, Ave could, without difficulty, apply ligature upon the root of the affected artery. M. 146 NEW ELEMENTS OF OPERATIVE SURGERY. Roux and another surgeon whose case I cannot now find, are the only ones who have had occasion to operate in this manner upon one of its secondary branches, namely, upon the internal or exter- nal circumflex artery of the thigh. The danger of a ligature upon the trunk of the femoral is too great, in my estimation, not to make it obligatory on the surgeon before coming to this operation to search carefully for the wounded branch, even though it Avere ne- cessary in order to effect this, to make a large and deep incision. [Spontaneous Cure of Femoral Aneurism by Valsalva's Mode. Mr. ElsAVorth, (see London Medical Times, January, February and March, 1844,) relates the case of a sailor, aged 47, received at St. George's Hospital in November, 1841, Avith an aneurismal tumor of the femoral artery of the size of a pigeon's egg, situated under Poupart's ligament. Having refused to have the external iliac tied, the patient Avas put upon the regimen of absolute rest and severe depletion, the thigh being kept semi-flexed on the pelvis. In a month, the tumor still retaining its dimensions, exhibited no longer any strong pulsations, Avhich latter entirely ceased at the end of another month. Nor were they perceptible in the external iliac above it. In the summer of 1S43 the patient, Avho had left the hospital, returned to shoAV that the disease had been completely cured ; nothing remaining in the groin but a small, hard, non- pulsating tumor of the size of a nut. Pulsation also had ceased in the external iliac and femoral. Popliteal Aneurism in a Child. Mr. Syme gives (Cormack's Lond. and Ed. Monthly Journal of Med. Science, Oct. 1844, p. 823, et seq.) a case of popliteal aneu- rism in a child, aged 7 years, in whom the tumor extended from the loAver part of the popliteal space under the bellies of the gas- trocnemii muscles so as to distend the calf of the leg. The Avhole tumor nearly disappeared under temporary compression of the tumor itself, or of the femoral artery. It rapidly increased between the age of 7 and 9 years, at which latter period Mr. Syme tied the femoral, and in a month dismissed his patient Avith a solid tumor of coagulum in its place of much smaller size. Sir A. Cooper never met with an aneurism earlier than at the age of eleven, and that was of the anterior tibial in a boy, (Lectures on Surgery, vol. II., p. 41.) Dr. Peach, hoAvever, informed Mr. Syme, (Cormack, ib.,\>. 824,) that he had Avitnessed the amputation of a child's thigh for popliteal aneurism of a very large size. And Dr. Croft also men- tioned to the professor of Edinburgh (Ibid.) that he had seen in the museum of an English provincial hospital the preparation of a carotid aneurism, for which the artery had been tied without suc- cess in a child of seven or eight years of age. ARTERIES OF THE ABDOMINAL LIMB. 147 As an illustration of the singular manner in which a large artery and vein may escape being Avounded, though lying in the track of a ball, M. Guthrie, (Cormack's Lond. and Edin. Monthly Journal, &>c. Dec. 1844, p. 1043,) has a preparation showing Avhere a ball passed between the femoral artery and vein without wounding either. T.] Article VIII.—External Iliac § I.—Anatomy. From the line of the sacro-iliac symphisis, where the primitive iliac artery bifurcates, to its passage under Poupart's ligament, the external iliac represents a slight curve, Avith its convexity outward and backAvard. Resting against the psoas muscles outAvardly, and upon the iliac vein behind and within, it is covered directly by an expansion of the facia iliaca. The crural nerve is separated from it by the tendon of the psoas, and by a very strong aponeurosis. A branch of the genito-crural nerve, sometimes runs along its inner and anterior surface, Avhich latter is crossed by the ureter, and in women by the ovarian vessels. The peritoneum, which at the same time conceals these various parts, adheres to it but very feebly by means of a very loose adipose layer, and even abandons it alto- gether in front, to be reflected upon the posterior surface of the abdominal Avails. At its entrance into the crural canal, the external iliac artery gradually rises upAvards, becomes much more superficial, and con- tracts some new relations. In that place it is supported by the body of the pubis, and the origin of the pectineus muscle ; the vas de- ferens crosses it in descending into the pelvis; the testicular cord, as it passes over the inguinal canal, does the same. The epigastric vein also is obliged to cross it, in order to open itself into the iliac vein, which latter keeps close to it, as in the thigh; the fibrous layer, which binds it down against the psoas and iliac muscles, has be- come sensibly thinner; the anterior iliac artery, and the epigastric, the only ones Avhich it gives off, separate themselves from it, the one a little outAvardly, the other a little inwardly, ordinarily at the level of the ilio-pectineal crest, sometimes higher, and sometimes loAver, by from four to six, or eight lines. The lymphatic gang- lions Avhich surround it, as far as the crural arch, and Avhich, in be- coming sAvollen, might compress it, have sometimes given occasion to the suspicion of diseases Avhich did not exist. The coecum, on the right, and the sigmoid flexure of the colon on the left, are the only viscera which separate it from the Avails of the belly. Nothing is more easy in lean subjects, and Avhen all the muscles are in a state of relaxation, than to make sufficient indirect compression upon it, to close it, as has been observed by Bogros, (These No. 153, Paris, 1823,) and as I have shoAvn farther above. Its anomalies hardly ever relate to other circumstances than its 148 NEW ELEMENTS OF OPERATIVE SURGERY. length, its size, and curvature, and to the points of origin of its principal branches. It may, hoAvever, happen that it will be composed of two trunks, placed by the side of each other, and which pass together under the crural arch, as M. James has seen in a patient in Avhom he tied the iliac artery, by the method of Brasdor. \ § II.—Indications. The external iliac artery is rarely the seat of spontaneous aneu- risms. If, in fact, it should be opened by an external cause, the pa- tient Avould necessarily die from the hemorrhage, before it Avould be possible to afford him the least assistance. M. Larrey, hoAvever, says, he has seen a varicose aneurism here, and I was fortunate enough, owing to the presence of mind of MM. Layraud and Du- rand, to cure, by means of the ligature, a boy in Avhom it was opened by accident. M. Carron du Villards relates, that M. Bar- baud (Sanson, These de Concours, p. 339) had the same good for- tune in a carpenter, Avho had the fold of the groin largely torn by a nail. But as it is not an external artery, and has only from four to five inches length, aneurisms, even from internal causes, cannot be very common here. The case of the young man I have mentioned above, is, probably, the only one of its kind, as Avill be mentioned further on. If the dread of gangrene, from the obliteration of a large arte- rial trunk, has been enabled to maintain its ground for so many centuries, in the presence of aneurisms of the thigh, and of the pop- liteal region, with much stronger reason, Avould even the very sug- gestion have been reprobated, of placing a ligature upon one of the first divisions of the aorta. Facts passed unheeded by, and science could not profit by them. In the case of Guattani, the compression was made above the profunda artery, and the circula- tion maintained itself in the limb. Baillie had found the femoral artery obliterated up to Avithin the pelvis, in the dead body of a man, in whom the pelvic limb Avas in no Avays altered. Guattani noticed a similar fact in 1767, in a subject Avhom he had treated for ingui- nal aneurism, by compression. In the dead body of a patient ope- rated upon by Gavina, in 1775, the iliac artery itself Avas com- pletely impermeable. It was the same in the* case reported by Clarke, and many others, (Voy. Casamajor, These Cit, 1825.) AH these proofs, the injections made by Guattani, and those even of Scarpa, which sIioav Avith Avhat facility liquids throAvn into the aorta pass into the arteries of the thigh and leg, though the exter- nal iliac had previously been tied tight, were not sufficient, and would probably still have remained a long time without application, in spite of the proposition of Sue, Avho, according to the statement of M. Paillard, (Rev. Med., 1829, t. I., p. 18,) had already recom- mended the ligature of the iliac artery, in the last century,—if ne- cessity had not compelled Abernethey, for the first time, to appeal to them in his behalf, in 1796. An individual, Avho had already ARTERIES OF THE ABDOMINAL LIMB. 149 undergone the operation by the method of Anel, for an aneurism of the popliteal trunk, entered St. BartholomeAv's hospital, for an inguinal aneurism on the opposite side. Abernethey (Journal de Corvisart, t. XXXI., p. 403) applied the ligature under the cru- ral arch ; a hemorrhage, Avhich supervened on the fifteenth day, left him no other resource than to penetrate into the belly, and to per- form upon the iliac artery Avhat he had done at first upon the fe- moral. The patient died, some time after, from a secondary hemor- rhage. A second operation Avas not more fortunate, but a third, performed in 1806, was followed by complete success. To set out from this epoch, it has been no longer possible to call in question the practicability of tying the external iliac Avithout causing morti- fication of the limb. At present it is one of the common operations in surgery. M. Freer, in 1806, and M. Tomlinson, in 1807, imitated Aber- nethey, and like him succeeded. This last named surgeon obtained another successful result in 1809. Out of seven patients, upon AvhomM. A.Cooper had operated upon up to 1814,four Avere cured; one died at the end of three months, of an aneurism of the aorta; another of gangrene of the limb ; and a third of hemorrhage. De- laporte Avas the first in France, who, in 1810, ventured to follow in the steps of the English surgeon ; his patient died on the twelfth day, Avith a putrid fever. Good lad and Dorsey, (V. Mott, Biogra- phical Memoir, 1836,) each succeeded once in 1811. In 1812, also, M. Bouchet (Bull, de la Fac, t. IV., p. 173) cured a Spanish prisoner, who died a year after, of an aneurism upon the opposite side. In 1812, moreover, a patient, treated by Albers, Avas carried off on the twentieth day, by tetanus. An old man of seventy-five years, operated upon by Ramsden, died on the third day. But in 1813, two new fortunate issues were obtained, one by M. Brodie, (Trans. Med., 1828, p. 328,) and the other by Norman, (Rev. Med., 1820, t. II.) M. LaAvrence, in his turn, succeeded in 1814; it Avas the same with M. Moulaud (Bullet, de la Faculte, t. V.,p. 584) in 1815. Gangrene, on the contrary, upon the fourth day, deprived M. Col- lier of a similar triumph, (Trans. Med.-Chir., t. VII., p. 136.) M. Smith—Soden, and Dupuytren (Bullet, de la Fac, t. VI., p. 319. Lec,ons, t. IV., p. 524) Avere less unfortunate, and each cured a patient in 1815. M. Cole, (Jour. Gen. de Med. et de Chir., 1818, t. I., p. 96,) in 1817, M. Albert, in 1818, MM. Wilmot, Kirby, Anderson, (Surg. Anat. p. 148,) NeAvbygin, and Post, (Mott, Bio- graph. Med. p. 18,) each successively obtained a similar success. The patient of M. Salmon (Hullet. de Ferussac, 1.1., p. 87) died on the sixteenth day. M. Wright, (Ibid., t. XVIII., p. 83. Journal des Progres, t. X., p. 247,) M. Richerand, (Pcgat, These No. 66, Paris, 1S37,) Vacca, (Bulletin de Ferussac, t. I., p. 87,) M. Killian, (Ibid., t. I., p. 450, M. White, (Guthrie, Opera Citat.,y. 16,) M. Da- crux, (Jour. Hebdom., t. Ill, p. 451,) M. Clot, (Trans. Med.-Chir., t. XIII., p. 218,) and many others may noAv be added to all these names. Delpech (Chirurg. Clin., t. I.) had not the same fortune ; his patient died at the expiration of a few days. M. Tait tied 150 NEW ELEMENTS OF OPERATIVE SURGERY. successively, on the 8th of May, 1825, and on the 16th of April, 1826, both iliac arteries in the same patient, with entire success, though on one side the peritoneum had been penetrated. M. Arendt, (Bulletin de Ferussac, t. VIIL, p. 80,) Avho did not leave but eight days of interval betAveen tAvo similar operations on the same individual, Avas not less fortunate. I, myself, performed the operation on the 6th of October, 1831; the ligatures came aAvay on the eleventh and thirty-fifth days, and the patient Avas completely cured. This case is even more remark- able than any other, in more respects than one. The patient, aged seventeen, tall and strong, while cleaning a table, in a dark part of the room, by accident, ran a carving-knife into his groin, and cut through the external iliac, at three lines above the epigastric ; the blood came out in torrents. MM. Layraud and Du- rand, (Jour. Hebd. Univ., t. VI., p. 346. Transact. Med., t. IX., p. 17,) Avho arrived almost immediately, compressed the artery attAvo inches above the Avound, and thus suspended the hemorrhage Avhile they sent to seek for me. Assisted by these two confreres, as well as by M. Duvivier, I hastened to lay bare the vessel, and to tie it, Avhile they compressed the aorta. No disturbing symptom made its appearance in the limb. The emission of urine, which Avas difficult on the second day, resumed its function Avithout any incon- venience ; symptoms of inflammation about the side caused some apprehensions during a Aveek ; the first ligature, placed by means of a curved needle, very high up, in order to allow of an opportu- nity of examining, Avith ease, the seat of the Avound, did not be- come detached till the thirty-fifth day; but the Avound finally cica- trized, (s'est mondifiee,) and the young man is noAv Avell. I have seen him many times since, and know that he is in the enjoy- ment of excellent health. A result like this demonstrates hoAV highly important it is to know hoAV to make compression upon the iliacs and the aorta, through the Avails of the belly, and proves, 1, That Ave may, Avithout the necessity of previous dilatation of the collaterals, effected either by compression, as has been proposed, or by the presence of an aneurism, successfully tie the ilio-crural trunk; 2, That the entire and sudden division of this trunk is not necessarily fatal. In adding to these cases those Avhich belong to MM. J. Smith, (Melang. de Chir. Etrang.,) Guthrie, (Injuries of Arteries, 1830,) Sainclair, (The Lancet, Aug. 6,1833—Gaz. Med. de Paris, 1833, p. 634—Med. Chir. Rev. 1833. p. 57,) B. Cooper, (Trans. Mid., Janv., 1832—Arch. Gener., t. XXX., p. 116.) V. Mott, (Gaz. Med. de Paris, 1837, p. 650,) Gibbs, (London Medical Jour., 1827, p. 97,) Liston, (Edinb. Medical 6r Surg. Jour., vol. XVI., p. 72,) Bujalski, (Bulletin de Ferussac. et Legat. des Princip. Art.,) Salomon, (Bull, de Ferussac, t. XVI., p. 449,) Lisfranc, (Archiv. Gen. de Mcd., 2e ser e, t. II., p. 514,) Nichet, (Gaz. Med. de Paris, 1833, p. 650,) (Mor- gan, (The Lancet, 1828, vol. I., p. 412,) Balingall, (Ibid., p. 618,) Renzi, (Velpeau, trad. Ital, p. 147,) Mirault, (Acad. Roy. de Med., 136,) Beclard, (Clin. Surg., 1822,) Baroni, (Gaz. Med. de Paris, ARTERIES OF THE ABDOMINAL LIMB. 151 1836, p. 200,) Ruan, (Ibid., p. 742,) Warren, (Communication Pri- vee, 1837,) Macfarlan, (Gaz. Mcd. de Paris, 1837, p. 2S5,) Ander- son, (Surgical Anatomy, p. 145,) Hobbart, (Edinb. Med. 6c Surg. Jour., vol. CXXXVL, p. 84,) and some others, which I have had it in my power to examine, Ave find already near a hundred ; but out of seventy-one, Avhose results I have ascertained, I perceive there Avere eighteen deaths, and that fifty-three Avere cured; that is, one in four. Such a calculation, I know, is too incomplete to justify rigorous conclusions ; but it shows, at least, that the ligature upon the external iliac artery, Avithout being generally fatal, is a very dangerous operation. III. Treatment.—NotAvithstanding the tAvo examples of cure by refrigerants, moxas and depleting remedies, made known by M. Larrey, and that Avhich M. Reynaud, (Gaz. Med. de Paris, 1837, p. 565,) has since given, the ligature at present should be preferred, in patients Avho are Avilling to submit to it, for all cases of inguinal and iliac aneurisms which admit of its application ; only Ave should not forget that, in carrying it beyond three inches into the pelvis, the neighborhood of the hypogastric artery may render it ex- tremely formidable. A. The Method of Brasdor.—Also, unless Ave should go to the primitive iliac, Avhen the tumor occupies the iliac fossa and there is not sufficient space in the groin to tie the femoral artery above the profunda, it Avould be alloA\rable to try again the method of Brasdor. The patient of M. A. Cooper did not die till two months after the operation: the pulsations in the tumor, Avhich Avas enor- mous, had ceased, and it was not ascertained precisely Avhat had caused his death. That of M. James, Avho Avas not more fortunate, had the iliac artery divided into tAvo nearly equal trunks. Never- theless, the unsuccessful attempt of M. White, though the femoral artery Avas obliterated beloAV the sac—the continuance of the pul- sations still perceptible at the bottom of the Avound in the young man Avhose history I have just related—and the facts related by M. Guthrie, (Oper. Citat., 1837, p. 90,)—do not allow of our plac- ing any very great degree of confidence in this method. To un- dertake it Avith any chance of success, it Avould require that we should be enabled to place the ligature between the tumor and the origin of the epigastric and circumflex arteries of the ilium, or that those branches pushed up by the aneurism should have become filled Avith clots and rendered impermeable, by the pathological pro- cess pointed out in the memoir of M. H. Berard, (Arch. Gen. de Med., t. XXIII.,p. 363.) B. Method of Anel.—Quite a number of modes have been de- vised to reach the external iliac artery. I. Process of Abernethey.—On the first occasion, Abernethey made an incision of about three inches, in the direction of the ves- sel above Poupart's ligament. It is this process Avhich M. Begin (Did. de Med. et de Chir. Prat., art. Aneurisme.) advises anew. In his second patient, Abernethey, fearful of wounding the epigas- tric artery, made his incision a little farther to the outside of the 152 NEW ELEMENTS OF OPERATIVE SURGERY. inguinal ring, and gave it a direction slightly oblique from below upAvards, in order more easily to avoid the peritoneum. II. Process of A. Cooper.—M. A. Cooper made a semi-lunar in- cision in the direction of the fibres of the aponeurosis of the exter- nal oblique ; that is to say, Avith its convexity doAvnwards, and which took its origin at some distance from the anterior superior spinous process of the ilium, and terminated near the inguinal ring : on raising the semilunar flap thus formed, Ave perceive the spermatic cord, the opening of the fascia transversalis, and the epigastric artery; and in passing the Singer under the cord through this last mentioned opening, says the author, Ave readily come to the iliac vessels. III. Process of Norman.—M. Norman decided upon making his incision in the direction of Poupart's ligament, following in other respects the rules laid doAvn by M. A. Cooper. M. Roux recom- mends that the incision should commence a little above, and at half an inch only distant from the spine of the ilium, to terminate afterwards upon the middle of the crural arch. IV. Process of Bogros.—Bogros thought that he could advan- tageously modify the process of Sir A. Cooper, or that of Norman, by advising to make the middle of the incision fall upon the point of Poupart's ligament, Avhich corresponds to the artery, and then to cut doAvn to the opening of the fascia transversalis, in order to find with certainty the epigastric artery, which should serve as a guide to lay bare the trunk Ave Avish to tie. M. Mirault, (Mem. de VAcad. Roy. de Med., t. VII.,) who was the first that made a suc- cessful application of this process upon man, considers it secure, and at the same time very easy. V. Process Adopted by the Author.—This is the one which has appeared to me to be the most simple and the most advantageous, and Avhich I followed in the young man whom I have spoken of above. a. First Stage, (premier temps.) The patient is laid upon his back, Avith the limb moderately extended. While some of the assist- ants hold him in this position, others stand ready to serve the sur- geon, Avho, placed on the side of the aneurism, makes an incision, slightly curved, three inches long, parallel with and a little above Poupart's ligament, the middle part of the incision passing on a level with the artery. The first cut of the bistoury goes through the skin, and the sub-cutaneous/ascia; if the branches of the cuta- neous artery bleed so much as to incommode us, Ave apply the liga- ture or torsion to it, before proceeding farther. The aponeurosis of the external oblique comes next; for greater security, though not indispensable, it is advisable to pass a grooved sound under it, be- fore dividing it. The fibres of the internal oblique muscle, next present themselves in their turn; those Avho have a practised hand may divide them, Avithout fear,Avith the cutting instrument; other- wise Ave separate their loAver portion Avith the point of the sound, pushing them backAvard and upward, Avith some degree of force, while the left fore-finger fixes and retains the loAver border of the ARTERIES OF THE ABDOMINAL LIMB. 153 wound ; Ave tear, in the same manner, the fascia transversalis, up to the spermatic cord, Avhich is pushed aside in the same direction as the fleshy fibres. b. Second Stage. At this stage, in order to avoid the peritoneum, especially Avhere it is our intention to place the ligature, at a point very high up in the iliac fossa, Ave make use of the finger instead of the sound; in other cases this latter has the advantage of iso- lating the tissues better, and of detaching them less extensively. After that, if the eye does not distinguish the objects, the fore-finger inserted in the wound, Avhose lips are kept apart, easily recognises the artery upon the inner border of the psoas, and the side of the upper strait. In grasping it, to raise it Avith tAvo fingers, as Scarpa recommends, and as many practitioners have done, we make useless, and sometimes dangerous lacerations ; it is infinitely better to rupture with the sound the sheath that it receives from the fascia iliaca,then to direct the point of this instrument upon its inner side, and detach it from the vein, by cautious movements forward and backward. After this separation, Avhich it is important should be made, to as little extent as possible, but Avhich should comprise the Avhole circumference of the artery, Avhich latter should be de- tached, with a great deal of caution, from the iliac vein, and from the nervous branch Avhich creeps upon their surface, Ave proceed to pass the ligature, either by means of the eyed probe, guided upon the grooved sound, or by the needle of Deschamps, or any other convenient instrument. c. Third stage.—In general, this ligature should be carried rather a little higher up than lower down ; the rule, at least, is to apply it above the epigastric artery, and it is said that Beclard lost one of his patients from having unintentionally placed it below. It is owing, in fact, to this inconvenience, and to prevent it Avith greater security, that Bogros recommends that Ave should seek for the epi- gastric before occupying ourselves Avith the iliac. But in proceed- ing as I have pointed out, Avhen Ave have laid bare this latter, it is always easy to find the other, and to leave it below the ligature. To prevent either the hemorrhage, or the return of blood, or the continuance of pulsations in the tumor, which may be occasioned by the supra-pubic artery, some persons have thought that, Avhe- ther wounded or not, Ave should place the ligature upon this at the same time Avith that of the iliac. Though this advice may in reality be followed Avithout great inconvenience, practical experi- ence, up to the present time, has shoAvn also that it need not be at- tended to. During the progress of the operation, and especially at the con- clusion of it, it is of the highest importance that the abdominal muscles should be kept in a state of relaxation, and that the pa- tient should make no effort nor attempt any movement. Otherwise the intestines Avould not fail to present themselves at the wound' and the Avounding of the peritoneum Avould be almost inevitable ' and although this lesion, as has been shown by the two cases of 154 NEW ELEMENTS OF OPERATIVE SURGERF. Post and M. Tait, is not as formidable as is generally supposed, Ave should, nevertheless, do all in our power to prevent it. VI. Appreciation.—The incision vertical or parallel to the artery, and the oblique incisions of Abernethey and M. Roux, present only one advantage, Avhich is that of allowing us to penetrate Avith less difficulty as high as Ave Avish; an advantage counterbalanced by the greater risk Ave run of Avounding the peritoneum. The lower or inner angle of the Avcund is the only point Avhich can be dilated to arrive at the vessel; it is, therefore, an unnecessary mutilation to make an extensive division of the Avails of the belly. In the process of M. A. Cooper, modified by Norman and Bogros, or in that Avhich I have given, as the incision crosses the vessel almost at a right angle, it is almost impossible to miss it. It is true an objection is raised that it does not alloAV us to go sufficiently into the pelvis, and that it exposes, more than any other, to the risk of AArounding the epigastric artery. But, on the one hand, Ave may by means of this incision, go even to the depth of three inches; and if the aneurism is higher up still, it is to the primitive iliac that we must address ourselves,and no longer to the external iliac; while, on the other hand, the tissues being divided layer by layer, and torn rather than cut, as soon as Ave arrive at the deep aponeurosis, I do not clearly see hoAV we are to Avound the epigastric Avhich is behind. HoAvever, experience has shown that we may succeed by all these modes; and the mode to be adopted is, as I am aware, much more a matter of choice than one of necessity. Though the transverse incision, hoAvever, is ahvays sufficient Avhen the tumor does not extend beyond the crural ligament, it may not, never- theless, ansAver our purpose when the disease goes higher still; it is then for the skilful surgeon to make application of the process suitable to each particular case. VII. Consequences.—The blood is carried into the limb after the ligature upon the iliac artery, as after the ligature upon the femoral above the profunda, by means of the gluteal, ischiatic, internal pudic and obturator arteries ; and, moreover, by means of the epi- gastric and circumflex ilii, through their anastomoses with the in- ternal mammary, with the ilio-lumbar artery, and with the lumbar arteries ; the proximity of the urinary and genital passages, and of the peritoneum and loose cellular tissue of the iliac or lumbar re- gion, demand all the attention of the practitioner, and the most prompt reli«»f as soon as accidents show themselves in this region; accidents, hoAvever, Avhich have nothing special about them, and which are treated by the means generally known. [External Iliac.—Dr. Edward Peace of Philadelphia, tied the external iliac successfully at the Pennsylvania Hospital, Philadel- phia, for inguinal aneurism on the right side, July 24th, 1841, on a robust seaman, aged 28 years. The ligature was applied as high up as possible to alloAV sufficient space for the formation of a coagu- lum above the epigastric artery. The rapidity of groAvth of the aneurism, and the subsidence of the temperature of the diseased limb, at first beloAV, and its subsequent augmentation above that of ARTERIES OF THE ABDOMINAL LIMB. 155 the other, Avere noticed in this case as among the usual characte- ristics of aneuiisms in this region. (Philadelphia Med. Examiner, New Series, Vol. 1, 1842, p. 225—230.) Up to July, 1844, it is asserted, on good authority, (Archives Gen. de Med., Paris, Juillet, 1844, p. 384,) that the successful ap- plication of the ligature upon the external iliac artery, had been performed at Paris only four times, (see also Stances de I'Acad. Roy. des Sciences, at Paris' Juin 3, 1844, Op. cit.) During that year, M. Malgaigne (Ib.) performed it on a young laAvyer for a large aneurism in the left groin, Avhich extended as high up as the spine of the ilium. A single ligature only was used, and this came aAvay on the 16th day. At the expiration of about five Aveeks,the Avound Avas, for the most part, closed, Avhen a rupture of the aneurismal pouch suddenly took place into the Avound, destroying the granu- lations. This accident, hoAvever, did not prove serious, as the pa- tient, at the expiration of three months after the amputation, was enabled to resume his pursuits; and at the time the case Avas given by M. Malgaigne, (June 3d, 1844, above,) his general health was perfect, the left limb being nearly as large and strong as the other, and having nearly the same temperature, though no pulsation was felt in any of its arteries. The incision Avas nearly vertical, slightly inclining towards the umbilicus. Femoral Aneurism cured by a Ligature upon the External Iliac. —A perfect cure of an aneurism in the femoral artery, by means of a ligature on the external iliac, was effected at the City of Dub- lin Hospital, (Cormack's Lond. fy Edinb. Monthly Journal of Medi- cal Science, May, 1843, p. 477; also, Dublin Journal of Medical Science, Nov. 1842,) by Dr. Houston on a man aged 26, a car- driver, of somewhat intemperate habits, in June, 1840. The tumor was of a spherical shape, four or five inches in diameter, and situ- ated a little above the middle of the left femoral. The pulsation Avas diffused in every part, and Avith a distinct bruit, both of Avhich Avere completely arrested by pressure over the iliac. There were several dilated veins on the affected side of the abdomen. The mo- tion of the heart Avas natural. The patient ascribed the tumor to a bruise received about a year before. The operation Avas performed after the manner of Sir Astley Cooper, and a circumstance was noted Avorthy of remembrance, that when the tendon of the exter- nal oblique muscle was divided, there was a tendency to forcible closure of the wound by this muscle, Avith every exertion of the body, however trifling. The patient Avas very unsteady in this case, and at every movement he made, the edges of the divided tendon Avere drawn, and for a moment hid under the lips of the superficial Avound. It was almost impossible to keep them separate by retraction. A curious anomaly Avas found in a vein lying on the artery as large as the brachial, Avhich, though it has never, Dr. Houston asserts, been noticed by surgeons or anatomists, he has ahvays found present in this situation—being the internal circum- flex ilii vein. The companion of the artery of the same name, and deriving some branches frequently from the upper part of the thigh, 156 NEW ELEMENTS OF OPERATIVE SURGERY. this vein crosses the iliac artery obliquely, to empty itself into the . iliac vein, at a point varying from half an inch to an inch above Poupart's ligament. A portion of the anterior surface of the iliac artery, is therefore, he continues, occupied by the oblique cross- ing of this vein, at the spot at Avhich it is usual to apply the ligature ; and unless the precaution of excluding it be taken, it may, as Avas near happening in this case, be either Avounded or included with the artery in the noose. Therefore it is that Dr. Houston directs the attention of surgeons to this fact. In (he case in ques- tion, he found, after bringing up his ligature upon the inside of the artery, that it Avas beloAV the point Avhere this circumflex ilii vein terminates in the iliac vein. Avhile on the outside of the artery the ligature Avas above the point where that vein had first applied itself to the artery; so that, had the noose been secured, as it thus lay, the vein and artery must have been tied down together by it. The outer end of the ligature Avas accordingly draAvn down from under the circumflex vein before the knot was applied. The patient did well. On the next day, the left foot and leg Avere someAvhat cold, and there Avas no pulsation in the aneurism, and in the evening of the seme day, the temperature of the left ham was tAvo degrees less than in the right. Six ounces of blood were taken ; but why, the surgeon does not state. On June 26th, there Avas only one degree of difference in the temperature, and on the 28th, none. The patient Avas discharged cured on the 25th of the succeeding month. The very same interruption to the venous trunks in the neigh- bourhood, which caused regurgitation into, and distension or vari- cose engorgement or dilatation of the abdominal venous branches on the affected side, probably caused also the unusually large volume of the circumflex, which, from its comparatively insignificant size when normal, most surgeons, though perfectly aware of its ana- tomical position, have thought it superfluous to mention. Had the case occurred a couple of years later, Dr. Houston Avould probably have found the knife unnecessary, and adopted the popular mode of compression now so extolled in that capital. T.] Article IX.—The Internal Iliac (or Hypogastric or Pelvic) Artery. § I.—Anatomy. In separating itself from the primitive iliac on a level Avith the sacro-iliac symphisis, the internal iliac (pelvienne) artery imme- diately abandons the external iliac in order to descend almost per- pendicularly into the cavity of the pelvis. Its outer surface is crossed at its origin by the iliac vein, and accompanied in the rest of its course by the hypogastric vein Avhich separates it from the psoas muscle and from the articulation. On its inner side it is united to the peritoneum only by a cellulo-adipose layer Avhich is ahvays very loose ; some lymphatic ganglions are also adjacent to ARTERIES OF THE ABDOMINAL LIMB. 157 it (lui adosses) in this part. The ureter ordinarily passes above and a little in front of it; on the left the beginning of the rectum lies over it at a greater distance, and its relations Avith the ccecum on the right are scarcely deserving of notice. We cannot attempt to reach it except from its origin to Avhere it gives off the gluteal, that is to say, to the extent of from one to two inches, in a word, on a line with the great ischiatic notch; the ilio-lumbar Avhich it sometimes gives off in this part, and which then immediately runs outwardly and upAvard between the psoas muscle and the bones, should also be noted, though the primitive iliac artery or the exter- nal iliac, still more frequently perhaps give off this branch. § II.—Indications. The trunk of the internal iliac (hypogastrique) artery is too deeply situated to be often the seat of traumatic lesions, and too short to make it necessary that Ave should treat of the aneurisms Avith Avhich it might possibly be affected. Sandifort moreover is the only per- son Avho relates an example of this kind. It is no longer so Avith its principal branches. In leaving the pelvis they are still large enough for their Avounds or spontaneous rupture to be followed by dangerous hemorrhage; the gluteal artery especially, which ter- minates as it arrives between the muscles of the same name, and which cannot like the ischiatic and pudic be easily cut down to externally, has many times caused death in this manner. Theden relates a case of it. In dilating a gun-shot Avound the gluteal artery Avas divided and the unfortunate soldier soon after died. The same thing occurred in consequence of an aneurism in a patient mentioned by Jeffreys, (Scarpa, p. 407.) J. Bell (S. Cooper, Dic- tionary, trad., p. 146) Avas more fortunate ; he saved his patient by applying the ligature to the Avounded vessel. M. Ruyer (Bulletin de Ferussac, t. XXIV., p. 109.—Auger, Rev. Med., 1832, p. 395) has since published an analogous result, and in the course of the year 1817, M. Brooke (S. Cooper, Diet, de Chir., p. 147) cured, or at least so he thinks, an aneurism in the breech by compression, digitalis and laxatives. But nevertheless it cannot be denied that the ligature upon the artery is the only means upon which Ave can rely at least in most of the cases of ancient and deep aneurisms. § III.—Operative Process (on the Internal Iliac.) This operation Avas performed for the first time in 1812 by M. Stevens, (Trans. Med.-Chir., Vol. V., or Anderson, Surgical Anat., p. 148,) on a negro female who had an aneurism in her left breech of the size of a child's head, and Avho recovered perfectly. The woman died ten years after from another disease, and M. A. H Slovens of NeAV York, informs me that he saw at London the ana- tomical specimen corroborating the correctness of the assertions of the surgeon of Santa Cruz. However M. R. Owen, (Bulletin de Ferussac, t. XXVII., p. 162,) who has dissected and preserved the 158 NEW ELEMENTS OF OPERATIVE SURGERY. specimen, says that the aneurism Avas in the ischiatic artery and not in the gluteal, as had been supposed. On the 12th of May, 1817, M. Atkinson (Medical and Physical Journal, Vol. XXXVIII., p. 267) of York repeated the operation of M. Stevens, in the case of a waterman Avho Avas found in the same situation as the negress Maila ; repeated hemorrhages and an extensive suppuration caused death at the expiration of twenty days. Since then M. P. White (Journal des Progres, t. IX., p. 264) of Hudson, [State of New York,] Avas more fortunate in the case of a tailor aged sixty years; for the space of a month there was a great deal of suppuration, but the patient finally recovered. M. V. Mott (Gaz. Med. de Paris, 1837, p. 650) who attributes this case to M. Samuel White, says moreover that the internal iliac artery had already been tied suc- cessfully in Russia ; but I have not as yet been enabled to procure any details of the case. On the other hand I am happy in having it in my power to add that M. V. Mott (Gaz. Med. de Paris, 1837, p. 530-550. Hosack, Archiv. Gen., 1837) himself has performed this important operation Avith entire success, though he had opened into the peritoneum in endeavoring to lay bare the artery. A. M. Stevens first divided the integuments, aponeurosis and muscles to the extent of five inches, a little to the outside and in the direction of the epigastric artery. After having detached the peritoneum by pushing it imvardly, from the spine of the ilium to the division of the primitive iliac artery, he isolated the hypogastric trunk Avith his fore-finger ; he then applied the ligature upon it at the distance of half an inch beloAV its origin. B. M. Atkinson adopted the same method ; but the blood flowed so abundantly that he was obliged to introduce his whole hand into the iliac fossa to enable him to reach and tie the artery. C. M. P. White made upon the side of the abdomen a semilunar incision, seven inches long, Avith its convexity turned tOAvards the ilium, and which commenced in the neighborhood of the umbilicus and terminated near the inguinal ring. After having thus divided the whole thickness of the Avails of the belly, tied some arteries, and detached the peritoneum, he raised the trunk of the internal iliac with the handle of his scalpel in order to tie it at an inch below its origin, and afterAvards used sutures and adhesive plasters to unite the wound. D. As this operation is performed upon sound parts far from the disease, it is easy to practise it upon the dead body, and to assure ourselves that an incision of five inches, as M. Stevens made it, is sufficient—even preferable to that recommended by M. P. White, since it enables us to avoid all the branches of the epigastric, with- out our incurring the risk of wounding the anterior iliac artery. E. Process of the Author.—We should succeed full as well, in my opinion, by prolonging to two inches farther, the outer extremity of the incision, recommended by M. A. Cooper, for the ligature upon the external iliac artery. It is the process Avhich M. Anderson (Surgical Anatomy, etc., 1822, p. 145,) prefers, in order, he says, the more easily to avoid the peritoneum and to prevent the con- ARTERIES OF THE ABDOMINAL LIMB. 159 secutive hernia, which took place in a patient of Kirby, (Ibid., p. 148,) as Avell as in that of M. Stevens, according to M. Scott, (Ibid., p. 149,) who noticed it also after an operation by himself. But we do not see how the incision of Abernethey Avould protect us better from this inconvenience than any other incision. In whatever manner made, Ave should guard ourselves against attenuating (amincir) or denuding the peritoneum too much Avhile detaching it with the fore-finger. Having arrived upon the inner border of the psoas, we should make use of the fore-finger to sepa- rate the artery from the very large (enorme) veins which it partially conceals. We depress (incline) its root, as Avell as that of the ex- ternal iliac downward and tOAvards the centre of the pelvis ; then, by means of the needle of Deschamps or the S shaped needle of M. Causse, or a flexible sound having an eye near its point, Ave pass the ligature. The greatest degree of precaution is here necessary; the venous trunks must be respected with care ; their Avails are thin, and nothing is more easy than to tear them. In displacing the artery, Ave may rupture the ilio-iumbar, and bring on a danger- ous hemorrhage, (epanchement.) F. Consequences of the Operation.—The ligature in question, so formidable at first sight, is less serious in reality as to its influence upon the circulation than that upon the external iliac or the femo- ral only. In fact it leaves intact all the appropriate vessels of the corresponding limb, and the tAvo internal iliac arteries communi- cate with one another by anastomoses so large and numerous, that after the obliteration of the one the blood must be readily carried by the other to the viscera which they nourish. But it is danger- ous in another sense ; first from the difficulties themselves attend- ant upon the operation, and secondly from the dissections (decolle- ments) Avhich must unavoidably be made in the midst of an exten- sive cellular tissue where inflammation and suppuration are readily propagated to a great distance. Article X.—The Gluteal Artery. If the obliteration of the hypogastric artery has the advantage of curing irrespectively all aneurisms of the breech, Avhatever may be the artery Avounded, its manipulation is, in fact, so fearful that Ave should be fortunate Avere Ave enabled to substitute for it the ligature upon the diseased artery itself. Noav this appears to me practica- ble Avhere Ave are treating a diffused or a circumscribed aneurism, or a traumatic or a spontaneous aneurism, so often as the diseased portion of the artery is in the breech. In fact the gluteal artery on leaving the pelvis lies naked upon the anterior and superior border of the great ischiatic notch, so that Avere Ave obliged to open the tumor before reaching the origin (racine) of the vessel, it Avould still be a thousand times preferable to the ligature upon the internal iliac artery. There it Avould be easy to compress it and to cauterize it, and close it Avith the end of the finger. Nothing Avould prevent us at first from introducing a conical gum-elastic bougie into the 160 NEW ELEMENTS OF OPERATIVE SURGERY. Avounded artery, to arrest the blood and raise up the vessel until Ave should pass a ligature around it. Many surgeons, moreover, had already put these precepts into practice, so that the ligature upon the gluteal artery is no longer a new operation. Muzell (Rougemont, Chirurg. du Nord, p. 377,) speaks of a practitioner who had performed it with success towards the middle of the last century, on the occasion of a Avound in the breech. It has been performed since, and Avith like success, by M. Carmichael, (Gaz. Med. de Paris]) for a false consecutive aneurism. A patient operated upon in the same manner by M. Murray (ibid.) for a diffused aneurism, succumbed. The same ligature applied to arrest a hemorrhage in the breech, by M. Baroni, (Ibid., 1835, p. 695,) has, on the contrary, succeeded perfectly. Operative Process.—In the case of a recent wound the best plan would be to incise and dilate largely, in order to come doAvn upon the opening of the artery, and to reach it at the bottom of the wound. If it proved difficult to seize hold of it Avith the forceps, Ave might relieve ourselves of embarrassment by transfixing (en embrochant) it with the elastic rod (baguette) of which I have spoken. Thus closed and held, it would allow of being isolated and tied without any trouble. For a systematic process, applicable to cases of aneurisms properly so called, I know of none more ex- act or more easy than that of M. Lizars or M. Robert. Surgeons who have described or performed the operation of the ligature upon the gluteal artery, have limited themselves, says M. Robert to recommending an incision parallel with the fibres of the gluteus maximus muscle. This want of precision, taken in connec- tion with the extremely deep position of the vessel, has rendered the operation one of the most difficult that are performed. We arrive at something better by basing the operative process upon exact principle's of surgical anatomy. Now, the point from Avhich the gluteal artery leaves the pelvis in turning round upon the upper border of the ischiatic notch, is situated just at the middle of a line draAvn from the postero-superior spinous process of the ilium to the apex of the great trochanter. The patient being laid upon his belly, the surgeon first ascertains the position of the two boney projections Avhich I have just named, and which is ahvays practicable, seeing Avhat little thickness there is in the soft parts Avhich cover them. He then makes in the direc- tion indicated an incision of from four to five inches in length, an incision which is then parallel to the fibres of the gluteus maxi- mus. Setting out from thence the operator immediately passes his finger into the wound to identify the position of the boney border, against Avhich in a case of necessity he might compress the artery if the violence of the hemorrhage should satisfy him that it was necessary. Separating finally the pyriform and gluteus medius muscles, Avhose approximated borders conceal the gluteal artery, there remains nothing more than to isolate the vessel and to sur- round it Avith a ligature. If the transverse section of any muscular bundles would lessen ARTERIES OF THE ABDOMINAL LIMB. 161 the difficulties, Ave should decideupon doing itAvithout any hesitation. The almost utter impossibility of obtaining an immediate reunion in such cases, and the danger of seeing the pus or inflammation extend into the pelvis Avould induce me to fill all the incisions with lint and not to attempt to cicatrize the Avound but by second intention. [Lesions of the Gluteal and Ischiatic Arteries, and the ap- plication OF A LIGATURE UPON THEM FOR WOUNDS, ANEURISMS,&C M. F. Bouisson one of the Professors of the Faculty of Medicine at Montpellicr has recently in an interesting memoir (Memoire sur les Lesions des Arteres Fessiere et Ischiatique, et sur les Operations qui leur conviennent, in the Gaz. Med. de Paris, t. XIII., No. 11,p. 162, et seq., Mars 15, 1845 ; Mars 22, 1845, p. 180, et. seq., and Mars 29, 1845, p. 195, &c.,) called the attention of practitioners to the sub- ject of Avounds of the gluteal and ischiatic arteries, Avhich he thinks has been much neglected, from an impression in his opinion quite erroneous, that these deep-seated anatomical relations present al- most insuperable obstacles to the application of the ligature to their trunks in Avounds, aneurisms, &c. The Professor of Montpellier, considers that the emulous impulse created by the ligature success- fully applied by Abernethey upon the external iliac excited the am- bition and attention of surgeons, to direct their efforts upon still larger trunks in the splanchnic cavities; a ligature upon the hypo- gastric for example, or even upon the common iliac for aneurisms in the gluteal region, Avhich might have been relieved by confining the operation to the sound portion of the vessels themselves, impli- cated, rather than by undertaking the hazardous experiment of opening into the pelvis for the trunk of the common iliac, which is so variable in its length and divisions. M. Bouisson having made the gluteal and ischiatic arteries the subject of particular researches, Ave avail ourselves of his valuable remarks on their anatomical and surgical relations. Anatomy.— The arterial vessels of the gluteal region arise from the hypogastric or internal iliac, emerge from the pelvis through the ischiatic notch; and are two in number, viz., the gluteal and ischiatic The trunk of the internal pudic (honteuse interne,) does not belong to this region, but in a manner so to speak accidentally. In the erratic course described by this vessel, it makes a sort of de- monstration (une sorte d'apparition) of passing out of the pelvis but soon re-enters it. The gluteal and ischiatic are in an inverse relation to each other in size, a laAv which M. Bouisson has con- stantly observed in the prepared pelves submitted to his inspection Thus if the ischiatic is larger than usual, the gluteal is less &c • the gluteal however being the largest of the two in nine cases out of ten—its calibre being usually double that of the ischiatic—thus the gluteal has six millimetres before its division, Avhile the ischiatic at its point of emergence has but three. Hence the greater size of the gluteal makes it the most liable of the two to aneurisms These two arteries of the gluteal region constitute inferiorly the limits of 162 NEW ELEMENTS OF OPERATIVE SURGERY. the hypogastric region ; one situated on its posterior plane curves in such manner as to present its concavity backwards ; passes be- tween the lumbo-sacral nerve and the first nerve of the sacrum, and emerges from the pelvis at the most elevated part of the ischiatic notch, between the pyriformis muscle, and the border of the bone ; this is the gluteal or posterior iliac ; the other seems to retain the primitive direction of the principal trunk, undergoing considerable diminution from the numerous branches Avhich it gives off; it di- rects its course downwards and issues from the pelvis underneath the pyriform muscle, between that muscle and the gemellus supe- rior ; this is the ischiatic or inferior iliac. Three portions of both these arteries are to be distinctly noticed: 1st, the intra-pelvic ; 2nd, the point of emergence ; 3rd, the extra- pelvic. 1. The gluteal in its inira-pelvic portion has a very short trunk, for it proceeds immediately downwards, backwards and outwards to reach the ischiatic notch. Besides its connection here with the lumbo-sacral and first sacral nerves, as above stated, it is accompa- nied by the gluteal vein Avhich is situated in front of it, Avhile the gluteal nerve is upon its inner side. The peritoneum only indi- rectly covers these organs ; being separated from them by the cellu- lar tissue Avhich becomes more and more condensed in proportion to its proximity to the ischiatic notch. At this last point it forms a sort of arcade or semicircular ring (anneau cintre,) the concavity of which embraces the vasculo-nervous bundle, and the extremities of which attaching themselves to the osseous portion of the ischiatic notch, thereby form a complete ring. The fibro-cellulous portion of this ring does not offer the same resistance in all persons ; it marks the termination of a sort of passage which might be called the glu* teal canal, from Avhence protrude the viscera in ischiatic hernia. The gluteal artery furnishes muscular branches, and in certain cases gives origin to the ilio-lumbar, the sacro-lateral (sacree latir- ale,) and the middle hemorrhoidal (l'ht-morrhoidale moyenne.) We have seen it, says M. Bouisson, give off the internal pudic, and the ischiatic itself. The point of emergence of the gluteal artery, corresponds nearly to the middle of the curvature of the great ischiatic notch. It is im- portant to knoAV the precise situation of this point, because it is the only one where the trunk of the gluteal artery can receive a ligature. Therefore it is that the professor of Montpellier has determined the folloAving relations of the external projecting portions of the pelvis to this point, and Avhich he gives as the result of a particular exa- mination of many pelves on Avhich the arteries Avere prepared by desiccation : — Pelvis of an adult man. Right side. Left side. Distance from the point of emergence to the anterior superior spinous pro- cess of the ilium, llcentimet.lll 11 10$ U4 " the posterior, « 6 " 6 6 6 7 " the most elevated part of the crest of the ilium, " 10 « 10 10 9 10 ARTERIES OF THE ABDOMINAL LIMB. 163 Pelvis of an adult woman. Right side. Left side. Both sides. Distance from the point of emer- gence to the anterior superior spinous process of the ilium, 10^ cent. 10| 10 11 " the posterior " " 6 7 6 7 " the most elevated part of the crest of the ilium, 9 It results from these measurements that the gluteal artery ob- serves a sufficiently constant position in its point of emergence from the pelvis, and that its relations Avith the projecting processes of the pelvic border, differ but little in men and Avomen, so that Ave may almost Avith certainty know AvheretocutdoAvn upon the arterial trunk to seize and tie it. The gluteal artery outside of the ischiatic notch, has but an inconsiderable extent—ordinarily not over five millimeters (millimetres) before dividing itself suddenly into its terminating branches ; sometimes it terminates on a line Avith the osseous border of the notch. M. Bouisson however, has seen tAvo specimens at the Museum of the Faculty, (at Montpellier,) in Avhich it did notdi- vide till at the distance of two centimetres beyond the ischiatic notch. These variations have an important bearing on the appli- cation of the ligature to the vessel, Avhose depth at this point de- pends upon the embonpoint of the subject. When the trunk divides only at a certain distance from the osseous border it may be seized Avithout difficulty ; but the operation becomes much more laborious if it does not go beyond the thickness of the bone of the ilium on a line Avith the notch. Nevertheless it is always accessible, and M. Bouisson has never seen it give off its terminating branches in the interior of the pelvis. In one case only he has seen the gluteal ar- tery, give independently of its terminal branches, a branch of con- siderable size, which originated on a line Avith the pyriform muscle, passing just behind and then under this muscle, from Avhence it emerged outwards to be distributed to the external organs of the pelvis. At its point of emergence the posterior iliac artery is covered by the gluteus maximus muscle, a cellular fascia of considerable den- sity being interposed betAveen them. The gluteal vein is not con- stant in its relations to the artery ; but the Professor has generally observed that it is situated behind, and on its inner side ; its trunk continues in the latter direction, passes around the artery and takes a definitive position in the interior of the pelvis, Avhere it is situated in front of it. This vein sometimes, does not properly speaking, become a trunk until Avithin the pelvis, so that on a line Avith the extra-pelvic portion of the artery, it consists only of tributary bran- ches of moderate size, Avhose lesion Avould be of no consequence in applying the ligature to the artery. The superior gluteal nerve, which comes from the lumbo-sacral, is on the inner and posterior side of the artery. The gluteal artery, in its extra-pelvic portion, divides into tAvo principal branches, Avhich separate on a line Avith the posterior 164 NEW ELEMENTS OF OPERATIVE SURGERY. border of the gluteus minimus muscle; one is superficial, the other deep-seated. The first proceeds outwards, in the interspace betAveen the glu- teus maximus and the gluteus medius muscles, and distributes it- self by numerous branches into the thickness of these muscles and the tissues in their neighbourhood. Some of these branches anas- tomose Avith those of the ischiatic artery. The deep-seated branch divides from behind forwards, between the gluteus medius and mi- nimus muscles ; it supplies a small nourishing artery to the bone of the ilium, and then soon divides again into three secondary branches, the superior of Avhich describes a course parallel Avith the superior border of the gluteus minimus muscle ; the second more volumi- nous, crosses the track of this muscle, from Avhich it is separated by an adipose layer of greater or less extent, and then directs itself towards the great trochanter ; the third goes obliquely downAvards and distributes itself upon the capsule of the ilio-femoral articula- tion. These different branches, whose numbers may vary, furnish branches Avhich penetrate into the glutei muscles, Avhere they anas- tomose Avith each other, and Avith those of the ischiatic. Beyond the limits of the gluteal region they anastomose Avith the divisions of the internal circumflex iliac, or Avith those of the external cir- cumflex iliac of the thigh, so that the obliteration of the gluteal trunk in no respect endangers the nutrition of these parts. The branches of the posterior iliac artery in these terminations are, it is to be observed, more or less perpendicular to the direction of the fibres of the gluteus maximus muscle, a circumstance Avhich should be taken into consideration for the choice of the direction to be given to the incision, Avhen Ave Avishto cut down upon the gluteal artery. 2. The ischiatic artery considered in its intra-pelvic portion, is a continuation of the trunk of the internal iliac, supplies some small branches to the muscles and organs of the loAver pelvis (petit bas- sin,) descends backAvards and upon the sides of the rectum, and issues from the pelvis at one of the openings (intervalles) of the sacral plexus (plexus sacre.) At its point of emergence which takes place at the loAver part of the ischiatic notch, it is situated betAveen the pyriform muscle and the small sacro-sciatic ligament, at three centimeters beloAV the gluteal artery, on a plane more internal, and in the direction of a line from the posterior superior spinous process of the ilium to the tuberosity of the ischium. At this same point the artery is situated upon the inner and posterior side of the great sciatic nerve; the corresponding vein is upon the posterior and inner side of the artery, and partially (tend) turns round it to take a position in front of it in the pelvis. In this manner the ischiatic artery is situated between its corresponding nerve and vein, relations sufficiently con- stant, and Avhich must not be lost sight of in the ligature upon this vessel. The internal pudic Avhich arises frequently from a trunk common to it and the ischiatic, and Avhich Harrison has even seen furnished by the latter externally, is situated in front of it and upon ARTERIES OF THE ABDOMINAL LIMB. 165 its inner side, but soon leaves it to return into the pelvis. These different organs are united by dense cellular tissue, and covered by the gluteus maximus muscle. The trunk of the ischiatic artery externally to the pelvic cavity, has but little extent; it almost immediately gives off branches Avhich proceed in opposite directions : one terminating near the os coccygis furnishes small branches to the coccygeus and levator ani muscles; the other destined to the gluteus maximus, passes outwards and distributes itself to the inferior third of this muscle in the cellular tissue Avhich surrounds the tuberosity of the ischium, and furnishes also a small branch Avhich goes to the fossa of the trochanter to supply the muscles of this region. The third descends to the posterior part of the thigh, accompanying the sciatic nerve which receives in its substance some of its small branches. The ischi- atic, in its terminating branches, anastomoses Avith the circumflex of the thigh and the perforating arteries, so that it establishes com- munications between the hypogastric and femoral (crurale) arteries. These anastomosing resources re-establish the circulation inter- rupted by the ligature upon either one of these vessels, but espe- cially upon the last. In these cases the divisions of the ischiatic are dilated to a remarkable degree. Boyer (Traite des Malad. Chirurg., etc., t. IL, p. 73, 4e edit.) says he has seen in a case Avhere the femoral Avas obliterated for a popliteal aneurism, the divisions of the ischiatic so much dilated, that the small artery Avhich penetrates into the sciatic nerve had acquired the size of the radial. Wounds of the Gluteal and Ischiatic Arteries. The shortness of their trunks external to the pelvis, their deep seated position, and the remarkable protection they receive from their situation on the posterior part of the body, and the thick masses of muscle and other tissue which cover them, and the pro- jections of the solid bones of the pelvis by Avhich they are sur- rounded, are the reasons Avhy they are so seldom Avounded. This docs however happen from falls, surgical operations in those regions, and especially from fire-arms. According to Theden death Ava- the consequence of Avounding the gluteal during a surgical operation. Guthrie relates the case of Colonel Macpherson in whom death Avas thus produced, by extensive hemorrhage from the gluteal wounded by a ball in the hip, and which diffused aneurism might have been prevented by a timely ligature on the trunk. Wounds of the arteries of the gluteal region may cause diffused false aneurism, circumscribed false aneurism or aneurismal varix. External hemorrhage is rare, as M. Bouisson remarks, if the wound does not extend deeper than the external portion of the gluteus maximus, and is easily arrested by compression. If the Avound however goes through this muscle, even the trunks them- selves may be divided and produce a copious hemorrhage. The anatomical relations indicate to the surgeon Avhat mischief the wound has made. If the Avound corresponds to the inferior third 166 NEAV ELEMENTS OF OPERATIVE SURGERY. of the gluteus maximus, it is to be presumed that the ischiatic artery or its branches have been divided. As the hemorrhage from this artery, owing to its smaller size, is less serious, compression may generally be relied upon, the small sacro-sciatic ligament behind it offering also an excellent point d'appui for pressure. If the wound is below and on the inner side of the sacro-sciatic spine, it may be presumed that the internal pudic is injured, and here compression is still more effective upon this bony prominence which Travers (vid. Harrison on the Surgical Anatomy of the Aiteries, Vol. II.) used in a desperate case Avith great success. If the Avound corresponds to the upper half of the gluteus maxi- mus muscle, and especially if on a line Avith the osseous border of the ischiatic notch, the branches of the gluteal artery or the trunk itself may be implicated if the instrument has penetrated deep, and the injuries to which are so much the more dangerous because this trunk being very short and lying under the ischiatic notch, affords no point d'appui for pressure. The hot iron may be used but the ligature is to be preferred. M. Bouisson relates in practical illustration of his valuable memoir, the case of a woman aged about 40, Avho on May 31, 1842, received three severe wounds in this region from a shoe- maker's knife inflicted by her husband. The surgeon called in soon after and found her bathed in blood, pale and exhausted. On the middle part of the left gluteal region he discovered a wound of three centimeters in length and still greater depth, from Avhich arterial blood freely issued. Hastening to sponge the bottom of the wound he soon reached the gluteal artery Avhich Avas found to have been divided near the bony border of the ischiatic notch: a liga- ture was applied to it and the hemorrhage ceased immediately. The lips of the Avound Avere brought together by adhesive plasters, and the Avhole supported by a compressing bandage. The other two wounds were found to be of no importance. The patient hoAvever continued greatly exhausted for six days, Avhen by means of stimulating treatment reaction took place and the parts soon after cicatrized perfectly, the ligature coming aAvay on the 8th day. An acute pain however Avas noAv felt at the lower angle of the wound, and radiating from thence in the course of the sciatic nerve and its divisions, gave reason to fear that the trunk of this nerve or its branches had been wounded. On the 12th day this pain Avas so intense as to deprive the patient of rest, and to excite a high fever and involuntary retraction of the limb of the affected side, indicative of traumatic neuritis. Acetate of morphine alone relieved the intense suffering, and in a month she Avalked about perfectly restored. Death Avould have undoubtedly ensued, he thinks, in this meagre subject, Avith an open, unobstructed wound, had not timely assist- ance arrived ; the smoothness of the track made by the sharp in- strument, facilitated the application of the ligature which Avas placed around the artery immediately above the division of the trunk,the latter having been Avounded precisely at the point where it is about ARTERIES OF Tim ABDOMINAL LIMB. 167 to give off its terminal branches. A single ligature Avith the for- ceps and tenaculum sufficed for the operation. M. Bouisson thinks the forceps of MM. Jules Cloquet, and Colombat, and Avhich have been called pinces-yorte-ligature (or ligature-forceps) might be used Avith advantage. Among the accidents that may ensue from the application of ligatures in these regions, says M. Bouisson, we may mention ab- scesses, or if only one ligature is used, the re-establishment of the hemorrhage from the free anastomoses of the branches of the glu- teal with one another, or with the ischiatic itself, which last acci- dent makes it advisable to apply a ligature on each end of the cut vessel. In illustration of this, M. Bouisson cites the case of Professor Baroni, of Bologna, (Bulletino delle Scienze Mediche, 1S35,) Avhere a peasant, aged 22 years, falling from a tree, struck his right gluteal region upon his sickle, making a deep Avound on the inferior por- tion of the gluteus maximus, and exposing the sacro-sciatic liga- ments and the os innominata. The hemorrhage Avas soon arrested, and the wound In-aled by first intention. But in a few days fever supervened, and a collection of pus formed, Avhich Avas evacuated, but followed on the fourteenth day by two successive and danger- ous hemorrhages. Though these Avere suspended by compression, M. Baroni deemed it. advisable to lay bare the Avounded trunk, upon each of the cut extremities of Avhich vessel a ligature Avas readily applied, and the hemorrhage definitively arrested. Diffused Hemorrhagial Tumor.—There is no artery, according to M. Bouisson, Avhose lesion more frequently leads to the formation of false primitive aneurism, than the gluteal. The depth of the vessel, its volume, and the impossibility of making exact pressure upon it, together with the arrangement of the muscular layers, all concur simultaneously in facilitating the infiltration of the blood, and its reunion into a vast collection. Should there be ever so little difficulty for the blood to make its escape outwardly, by reason of the narrowness or obliquity of the Avound, or those two circumstances united, it insinuates itself under the gluteus maximus muscle, Avhich it gradually raises up so as to form sometimes a tumor of immense size. The Professor of Montpellier gives to Jno. Bell the credit (Trait, des Plaies, trad, du Professeur Estor, p. 105, et suiv.) of having been the first to point out, in a clear manner, the danger of the hemorrhage, and the difficulties of the operation for this false aneurism in the gluteal artery. He thinks, however, that the illus- trious English surgeon has sorneAvhat exaggerated the danger of the operation, and that, if prompt surgical means Avere immediately had recourse to in Avounds of this artery, the hemorrhage would rarely accumulate to the enormous quantity of eight pounds of blood, Avhich Bell asserts it sometimes does; nor Avould the opera- tion, if performed in time, require the frightful incision of two feet, which that surgeon made in one case, and Avhich necessarily endan- gers the exfoliation of the ilium. False Circumscribed Aneurism.—However favorable the arrange- 168 NEW METHODS OF OPERATIVE SURGERT. ment of the tissues on this part are to extensive effusion of the blood, compression properly made Avill, by bringing the layers of these tissues into closer contact, prevent the hemorrhage from dif- fusing itself into their interstices, and thus frequently establish limits to its progress, and give rise to the formation of a sort of aneurismal- sac. A pulsation will then be perceptible to the hand and ear, and a peculiar bruit synchronous with the dilatation (or expansion) of the tumor. As an example, he quotes a case of this kind : Master West, aged 17, operated upon and cured by M. R. Carmichael, in 1833, (See Gaz. M'.d., 1834; Dublin Journal, fyc.) From the success of this case by M. Carmichael, M. Bouisson dates the reception of the operation of a ligature on the gluteal as one that has been recognised as practicable. In pointing out the fact, however, that the development of the tumor proceeds to so much greater extent downwards than in any other direction, and that the artery may be left accessible at only half an inch depth from the surface of the integuments, he deduces therefrom, as it appears to us, a valuable argument in favor of a transverse incision on a level with the border of the ischiatic notch, in preference to making it, as M. Carmichael did, in a direction parallel Avith the fibres of the gluteus maximus muscle; for, in the former case, M. Bouisson has frequently ascertained on the dead body, that Ave may easily avoid opening into the sac, and crowd it,in fact, doAvnwards and out of our way, while in the latter Ave can scarcely escape from penetrating into the tumor, and thus recurring to the ancient process, obvious- ly he might have remarked, more dangerous at this artery, because of the impossibility of making pressure upon the vessel on the car- dial side of the tumor. Varicose Aneurism, (Aneurisme Variqueux.) The position of the gluteal vein being closely united Avith, and more superficial than that of the artery, favors, of course, the production also of a vari- cose aneurism. [For this kind of aneurism, see the excellent prac- tical observations of M. A. Berard, in our note under the Veins. T.] Generally, this vein, Avhich in some persons is of considerable size, is found on the posterior and inner side of the artery, so that it may possibl)'" be Avounded by the instrument if Ave penetrate to any depth. In a subject upon Avhich he Avas making experiments Avith the ligature, he accidentally met Avith a varicose dilatation of the gluteal vein of the size of a nut, and completely covering the ar- tery, so that the vein Avould necessarily have had to be Avounded in tying the artery. The ischiatic artery may also be subject to the forms of aneurism described, and also to an aneurismal vnrix,(nne variceaneurismale,) as shown in the following case, described by Professor Riberi, of Turin: (Gaz. Mid. de Paris, 1838:)—A peasant, aged 25, Avas Avounded in the year 1832, by a small sickle on the right breech, opposite the ischiatic notch, and on the track of the ischiatic artery. The hemorrhage was arrested by compression, and in four- teen days the wound perfectly cicatrized, but left a pulsation in the part, Avith pain in walking, and gradual enlargement of that breech, ARTERIES OF THE ABDOMINAL LIMB. 169 Avhich obliged him to enter the hospital a year after. This breech Avas a third larger than the other. When placing the finger on the cicatrix and on the osseous border of the notch, at some lines Avithin this opening, a distinct pulsation Avas felt to the extent of three or four lines; and also obscure diffused pulsations throughout the whole of the breech, Avith a sensation of murmur (fremissement) and tre- mor, (tremblement,) both radiating from the notch. Two venesec- tions, ice to the part, and compression by the tourniquet, in three months dissipated the pain, the tumor, and the pulsations, except that the latter Avere still felt at the cicatrix. Pressure Avas applied directly to this part, and the patient returned home and remained there three years. In the summer of 1838, the patient returned to the Clinique Avith the tumor and pulsations to the same extent as at first, but without pain, and complaining only of a numbness of the limb. Compression Avas had recourse to by means of a truss and suitable pelote, and relief again obtained Avhen the patient left the hospital, Avithout being operated upon. This case is briefly alluded to by M. Velpeau, (p. LVI. of the Appendix prepared to Vol. I. of this Avork; vid.,) as undoubtedly one of aneurism proper of the artery itself; but as it did not reach M. Velpeau until the text of his Avork Avas put to the press, we have thought it advisable to insert the details in this place. The term varice aneurismale, Avhich is the phrase made use of in the case as reported in the Gaz. Medicale of Paris, 1838, means, or should mean, as will be seen by a reference to our note already alluded to on M. A. Berard's paper, (see under Veins, infra.,) quite a different thing ; though it is undoubtedly understood by M. Bouis- son, as Ave see by the caption above, under Avhich he places it, to mean varicose aneurism. The contradictory use of these phrases leads to much confusion and to errors, Avhich Avould not happen if authors Avere as explicit and lucid in defining the true surgical anatomy of parts as M. A. Berard has been. Spontaneous Aneurisms of the Gluteal and Ischiatic Arteries.— M. Bouisson has seen six cases of these, four on the left and two on the right breech. The causes are obscure—sometimes they occur Avithout any apparent cause, at other times from contusions or from the efforts made in evacuations by stool. Their progress is slow, especially Avhen all the coats of the artery have not been simultaneously injured to the same extent. It is often some time before ihe patient himself is aware of their existence; Avhich is finally disclosed by a circumscribed pulsative tumor under the skin in the middle of the gluteal region. Then follows pain in the part, Avith numbness and difficulty of motion in the lower extremity on the side diseased, in consequence of the pressure made by the tumor on the sciatic (sciatique) nerve. The tumor may remain stationary for years, as occurred in a physician whose caseWas communicated to M. Bouisson by his colleague, M. Dubrueil. At other times they go on increasing until they end in death, by the usual termi- nation of all aneurisms in rupture, or death may ensue from the 170 NEW ELEMENTS OF OPERATIA'E SURGERY. interference Avhich the pressure of the tumor causes Avith the inner- vation and nutrition of the limb. The diagnosis is exceedingly obscure Avhen the tumor is not large, because it is next to impossible to make behind the tumor pressure of the short trunks of the arteries in question, against any firm support; Avhile no satisfactory information can be obtained by compression of the capillary circulation on the distal side, because the arterial trunks in question break up so rapidly in their minute distribution. From the proximity of the two trunks also, an aneu- rism of the gluteal artery has, he thinks, in two instances, been mis- taken for an aneurism of the ischiatic, one that of M. Stevens, the other M.Ruyers. Thiserror,however, proved of no importance in a case Avhere the hypogastric artery Avas tied. A cystous or an erec- tile tumor also, situated over these trunks, and receiving their pulsa- tions, may also erroneously lead to the supposition that an aneurism exists. So, also, an abscess slowly formed in this region, may cause a similar error ; Avhile, on the other hand, a true aneurism may be mistaken for an abscess, as noticed in the case by White, Avhere the aneurism, being opened, discharged a pint of blood, and rendered it necessary to place a ligature on the internal iliac. The Journals mention a recent, case, (Ann. de la Chir. Frang. et Etrang., Mai, 1843, p. 116,) where an eminent surgeon of London tied the primi- tive iliac in a patient Avho Avas supposed to have gluteal aneurism; but in Avhom death, Avhich took place eight months after, disclosed the fact that it Avas an cncephaloid tumor. M. Bouisson furnishes, in illustration of his remarks, the two following interesting cases Avhich have recently occurred under his OAvn observation : — 1. Aneurism of the Left Gluteal Artery cured spontaneously.— Autopsy.—This case Avas that of a Avoman Avho died at the Maison Centrale, at Montpellier, in the Avinter of 1842. No particulars could be obtained of the previous condition of the patient. Exter- nally, there was no cicatrix or appearance of aneurismal tumor in the gluteal region in question. The embonpoint of the patient may, in part, have concealed any appearance of tumor. Upon in- jecting the arteries of this patient, a circumscribed aneurismal tumor, in the course of the dissection, Avas found upon the extra-pelvic portion of the gluteal artery. It Avas of the size of a pullet's egg, flat- tened a little from before backwards, in the direction of the pyriform (pyramidal) muscle, and sacro-sciatic ligaments, which it covered. Its base was situated downwards, while above it Avas attached by a pedicle of a centimeter in diameter, to the extremity of the trunk of the gluteal artery, at the point Avhere this vessel furnishes the terminal branches which are distributed to the muscles of that re- gion. The gluteal artery itself Avas of considerable size, and ex- tended two centimeters, at least, beyond the upper border of the ischiatic notch ; so that it might have readily been included in a ligature, if the progress of the aneurism had rendered an operation necessary. The tumor evidently shoAved that it was an aneurism which had ARTERIES OF THE ABDOMINAL LIMB. 171 been cured spontaneously. The Avails of the sac Avere thickened, and contained here and there cartilaginous plates or calcareous granulations. The narrow portion by which it was adherent to the arterial trunk, Avas plugged up by clots of blood and organized lymph; nevertheless, the artery itself was not only not obliterated at this point, but on the contrary dilated, as Avere also the branches which Avere given off from it. The branches of the gluteal artery were, in fact, in that remarkable condition described by M. Bres- chet, under the name of cirsoid (cirsoide) dilatation, or arterial varix, (varice arterielle.) The obstruction in the neck of the aneu- rism Avas so complete, that the injection Avhich distended the trunk and the divisions of the gluteal, had in no degree penetrated into the cavity of the tumor. In opening this latter, M. Bouisson found it completely filled Avith fibrinous layers, (couches fibrineuses) still retaining the color of the blood, but Avith appearances of a new organization, Avhich had acquired considerable density, and pre- sented very evident osseous granulations. The surrounding organs Avere normal, and the hypogastric artery had its usual arrangement. This case, M. Bouisson remarks, presents the rare instance of the spontaneous cure of an aneurism, Avithout obliteration of its connecting arterial trunk ; Avhich result, in this case, he thinks was OAving to the tumor being turned downwards, and making no pres- sure on the terminal branches of the gluteal artery. In one part, the tumor appeared to be flattened and compressed betAveen the gluteus maximus muscle and the organs Avhich fill up the space of the is- chiatic notch, (l'echancrure iliaque,) Avhich compression between the two layers, one muscular, and the other fibrous layers, contri- buted^. Bouisson thinks, to the spontaneous cure. The pathological arrangement of the parts here also shoAVS the preference Avhich should be given to the transverse incision, had an operation been required. 2. The other case Avas that of M. Ruyer, already mentioned, Avhere an aneurism of the left ischiatic artery was mistaken for one of the gluteal. As this was published in the Revue Medicale, 1832, and is known to the profession, Ave shall briefly state that it occurred from contusions in a Avoman of robust constitution, aged 66. This neglected case, finally, after years of suffering, terminated in death in 1826. The tumor had acquired an immense size, being 21 inches in circumference, and filled Avith blood and pus. Its pressure had almost totally destroyed the three glutei muscles. The primitive iliac had here and there traces of ossific matter. The gluteal artery lay in its natural position at the bottom of this vast cavern, Avhere its calibre Avas so enlarged as to admit the index finger, Avhile the Avails of the extra-pelvic ;ortion of this trunk at an inch outside the pelvis were healthy. The artery is supposed in reality to have been the ischiatic. M. Bouisson, after revieAving tie four Avell-knoAvn cases of liga- ture upon the hypogastric or internal iliac artery for aneurisms in the gluteal region, by Messrs. Sievens, Atkinson, Pomeroy White and Mott, gives it as his decided opinion in accordance Avith our 172 NEW METHODS OF OPERATIVE SURGERY. author, M. Velpeau, (in the text above,) that notwithstanding the successful issue in three of the cases out of the four, the operation is of too hazardous a nature to be repeated. Among other objections connected with this operation, such as peri- toneal inflammation, and abscesses in the pelvic cavity, he mentions also the anomalies which particularly characterize the course and distribution of this artery, as is noted by Meckel, (Manuel d'Anat. Gentr., fyc.,) M. Theile, (Angeilugie, Encyclopedia Anat., t. III., p. 530, et suiv.,) and M. Is. Geoffroy Saint-Hilaire, (Hist. Gin. et Partic. des Anomalies de I'Organ., t. I., p. 456, et suiv.,) where will be seen that there is no branch of this artery, so to speak, Avhose place of origin is not subject to variations ; and as most of these branches have considerable size, the point at Avhich they are given off from the trunk of the hypogastric cannot be a matter of indiffer- ence in the application of the ligature. It is easy to perceive that if this is placed immediately below the abnormal insertion of a con- siderable sized branch, the obliteration of the trunk will be rendered difficult,and the patient operated upon Avillrunthe risk of a hemor- rhage so much the more dangerous as the vessel is situated at a greater depth, and Avhich cannot be arrested but by means that are exceedingly uncertain. This he thinks Avas the cause of the con- secutive hemorrhage which proved fatal in the case of M. Atkinson. The trunk of the hypogastric is extremely variable in its calibre, and especially in its length, and its direction also is very irregular, all Avhich facts M. Bouisson has been enabled to verify by a great number of specimens in the museum of the faculty of Montpellier. Its length varies even from 2 to 10 centimeters. In a preparation made by M. E. Delmas, of Montpellier, M. Bouisson remarks, that on the right, the two arteries, external iliac and hypogastric, preserve their normal relations, but are changed in texture and contain osseous plates. The tendency to ossification in the hypogastric arteries had been noticed by Haller, and since by Sandifort who mentions (Fabulce Anatomicce, Sf-c, Leydcn, 1804) a remarkable case of this kind, followed by aneurism. On the left side, in the speci- men of M. Delmas the relations of the two arteries are reversed, their curvatures being in an opposite direction, and placed in such man- ner that the hypogastric is in a certain portion of its length in front and to the outside of the external iliac, an arrangement analogous to that Avhich exists in the normal state, in the origin of the internal and external carotids, and which might have led the operator into an error by inducing him to tie the external iliac in place of the hypogastric. M. Bouisson does not. absolutely deny that there may be cases when the hypogastric artery should be tied for aneurisms in the gluteal region ; but he wishes to dissuade from such opera- tions Avhenever it is practicable to lie the gluteal or ischiatic, and this he thinks may be generally done Avith success by tying the cardial portion or both ends of the Avounded vessel" if the tu- mor is but slightly developed, and if there is immediate hemor- rhage, and the operation is performed as soon as possible after the ARTERIES OF THE ABDOMINAL LIMB. 173 injury is received. If the arterial lesion is purely local we may tie the vessel beyond [au-dela, i. e.,on the distal side of) the aneurism. The cardial operation on the retro-pelvic trunks is especially indi- cated, and of incontestible advantage in traumatic aneurisms of that region, particularly Avhere the branches of these trunks are the seat of the aneurismal tumor, (i. e., false diffused or false circumscribed aneurism.) Manual of the Operation for tying the Gluteal Artery.—Process of M. Bouisson.—After repeated trials on the dead body, the pro- fessor of Montpellier is satisfied that the method of Harrison, (Sur- gical Anatomy of the Arteries, vol. II., No. 93, Dublin, 1829,2d ed.,) that of making the incision parallel Avith the fibres of the gluteus maximus muscle, though hitherto universally adopted, is defective, particularly in fat persons Avith thick muscles, not only because of the depth Ave are then obliged to go, and that their separation by this kind of incision is, in consequence of the retraction of the mus- cle exceedingly difficult, but also because Ave are more likely to wound not only the gluteal vein but the branches of the gluteal and ischiatic arteries, and the ramifications of those arteries, inas- much as their general course is transverse to the fibres of the mus- cle in question. A fortiori the transverse incision is infinitely pre- ferable, enabling us to save those arterial branches, and, moreover, the fibres thus divided transversely, separate Avider apart, while modern surgery, especially the operations of M. Jules Guerin, have established indisputably that the thickest and widest muscles, di- vided through and through, readily unite by the fibro-plastic mate- rial analogous to muscular tissue, deposited in the division, and soon re-acquire all their primitive functions. The surgeon should bear in mind the point of emergence of the gluteal artery, Avhich is at the most elevated part of the ischiatic notch at eleven centimeters from the antero-superior spinous pro- cess of the ilium, six centimeters from the posterior superior spinous process, and ten centimeters from the most elevated part of the crest of that bone. The patient being placed on his belly, the surgeon makes a transverse incision of 6 or 7 centimeters in extent, the middle of Avhich corresponds to the point of emergence of the ves- sel. This incision divides the skin, cellular tissue and gluteus maxi- mus, and lays bare the aponeurosis in a line Avhich is tangent to the curve of the ischiatic notch. The borders of the Avound being kept asunder, the aponeurosis is divided by a grooved sound a lit- tle below the artery, Avhose pulsations are readily perceptible in tracing the osseous border of the ischiatic notch. The surgeon, provided Avith a grooved sound slightly curved and pierced at its extremity Avith an eye through which the ligature passes, cau- tiously separates Avith it the cellular tissue which encloses the bun- dle of vessels, pushes the vein or the veins, where there are several, backwards, and the nerve inAvards, insinuates the beak of the sound between these organs and the artery, and raises the last under the osseous border of the ischiatic notch. The extremity of the sound must be made to go down sufficiently deep, in order to be sure of 174 NEW METHODS OF OPERATIVE SURGERY. seizing the arterial trunk; otherwise Ave may run the risk of includ- ing only one of its divisions, (See a case of this kind related by Malgaigne, Anat. Chirurg., t. II., 1S3S,) and miss the trunk itself. The transverse incision, it will be found, gives an infinite deal of facility to these manipulations. The gluteal is stated by Muzel (Medicinische und Chirurgische Wahrnehmungen, Berlin, 1754, 64 a 72, in octavo,) to have been first tied by a surgeon in the middle of the last century, and not again until by Jno. Bell, in 1808. Manual of the Operation for Tying the Ischiatic Artery.—Process of M. Bouisson.—Though often wounded and the seat of aneurisms, M. Bouisson knows of no case in Avhich a ligature has been applied to it; though this can be done, he thinks, Avith even more ease than upon the gluteal. Lizars and Harrison recommend an incision similar to that for the gluteal, though the latter remarks that it should be an inch and a half lower down. Chelius attributes also to Zang the recommendation of a small incision parallel to the fibres of the gluteus maximus, but external to the tuberosity of the ischium, by Avhich Ave arrive at the external border of the tubero-sacral ligament and find theischiatic artery on the ischio-sacral ligament. M. Bouisson has frequently reached the ischiatic artery by means of the same transverse incision, Avhich he recommends for the glu- teal. The ischiatic artery emerges from under the pyriform (pyra- midal) muscle, precisely at the middle of a line draAvn from the postero-superior spinous process of the ilium to the tuberosity of the ischium. A transverse incision of six centimeters in extent should pass through the point indicated, going through the skin, cellular tissue and gluteus maximus. The artery is found on the inside of the sciatic nerve, and the vein on its posterior and inner side, Avhen the former is carefully separated and raised up in the manner described for the gluteal. The same incision Avould answer for the internal pudic, Avhich is situated at a few millimeters from the inner side of the ischiatic. Process of M. Diday for Ligature upon the Gluteal Artery.—The interesting researches of M. Bouisson have given occasion to M. Diday, (See his letter to M. Guirin of the Gazette Med. of Paris, April 5,1845, t. XII., p. 219,) to recala process for tying the gluteal artery Avhich suggested itself to him when he Avas a student of anato- my, and which he states to have been as follows :—The patient, being placed upon his belly, a thread is stretched from the point of the coccyx to the most elevated point on the crest of the ilium about two inches behind the antero-superior spinous process of that bone. From the middle of this thread, a point easily determined by dou- bling the thread upon itself, draw an imaginary perpendicular line. This perpendicular indicates the direction to be given to the in- cision in order that it may fall in a line with the fibres of the gluteus maximus. The gluteal artery emerges from the pelvis exactly at the point of intersection of these two lines. In other respects M. Diday proceeds after the manner of Harrison, but totally condemns as obscure and uncertain his geometrical diagrams of lines, points ARTERIES OF THE ABDOMINAL LIMB. 175 and measurements for determining the exact locality of the artery. M. Diday's process, the originality of Avhich lies in the anatomi- cal rules by Avhich Ave are to recognise the true position of the gluteal artery, and not in the process of the operator, is favorably mentioned by M. Petrequin, (Traite d'Anatom. Medico-Chirurg. et Topog., p. 655,) Avho, Avhile himself proposing a neAV method, remarks, however, that by folloAving the interlineations of M. Diday Ave should run the risk of falling someAvhat .in advance of the artery. Inasmuch as the points and lines designated may help to a cer- tain extent to identify Avith greater precision the true position of the artery, but Avhich from the diversity in the anatomical relations of the pelvis being as infinite as the individuals of the human species itself, never can be mathematically arrived at, Ave have thought it ad- visable to eive above the rules as laid doAvn by M. Diday ; but the transverse incision afterwards, according to the process of M. Bouis- son, is, in our view, sustained by such unansAverable arguments, that it should always have the decided preference. T.] Article XI.—The Primitive Iliac Artery. § I.—Anatomy. There are two circumstances that cause a variation of length in the common iliacs : 1, in place of the fifth, it is very often on the body of the fourth lumbar vertebra that the aorta bifurcates ; 2, the trunk (racine) of the secondary iliacs may be found much nearer than usual to the sacro-vertebra I angle ; 3, one of the primitive iliacs may be longer than the other, and that because the trunk, (i. e., the aorta,) from Avhich they arise, is not always found on the median line. Their length, however, apart from some exceptions that are sufficiently rare, hardly ever varies more than from three or four lines to an inch. They rest (sont appuyees) upon the side of the sacro-lumbar angle, the Avings of the sacrum, and against the inner side of the psoas muscles. On the right, the vein is outside and then behind;. on the left, op the contrary, it lies upon the in- side, and does not arrive there until after having passed under the root of the arterial trunk on the opposite side. The peritoneum alone covers them; so that in thin subjects it is still more easy to compress them than the external iliacs, provided however Ave have taken care to separate the mass of small intestines from them. § II.—Indications. Bogros opened, in my presence, a subject Avhose primitive iliac had been Avounded by a pistol-ball, thirty-six hours before death. M. Gibson relates a similar fact, and it is easy to conceive, that aneurisms may extend from the two secondary iliacs, as far as to the common iliac, and even attack the latter the first. 176 NEW ELEMENTS OF OPERATIVE SURGERY. It required no little boldness to undertake to obliterate an arterial trunk of such size, approximated so near to the aorta, and so deeply situated. Where the external iliac is wanting the blood passes into the limb by the internal iliac ; Avhere one hypogastric is Avanting the blood is furnished by the other, but Avhat can replace the common iliac ? Hoav deprive an entire fifth of the body of sanguineous circulation, Avithout causing its death ? Many sur- geons at first believed the thing impossible. At present it is no longer a question; practice has ansAvered in the affirmative ; and if refrigerants, depletives, relaxants, and digi- talis should have failed, and if the aneurism should have ascended so high as to make the ligature upon the external iliac uncertain, or insufficient, and forbid the employment of the method of Brasdor, then the ligature upon the primitive iliac should be made trial of as a last resource. M. Gibson (Medical Recorder, vol. III., p. 185) performed it un- successfully for a wound in the case I have mentioned above, but it quickly terminated in death. But the Professor V. Mott, (American Journal of Medical Sciences, Nov. 1827,) Avho Avas the first to per- form it according to precise rules, on the 15th of March, 1827, for an aneurism of considerable size, saved his patient; neither hemor- rhage nor gangrene supervened, and the individual Avas enabled to resume his customary occupations. In the year following, M. Crampton, (Med. andPhys. Journal, January, 1831,) desirous of imi- tating the skilful practitioner of New York, was not so fortunate; his patient died from hemorrhage on the fourth day. The case, nevertheless, Avas in effect one of very great importance. The cir- culation, heat, and sensibility, momentarily suspended, had been completely re-established in the limb ; everything promised a neAV triumph, Avhen the ligature appeared to have got displaced, and an internal hemorrhage came on, Avhich destroyed these favorable an- ticipations ; on opening the body, the circumstances Avere such as to lead to the belief, that the ligature of animal substance, Avhich M. Crampton had used, (Arch. Gen. de M d. t. XXV., p. 561,) had been dissolved, or ruptured, before having obliterated the artery. The authenticity of these two operations is, moreover, sufficiently guaranteed by the name alone of the authors; one enjoys a repu- tation and a celebrity justly appreciated in America and by all Eu- rope, the other is at the head of a public establishment and hospital in England. [Dublin, in Ireland. T.] In addition to all Avhich, many other repetitions of the operation since 1831, the epoch Avhen I Avrote these lines, have made the ligature upon the primitive iliac artery a common occurrence, Avhich is no longer looked upon as extraordinary. Though a Avounded horse, on Avhich M. Gedding (Jour, des Conn. Med.-Chir., t. III., p. 42S) performed this opera- tion, died on the sixth day, of peritonitis; a patient Avhom M. Leuret saw at the hospital of the Surgical Academy of St. Petersburg, and the details of Avhich have been published "by the operator, M. Sa- lomon, (Gaz. Med.de Paris, 1837, p. 598-650,) recovered perfectly. A celebrated surgeon of London, M. Guthrie, had no hesita- ARTERIES OF THE ABDOMINAL LIMB. 177 tion in performing it. Unfortunately, the six lines that M. Han- cock (Velpeau, Anat. Chir., trad. Angl., p. 239) has devoted to the description of the case, though he says he attended to the progress of the case, do not explain, with sufficient clearness, Avhat was the result. § III.—Operative Process. As to the process to be folloAved, it is exactly the same for the common iliac as for the external iliac. M. Mott commenced his incision on the outer side of the inguinal ring, half an inch above Poupart's ligament, and carried it to above the superior spinous process of the ilium, giving it a semicircular direction, and an ex- tent of about eight inches. That of M. Crampton, also, of a semi- circular form, the concavity tOAvards the umbilicus, and the length about seven inches, extended from the last rib to the antero-supe- rior portion of the crest of the ilium. Both detached the peritoneum with the fingers, and nothing occurred to lead to the belief that they found any great difficulty in seizing or tying the vessel. In these cases the circulation of the blood is re-established by the anastomoses of the internal mammary, and of the epigastric, with the lower lumbar arteries, and the anterior iliac, or even the ilio- lumbar, and also the anastomoses of the hypogastric artery and other branches upon the sound side, with those of the diseased side. [See Remarks of Dr. Mott, infra, on Aneurisms, and also a note under the same, on the Ligature of the Primitive Uiac. T.] Article XII.—Abdominal Aorta. § I.—Anatomy. Situated in front of, and a little to the left of the bodies of the vertebrae, accompanied by the vena cava, on the right, enveloped in a fibro-cellular sheath, crossed posteriorly by the lumbar veins, anteriorly by the pancreas, duodenum, the splenic vein, or the trunk of the vena portarum, and the left renal vein, surrounded by vessels and lymphatic ganglions, and having in front of it the stomach, the transverse meso-colon, and the root of the mesentery, —the abdominal aorta, from its passage through the pillars of the diaphragm, to its bifurcation in front of the sacro-vertebral angle, furnishes a great number of branches, which it is important should be kept in view. The coeliac, the emulgent, and the great mesen- teric, derive their origin from its upper half, that is to say, they are given off from it above, or in the meso-colic portion of the mesen- tery. A long interval, therefore, separates them from the inferior mesenteric, which is given off from it at an inch and a half, or two inches, above the common iliacs. In crossing the bodies of the vertebrae, the lumbar arteries are bound down by small and ex- tremely strong fibrous arcades, and thus constitute so many fixed 12 178 NEW ELEMENTS OF OPERATIVE SURGERY. roots, Avhich prevent the aorta from being displaced more than a few lines, either in this or that direction, Avithout almost inevitably causing their rupture. It is evident, from the ensemble of these relations, that by pushing the small intestines to the right, or keep- ing them aside, in any manner Avhatever, the aorta may be easily compressed against the vertebrae, between the two mesenteries, or immediately above its bifurcation; that these two points are the only ones Avhich present an opportunity for surgical resources, and that it is there that it would be necessary to apply the thumb, through the walls of the abdomen, until something better could be done, if it became urgent to suspend a serious hemorrhage in the lower arterial system. § II.—Indications. No artery of the splanchnic cavities is more frequently the seat of aneurism, from internal causes, than the aorta ; and in no artery does either aneurism, or the slightest traumatic lesion, present so many dangers, or is more frequently followed by death. If it be that no wound, or ulceration, nor any solution of continuity in an artery, can be cured without effecting the obliteration of the vessel, which is the seat of it, how can Ave conceive that such a termina- tion, admitting that it may be possible, in the aorta, Avould not, at the same time, be of necessity mortal ? Yet such, nevertheless, would seem to be the fact, from the several cases Avhich follow: 1. Stenzel (De Steatomatib. Aorte) gives the case of tAvo steato- matous tumors, in the substance even of the Avails of the aorta, under its arch (crosse ;) the arterial trunk Avas almost impermea- ble. Nothing had led to the suspicion of such an arrangement during life : 2 and 3. Meckel (Acad, de Berlin, t. XII., p. 62) saw two dead bodies, Avith the abdominal limbs well nourished, and the aorta considerably contracted under its curvature ; 4. M. A. Seve- rin, (De Recondit. Abscess., etc., lib. IV.,) the aorta under the emul- gents completely shut up by a solid concretion ; 5. Staerk, (Ann. Med., vol. I., p. 260, ou Barth, Press. Med., t. I.,) a similar case to those of Meckel; 6. Paris, (Journal de Desault, t. II., p. 107,) the aorta under the arch, reduced to the extent of some lines, to so small a calibre, that it Avas difficult to introduce a croAv-quill into it; 7. Complete obliteration at the same point, seen by Graham, (Trans. Mkl.-Chir., vol. V., p. 287,) 8. Rainy, (Journal de Leroux, t. XXXII., p. 377,) saAV a similar fact at the hospital of Glasgow, 1814; the specimen Avas given to M. Monteith. 9. Monro, (Jour- nal des Progres, t. IV.,) the aorta obliterated, in consequence of the relics of an old aneurism immediately above the primitive iliacs; 10. Goodisson, (Bulletin de la Faculte, t. VI., p. 130,138,) an oblite- ration extending to the two common iliacs ; 11. ReynauJ, (Journal Hebdomad., t. I., p. 161,) an extreme contraction of the thoracic aorta. 12. M. A. Meckel, (Jour. Compt. des Sc. AFd., t. XXX., p. 88,) the aorta so contracted under the arterial canal, that it was with difficulty a small straw could enter it. M. A. Cooper, ARTERIES of the abdominal limb. 179 ((Euvres, etc., trad. Chassaignac et Richelot, p. 542,) complete ob- literation of the abdominal aorta. M. Key, (Journ. des Progres, t. II., p. 19,) another in a paraplegic. To these facts we may add those of Piorry, (Journal Universel des Sciences Medicates, Mars, 181 a,) the aorta contracted near the arch ; Baffos, (Archiv. Gen. de Med., t. XIV., p. 611,) the iliac aorta obliterated; Nicod, (Archiv. Gen. deMed., t. VII., p. 466,) the same by concretion; Pailloux, (Biblioth. Med., 1829, t. I., p. 337,) the aorta beloAV obliterated by concretion; Berton, (Rev. Med., 1829, t. II., p. 244,) thoracic aorta, aneurism, and concretion; Schles- inger, Encyclop. des Sc. Med., 1836, p. 85,) abdominal aorta oblite- rated ; Legrand the same; (Retrecissem.de VAorta, &c, 1834;) also those of Spangenberg, Hervey, Laennec, Bright, and H. Ber- ard, (Diet, de Med., 2e edit., t. IIL, p. 400,) and those of Nixton, Andral, Larcheus, Fontanus, Dell Arme, Morgagni, Jordan, Mai- sonneuve, collected by M. Barth, (Presse Mcd., t. I., ou These No. 189, Paris, 1837. An excellent work of reference.) In almost all these subjects, the state of the aorta was evidently the result of disease; in all, the circulation had continued to go on above the strangulation; those mentioned by M. Rainy and M. Key Avere the only ones that complained of an habitual Aveakness in the legs,or palsy. On the other hand,M. A. Cooper and Beclard have, it is asserted, often tied the ventral aorta in dogs, Avithout causing gan- grene in the hinder parts (train de derriere) of these animals. In 1823, I dissected a cat, upon which M. Pinel-Crandchamp had performed this operation four months before, and in Avhich the abdominal aorta Ava§ transformed into a fibro-cellular filament, from the supe- rior mesenteric to the origin of the primitive iliacs.- M. Scoutetten, (Archiv. Gen. de Med., t. XIII., p. 505,) Avho has effected the ob- literation, in succession, of the tAvo femorals, the two carotids, and the tAvo subclavians, in the same animal, Avithout causing death, also tied the aorta in one of the dogs he had thus treated. Though an acute peritonitis had supervened in this animal, the day after the operation, he had begun to Avalk, and to recover his appetite, Avhen laceration of the aorta above the ligature suddenly caused his death, on the seventh day. If this assemblage of facts would not authorize us to conclude that we might tie the abdominal aorta in man, Avithout danger, they prove at least, and unansAverably, as it appears to me, that in •spite of this ligature, the blood Avould ultimately create for itself a channel to reach the loAver limbs. The intercostals, and the supe- rior lumbar arteries, the internal and external mamillaries, and the transverse and posterior cervicals, are large enough, in fact, to carry the fluids below the strangulated point. If the ligature A\ras placed between the two mesenteries, in place of being applied be- low, avc should have, in addition, the great arcades formed by the union of the right and left colic, to re-establish the circulation. The human body being, in reality, nothing more than a vast net- Avork, (un vastc reseau,) a great vascular circle, no one, at the pre- sent time, and much less now than ever before, can entertain any 180 NEW ELEMENTS OF OPERATIVE SURGERY. apprehension that Ave should arrest the course of the fluids that cir- culate through it, by obliterating any one portion of it. Would then the ligature of the aorta be useful and practicable ? That it is practicable Ave can have no doubt, since MM. A. Cooper, James, and Murray, have performed it; the first at London on the 25th of June 1817 ; the second at Dublin in 1829 ; the third at the Cape of Good Hope in 1834. As to its utility it is not near so Avell demonstrated. The patient of M. Cooper, ((Euvres, trad. Franc., p. 548,) died at the end of forty hours; that of M. James, (The Lancet, 1829, Vol. IL, p. 607,) survived only three hours ; and I find that the patient of M. Murray, (N Amer. Archiv. of Med. and Surgical Sciences, 1835, p. 297,) died at the expiration'of tAventy- three hours. Aneurisms in one or both the common iliacs, or those which might develope themselves beloAV the inferior mesenteric, could alone claim this operation ; but the observations of MM. Monro and Goodisson, and the cases of spontaneous cure of aneu- risms of the aortic arch, as related by MM. W. Darrach, Berton and Calmeil, (Journal des Progres, le serie,) shoAV what the system can do under such circumstances. But do not internal treatment, cold applications, and moxas, combined with the methods of Valsalva, Guerin, and M. Larrey, in fact, offer in such cases, more chances of success than any operation that could be imagined? Would not the ligature first applied to the external iliac upon one side, and then upon that of the other, according to the method of Brasdor, be preferable to that upon the aorta ? HoAvever, as it is possible that the essay of the English Surgeon may be repeated, I think it proper to point out the operative process. § III.—The Operative Process. I do not deem the suggestion of penetrating into the left loin to reach the aorta, without opening into the peritoneum, as some modern writers have recommended, of any value or Avorthy of be- ing discussed. The only process that prudence would allow us to undertake, is the folloAving :— The patient being laid upon his back, ought to have the head, thighs, and legs, moderately flexed, in order to put the walls of the belly into a state of complete relaxation. An incision of from three to four inches long, is then made upon the linea alba, a little to the left, to avoid the umbilicus, above Avhich it would as I think, be advisable to prolong a little farther than below. Having reached the peritoneum Ave puncture it, in order to divide it more freely with the blunt pointed bistoury guided upon the finger ; by this opening the forefinger pushes aside the intestines, penetrates to the spine, recognises the pulsations of the artery, detaches the left layer of the mesentery and the subjacent cellular sheath with the nail, and gently separates the aorta from the vena cava and the vertebrae, so as to isolate it in a proper manner. If the subject should be thin, and the walls of the abdomen be brought very near to the vertebral column; if the eye in fine, could folioav the instru- ARTERIES OF THE ABDOMINAL LIMB. 181 ment up to that point, a sound Avould advantageously replace the finger. The ligature is applied by means of the needle of Des- champs, or the ordinary ligature-holder, (porte-fil;) it is tightened by a double knot, while one of its ends is cut near the artery ; and the other is brought through the Avound Avhich it is advisable to unite by some stitches of suture. If the ligatures of animal sub- stance offered the same security as the others, this Avould be a case for giving them the preference and leaving the knot at the bot- tom of the Avound; but experience not having yet decided upon these, I dare not recommend their employment here. M. Cooper, placed his ligature at three quarters of an inch above the primitive iliacs. It Avould probably be better to place it above the loAver mesenteric artery; the reason for this I have given above. M. James before tying the aorta at the Exeter Hospital, July 5th, 1829, had endeavoured to obliterate the external iliac by the method of Brasdor, on the preceding 2d of June, without obtaining therefrom any marked advantages. At the opening of the dead body the ex- ternal iliac artery Avas found divided into two trunks, which Avould have sufficiently explained how the first operation, which was fol- lowed by a diminution in the pulsations of the tumor had not pre- vented them from soon after re-acquiring their former force. The process also of M. James is nearly the same as that of M. A. Cooper's. M. Murray, (Gaz. Med. de Paris, 1834, p. 502,) says, he made his incision to the left, in the direction of the aorta, and after the method of Guthrie, because he could not operate to the right, OAving to the size of the tumor Avhich ascended very high in the belly. [Two cases of this rare form of aneurism, are related by J. Arthur Wilson, of St. George's Hospital, London: one in a female aged 24, Avho had been four months laboring under icterus, and severely sa- livated, and Avho after a few Aveeks more of severe suffering from pains betAveen the shoulders and in the epigastric and right hypo- chondriac region, died in a state of great exhaustion. She had her menses twice, hoAvever, in the last seven weeks of her life, and it Avas remarked that the catamenial blood had a large proportion of bile. The autopsy disclosed an apparently vast liver, filling up the Avhole space on the right, and of a globate shape. It Avas smooth on its surface and firm in texture, and Avas found to occupy the place of an envelope to an aneurism situated at an inch from the origin of the trunk of the superior mesenteric artery. The ductus choledocus was compressed and almost effaced throughout its Avhole extent by the contact of this tumor. The liver Avas sound though livid. The biliary ducts Avere greatly enlarged; the gall bladder contained bile and some calcareous concretions. The Editors of the Journal des Connaissances Medico-Chirurgicales, (Paris, April 1,1842,p. 169,) speaking of these cases, think this might have been diagnosed, or at least suspected, if the ear had been applied on the region of the liver. The touch however, Ave should suppose must have clearly indicated the great displacement of the organ. In the second case, Avhich Avas antecedent to the above, the tumor 182 NEW ELEMENTS OF OPERATIVE SURGERY. made a prominence externally of the size of a small orange, dis- appearing in certain positions. The patient Avas sensible of pulsa- tions in the epigastrium, various symptoms of suffocation, and often discharged blood from the mouth. There was no jaundice. The autopsy showed an aneurism at the commencement of the trunk of the superior mesenteric communicating freely Avith the aorta. The lungs contained traces of vomicae and were also tuberculous. T.] CHAPTER II. ARTERIES OF THE THORACIC LIMB. Article I.—Arteries of the Hand. § I.—Anatomy. The Radial Palmar Arch, extending in the form of a segment of a circle with its convexity fonvard, from the dorsal origin of the first inter-osseous space, to the hypothenar eminence, Avhere the ul- nar artery completes it; being embedded in the muscles, Avith the bones of the metacarpus behind, and the flexors of the fingers and the other soft parts in the palm of the hand in front, is too deeply situ- ated as respects aneurisms, to require any particular consideration. The ulnar or superficial arch, represents Avith sufficient exactness the shape of an arc, with its convexity downAvards, of about fifteen lines in depth, and the extremities of Avhich Avould fall upon the pro- jections of the pisiform bone, and the os trapezium. Covered near its root by some fibres of the muscles of the little finger, by the pal- mar aponeurosis in its middle part, and over that by the sub-cuta- neous tissue in its Avhole extent, it furnishes from its convex portion the collateral arteries of almost all the fingers. The branches of the median nerve, the tendons of the sublimis, the profundus, and lumbricales muscles, and a ATery loose synovial membrane separate it moreover from the deep arch, with Avhich it is made to commu- nicate, by means of the anterior branch of the radial artery, a collateral of the thumb and the deep branch of the ulnar. § II.—Indications. We often meet with Avounds in the hand which may become alarming from the hemorrhage Avhich results from them. In a case mentioned by Timeus, (Bonet, Corps de Mul, part IL, p. 188, Obs. 37,) the loss of blood by frequent repetitions ultimately caused the death of the patient. Camper (Demonstr. Anat. Pathol, etc., 1760) says the arm had to be amputated to arrest the hemorrhage in a case of Avound in the deep palmar arch. The hand is also sometimes the seat of circumscribed aneurisms. Guattani met with ARTERIES OF THE THORACIC LIMB. 183 one in front of the thenar eminence, Avhich Avas equal to the size of an orange. Becket, Fabricius of Hilden, and the Gazette Medi- cale, (1837, p. 524,) each furnish another example of this kind. In the case mentioned by Tulpius, (Bonet, Oper. Cit., t. IV., p. 40, Obs. 59,) it Avas situated betAveen the thumb and index finger; and at the hypo thenar eminence in that of Sommt-. M. Champion Avrites me that he has seen one in the palm of the hand. An analo- gous case Avas seen by M. Carrere (Gaz. Med. de Paris, 1834, p. 255.) The treatment of such lesions is not free from embarrassment; sometimes almost any thing Avill succeed, Avhile at other times almost every thing fails. The patient of M. Champion had received a cut from a knife ; the compression Avas badly made ; the hemor- rhage returned; the compression Avas applied better; the aneurism was formed ; the patient did nothing farther. Like M. Carrere, I have seen the best applied compression fail in a stout lacl Avho had wounded the superficial palmar arch; also in another in which the deep palmar arch had been Avounded in opening an abscess. As Avith the cases of M. Quoy (Jour, des Conn. Med.-Chir., t. III., p. 269J and M. Pigeaux, (Arch. Gen. de Med., 2e serie, t. X., p. 237,) I found in 1838, in a young man Avho had thrust a knife into the palm of his hand, that compression answered perfectly Avell. The hemorrhage of which M. Dubreuil (Gaz Med. de Paris, 1834, p. 726) speaks, coming from the palmar arch at the bottom of an ab- scess, at first resisted compression. The brachial artery Avas tied, but the blood reappeared. A second compression Avas successful. Compression made in tAvo other cases with an instrument of which the sugar-tongs would convey a correct idea, succeeded very Avell. (Jour, des Conn. Med.-Chir., t. III., p. 10.) M. Grisolle (Ibid.) also cites two cases, Avhere the compression no longer direct, but made upon the radial or ulnar arteries, Avas attended Avith complete suc- cess. The red hot iron applied by Dupuytren cured the child that M. Carrere had treated by compression. In other respects the course to be observed is this : Is the case one of hemorrhage and recent diffused aneurism 1 I have then twice succeeded by tying the tAvo ends of the artery at the bottom of the Avound. To divide the palmar aponeurosis and the arterial arch itself as Camper recommends, (Oper. Cit.,) Avould be a means to be tried. If the first trials of compression made upon the palm of the hand Avith tampons, agaric, and compresses and a bandage, or Avith the forceps of M. Gallias, (Jour, des Conn. Med.-Chir., t. III., p. 10,) should not succeed, it should be made in a third manner. If the direct compression is poAverless or too uncomfortable to be borne, we must then have recourse to indirect compression upon the radial and ulnar above the wrist, as M. A. Berard has done (Gaz. Mid. de Paris, 1833, p. 706.) Finally, if in spite of these means skilfully employed, the hemorrhage should return, or inflam- mation and swelling should threaten to attack the hand, there Avould be no longer room to hesitate ; the ligature must be applied by the method of Anel. The ligature upon the radial only, aided by com- 184 NEW ELEMENTS OF OPERATIVE SURGERY. prcssion upon the ulnar, Avas sufficient in the case cited by M. Berard or M. Pigeaux, and in a patient of Duges, (Jour, des Conn. Med.-Chir., t. I., p. 210.) Sometimes Ave succeed by tying only the upper end of the Avounded vessel; but as the two arteries of the fore-arm communicate freely with each other in the hand, it is more secure and generally better to surround each of them Avith a ligature, though only one of them has been opened. In a pork dealer Avhose superficial palmar arch had been divided, the bleed- ing came on copiously five times in succession in spite of compres- sion both direct and indirect. I tied the ulnar and radial Avithout Avaiting any longer, and though a phlegmonous tumefaction had already seized the hand and fore-arm the cure Avas effected. A young butcher Avho had had the root of the deep palmar arch and the collaterals of the index finger opened, Avas exhausted in conse- quence of repeated hemorrhages, Avhen MM. Layraud and Vigue- reux sent for me. Compression, astringents and cauterization had been made trial of. I immediately tied the tAvo arteries of the fore- arm, and all the difficulties Avere arrested. In the cases of circumscribed aneurism the operation above is the one Ave have to depend upon ; there Avould in fact be no choice; the method of Anel only is applicable to these cases. By the an- cient method, or the opening of the sac, Ave should have to encoun- ter too many difficulties in laying bare and especially in seizing the artery. The hazard incurred by M. Roux in a patient in Avhom he employed this method, and by M. Manoury in another, and the dangers of every kind to which Ave are exposed in making inci- sions into the palm of the hand, sufficiently show that in such cases the ligature to the radial or ulnar above the Avrist Avould be prefer- able ; it did not however prevent the boy upon Avhom M. Roux (Gaz. Med. de Paris, 1837, p. 524) had made use of it for an aneurism at the thenar eminence, in 1836, at the Hotel Dieu, from dying in consequence of repeated hemorrhages. § III.—Operative Process. A. We could nevertheless reach Avithout difficulty the superficial palmar arch near its root, by commencing upon its radial or pisi- form side, an incision, Avhich should be prolonged fonvards to the extent of about an inch and in the direction of the last metacarpal space. We should have to divide in succession the skin and its cellulo-filamentous lining, a sufficiently thin aponeurosis and some fleshy fibres. B. It Avould also be very easy to tie the origin of the deep arch upon the back of the hand: the termination of the radial is found there at the bottom of the groove which separates the posterior ex- tremity of the two first metacarpal bones; a fibrous lamella sepa- rates it from the tendons of the thumb, the cephalic vein and the skin. The thumb and fore finger should be extended and kept wide apart from each other, in order that the surgeon may not be incommoded by the dorsal tendons of these two fingers. An ob- ARTERIES OF THE THORACIC LIMB. 185 lique incision of an inch or an inch and a half long is then made at three lines from the ulnar side of the artery and in the direction of the long extensor of the thumb. Under the skin are seen large veins of the metacarpus and one of the branches of the radial nerve. If they Avere still in the xvay after pushing them aside they must be divided; the artery is still concealed by the aponeu- rosis, which must not be divided except upon the director. Finally in isolating the vessel by the point of the sound, it is important not to lose sight of the neighborhood of the carpo-metacarpal articula- tions. Article II.—Arteries of the Fore-arm. § I.—Anatomy. In the fore-arm, the posterior inter-osseous artery, distributed between the tAvo corresponding muscular layers, and the anterior inter-osseous, accompanied by its nerve, and lying upon the liga- ment of the same name, are of too little size, and too deeply situ- ated to require the direct application of the ligature. It is, there- fore, the radial and ulnar alone Avhich the surgeon must look to under these circumstances. A. In its lower third, the radial artery, situated in the groove which separates the tendons of the flexor carpi radialis, and of the supinator radii longus, is covered only by a single aponeurotic layer, the sub-cutaneous tissue and the skin ; one or two veins run by the side of it; the nerve is at some lines outside of it, and it lies almost naked on the anterior face of the radius. Elseavhere, its relations are a little more complicated. Resting against the prona- tor radii teres, or the radial portion of the flexor digitorum sublimis, where it is fastened by a fibrous lamella, this artery, concealed also by the inner border of the supinator radii longus, is, nevertheless, separated from the integuments in the same manner as below, by the anti-brachial aponeurosis, and by the superficial layer, in its Avhole extent. Its course is indicated by a line draAvn fr-m the middle part of the elbow to the base of the styloid process, or by the outer groove (gouttiere) of the fore-arm. It sometimes runs immediately under the skin; more frequently it turns back upon the outer surface of the radius at the middle of its length; Avhile in other cases its principal branch'lies in front, and goes to form al- most entirely the superficial palmar arch. B. The ulnar, (cubital,) concealed above by the entire thickness of the superficial muscular tissue, is on that account only submit- ted to surgical operations in its three lower fourths, Avhere it is found upon the flexor digitorum profundus, betAveen the flexor digi- torum sublimis and the flexor carpi ulnaris; the vein is outside, and the nerve on the inner, that is, the ulnar side ; at first, an apo- neurosis, then the flexor carpi ulnaris muscle, (muscle cubital,) or its tendon, then another fibrous layer, and afterAvards the adipose tis- 186 NEW ELEMENTS OF OPERATIVE SURGERY. sue, separate it from the cutaneous envelope; Ave may trace its course by means of a line draAvn from the inner condyle of the humerus to the radial side of the pisiform bone, for its two loAver thirds, and by a line drawn from the middle of the bend of the arm to the union of the middle third Avith the upper third of the ulna, for the upper third of its c6urse. Its anomalies of position are much more frequent than those of the radial; I have often found it betAveen the aponeurosis and the skin, either in its Avhole or a part of its length ; I knoAV many persons Avith this peculiarity. At other times Ave find it between the aponeurosis and the muscles; in certain cases it runs for a long distance near the axis of the limb, and does not approximate to the ulnar nerve until when it is near the Avrist. § II.—Indications. There is no doubt but that an aneurism of the radial near the wrist might yield to compression, nor is there any that Ave ought to attempt this means in irritable, timid subjects, like the one for exam- ple that A. Petit speaks of, and Avho died of spasms from a ligature upon the radial; it is equally certain also, as M. Pigeaux (Arch. Gen. de Med., 2e ser., t. X., p. 337) says, that most of the hemorrhages of the fore-arm could be arrested by compression properly made. A. Compression.—The patient of Tulpius above referred to was cured of his aneurism by this mode. A Avound of the radial near the carpus, was also cured by means of a kind of tourniquet in- vented by Scultetus, (Arsenal de Chir., p. 335, obs. 89, pi. 19, fig. 4.) In another case Formi (Bonet, Oper. Cit., t. I., p. 190) suc- ceeded equally Avell by plugging Avith tents, (tamponnement,) and compression. The patient treated by Favire, also had a Avound of the radial. The arteries of the fore-arm are Avounded; the radial is tied; the hemorrhage reappears; Avhich is the artery Avounded? they could not tell, says Dudaujon; (These, Paris, 1803;) in this doubt they attempt indirect compression with an apparatus expressly made for it; the patient got Avell. Compression proved insufficient, and it was necessary to come to the ligature in the cases of Herin, (Pathol. Chirurg., t. IL, p. 48,) Mestivier, Martin, (Arc. Journ. de Med., t. XXX., p. 270—274,) Pelletan, (Clin. Chir., t. IL, p. 270,) and Ouvrart, (Obs. de Med. et de Chir., p. 253—255.) Bourienne, (Journal de Horn,t. VII.,p. 277,) Avho rejects the ligature as use- less, and also strong compression, employed Avith success in the case of a Avound of the inter-osseous artery, cauterization, aided by slight compression. But M. Gouraud (Essai sur la Formation des Os, These de Paris) speaks of a similar lesion Avhich could not be cured by compression, and Avhich obliged him to tie the trunk of the brachial. A patient of Avhom Detharding (Planque, Bibl, t. XXVII., p. 40) speaks, Avas more fortunate. The artery of the wrist is opened. The patient cannot support the tourniquet. They Avere about to amputate, when one of the surgeons introduced a plug (bouton) of blue vitriol into the vessel, and stopped the blood. ARTERIES OF THE THORACIC LIMB. 187 Plugging Avith tents, and compression, succeeded very Avell in a case of Avound of the ulnar, related by Leprince, (Journ. de Horn, t. I., p. 398.) M. Quoy (Journ. des Conn. Med.-Chir., t. L, p. 26,) effectually arrested, by means of direct compression, a hemorrhage of the arteries of the Avrist, by deciding to make the compression on the two arteries separately. M. B. Cooper (Presse Med., t. I., p. 455) Avas not less fortunate for a wound of the ulnar. I have al- ready remarked that the hemorrhage did not return in one of my patients who had the ulnar artery divided, though compression Avas not made upon the brachial longer than twenty-four hours. B. All this does not prevent the ligature from being the most cer- tain remedy, and the one that may be employed with least danger in lesions of arteries of the fore-arm. Compression and the ligature, moreover, are two resources which Ave must often in these cases call to the aid of each other. Instead, for example, of tying those two ar- teries at the same time for a Avound in the hand, as the extensive anastomoses of the palmar arches would seem to require, Ave may content ourselves with placing a ligature on the principal, and Avith compressing the other. At and above the wrist, if the upper end of the artery Avhich has been opened has been tied, it will then be found sufficient, in order to prevent the return of blood or the hemorrhage, to make compression upon its loAver end. Since I laid doAvn these rules, M. A. Berard, (Gaz. de Paris, 1833, p. 706,) has confirmed them by two facts. A case published by M. Quoy, (Journ. des Conn. Med.-Chir., t. L, p. 269,) sustains them in the same manner. I may say as much of that of Duges, (Ibid.,]). 210,) and of some others. With M. H. Berard, (Arch. Gen. de Med., 2e serie, t. VII., p. 448,) and M. Sedillot, (Gaz. Med. de Paris, 1834, p. 41,) the method of Anel Avas found sufficient to arrest a hemorrhage on the fourteenth day from a Avound either of the ulnar or the brachial artery. It would be the same for circum- scribed aneurisms ; Somme,(G'a2:. Med. de Paris, 1833, p. 695,) al- so cured his patient by tying the ulnar in the middle of the fore-arm. It is nevertheless true, that in a patient Avho had had the radial ar- tery wounded, M. Dubreuil, (Ibid., 1834, p. 726,) after having tried compression and the ligature upon the radial and then upon the ulnar, Avas obliged to come to the ligature of the brachial artery itself. If the wound Avhether traumatic or spontaneous, Avere situated in the dorsal branch of the ulnar artery, of which MM. Pillet, (These No. 176, Paris, 1827,) and Baretta, saAV an instance at the Hospi- tal of Lyon, or in any other branch in the same region, the ligature Avhich is attended Avith but little danger, and easy of application, and Avhich should be placed above and under the disease, by the ancient method, should be preferred to any other mode. § III.—Operative Process. Unless the ligature is to be made in the wound itself, it is to be 188 NEW ELEMENTS OF OPERATIVE SURGERY. applied immediately above the wrist, or to the upper third of the fore-arm. A. The Radial above the wrist.—When we Avish to tie the radial artery above the Avrist, the hand should be placed in supination. The surgeon seated outside, makes Avith a straight or convex bis- toury an incision into the integument of from one to tAvo inches, in the direction of the artery, between the flexor carpi radialis and the supinator longus, taking care not to go too deeply at first. After- Avards he divides the aponeurosis Avhich has been previously raised up, in such manner that the bistoury passed along the groove of the sound cannot touch the vessels. As the nerve is situated at a great distance from it, and the collateral vein is of but little importance, it is a matter of indifference Avhether the artery is seized by its inner or outward side; only that Ave ought to avoid denuding it to too great an extent. B. The Ulnar above the wrist.—The hand and the fore-arm are placed for the ulnar as in the preceding case. We. give the incision the same extent and the same direction. Nor should it either de- scend to a line with the radio-carpal articulation; also it is upon the radial border of the flexor carpi ulnaris, or in the inner groove of the fore-arm, that this incision is to be made. After having di- vided the skin, the adipose tissue and the thin fibrous layer which covers the tendon of the flexor carpi ulnaris, and pushed this tendon inwardly, Ave perceive the artery through a second aponeurotic layer, situated on the radial side of, and a little anterior to, the ulnar nerve. C. The Radial at the upper third of the fore-arm.—As Ave are obliged to penetrate deeper in the upper third of the fore-arm than below, it is advisable to give at least two inches of extent to the Avound, Avhich should be a little oblique from Avithin outward, in order not to go too far from the line of the track of the artery. If then the superficial radial vein or the common median should pre- sent themselves under the skin, they must be pushed aside with the sound. It is better to fall some lines without than Avithin the bor- der of the supinator longus muscle ; at this outer side the aponeu- rosis has not yet divided, (dedoublee) and Ave find only a single layer of it. In the other, that is to say, on the border of the mus- cle itself, a first layer has to be first divided, and then the fleshy bundle is drawn to the distance of some lines outwardly ; a second layer is seen beneath, this is divided upon the sound, and then the artery may easily be seized hold of. D. The Ulnar on the. middle third of the fore-arm.—The ligature upon the ulnar on its upper third, or its middle portion, is deemed one of the most difficult in the thoracic extremity, Avhich is owing probably to the fact that most authors have given but very vague rules for performing it. Nevertheless, I have not found that it re- quired either on the dead subject, or on the living body, much more address than the radial, if Ave adopt the following mode :— Process of the Author.—We make an incision of from three to four inches, which commences at three fingers width from the ulnar ARTERIES OF THE THORACIC LIMB. 189 articulation (trochlee) of the humerus, and descends to the middle of the fore-arm, in the direction of the line mentioned above. When the aponeurosis is laid bare, Ave seek for the interstice of the flexor carpi ulnaris and the flexor of the little finger. In order not to be deceived, it is sufficient to draAv the internal border of the Avound towards the ulnar side of the limb; directing our attention then to the median line, the first rather opaque (un peu epaisse) and yel- loAvish or grayish appearance (trace) that we meet is a certain mark of the interstice sought for. We then incise the aponeurosis on the outer border of this line to the same extent as the skin. That being done, we separate the flexor carpi ulnaris and flexor of the little finger from each other Avith the fore-finger, the handle of the scalpel, or the sound. We soon perceive, at the bottom of the wound, a large yelloAV or whitish cord, Avhich is the ulnar nerve, having the artery on its radial side. To seize this latter, it is not even necessary that Ave should see it, as we are certain to raise it up by directing the extremity of the sound betAveen it and the nerve. II. Process of M. Guthrie.—If the disease Avas situated higher up upon the ulnar artery, inasmuch as it changes its direction and becomes more and more difficult to cut down to, it Avould be evi- dently preferable to tie the brachial itself. M. Guthrie, who has done this once successfully, recommends that we should always pro- ceed to search for the ulnar itself in the part wounded, though it should be necessary to cut through the muscles transversely ; but this advice ought not to be folloAved, unless there already existed a wound of considerable size, Avith contusion of the parts. Article III.—Arteries of the Elbow. § I.—Anatomy. At the bend of the arm the humeral artery terminates, by giving origin to the radial and ulnar branches ; but in place of this occur- ring opposite to, or below the coronoid process, its bifurcation some- times takes place in front of the articulation, or even much higher. In descending, it folloAvs an oblique direction from Avithin outAvards, is situated upon the inner bundle of the brachialis internus muscle, between the biceps flexor cubiti, and pronator radii teres, and quite beloAV, inclines to cross in the same direction the anterior sur- face of the tendon of the biceps. The deep-seated vein, (veine profonde,) runs upon its radial side, and the median nerve, Avhich sometimes touches its ulnar border, is not unfrequently separated from it by a fasciculus of the brachialis internus muscle. A cellular sheath, of greater or less density, encloses it, as well as the vein. Crossed, and as if bridled doAvn by the fibrous bandelette of the biceps, afterAvards covered by the aponeurosis of that region, it has in front of it, at first the trunk of the basilic vein, then the corresponding median vein, the branches of the internal cutaneous nerve, and the cellulo-adipose tissue, which organs separate it to 190 NEW ELEMENTS OF OPERATIVE SURGERY. a greater or less distance from the skin. When the bifurcation takes place higher up than usual, the nerve lies, in general, between the tAvo arterial trunks, and it is then that the ulnar is specially inclined to creep under the skin. § II.—Indications. The bend of the arm is the part of the body Avhere aneurism is most frequently met Avith, especially false, or traumatic aneurism, whether diffused, circumscribed, or varicose. Spontaneous aneu- rism may be caused there, as in front of all the articulations, by a violent extension of the fore-arm, as happened, for example, in the innkeeper mentioned by Saviard, (Observ. Chirurg., &c, p. 22,27.) It is much more rare here, however, than in the ham, or even at the fold of the groin. Apart from those which have been related by Fordyce, Flajani, Paletta, Lassus, Pelletan, and M. Roux, there are scarcely any instances of these aneurisms to be found in the most approved authors, and Scarpa himself does not appear to have met Avith them. As to varicose aneurism this is pre-eminently its seat, whether it exists in its natural state, or is complicated Avith a false circumscribed aneurism. I have also seen a varicose dilatation of all the arteries of the hand and fore-arm, extending up as high as the tendon of the biceps. It Avas at the fold of the arm that an aneurismal sac was seen by Physick, (Dorsey, Elemen. de Chirurg., t. IL, p. 268, pi. 24,) of the size of an egg, between the vein and artery, Avith both of Avhich it communicated. It is not only for aneurisms at the bend of the arm, but also for those Avhich occupy the upper third of the fore-arm, that Ave apply the ligature upon the brachial artery, in this region. At the present day it is even much more frequently for these last f.u: i Ave have re- course to it, than for the first, since, in such cases, the method of Anel obliges us to carry the ligature to a point situated at a greater or less distance above the elbow. A. The cure spontaneously, or with the aid of compression, oi aneurisms at the bend of the arm, has been so often observed, that it has noAv become quite a common thing. D. Pomarest (Biblioth. de Bonet, t. IV., p. 104) relates the case of a patient who never Avould submit to an operation, and in whom the aneurism ultimately burst, and thus got completely Avell. A hemlock plaster, aided by astringents, purgatives, and compression, succeeded Avith Fabricius, of Hilden, (Ibid., p. 96,) for an aneurism of the size of an egg. We find in Plater (Bonet, Corps de Mid., t. III., p. 24) the case of an aneurism of this kind, in Avhich nothing Avas done. Demarque (Oper. Citat., p. 504) cured four of these aneurisms by bandages, aided by topical astringents. Monteggia speaks of a man seventy- six years of age, Avho had the artery opened during a bleeding, and Avhom it Avas proposed to cure by a bandage. The patient could not support this treatment. Different accidents, which at first seemed quite alarming, ultimately disappeared, and with them the aneurismal tumor. Galen cured an aneurism at the elbow, in a ARTERIES OF THE THORACIC LIMB. 191 young man, by regular compression. Genga appears to have suc- ceeded often by the aid of a bandage, generally attributed to The- den. White, Desault, Foubert, and Scarpa, have given examples in favor of this method, which the Abbe Bourdelot gave popularity to, more than a century since, by having applied it successfully upon himself. I have, myself, employed it with success in tAvo cases of recent varicose aneurisms. It has succeeded three times with Mothe, (Mel. de Med. et de Chir., p. 61 et 66,) Avho, on the other hand states, that in another case, it produced gangrene. Compression appears likeAvise to have succeeded in two rather imperfectly de- scribed cases, by M. Heustis, (Jour, des Conn. Med., t III., p. 72.) A young Avoman who had had the fold of the arm Avounded by the cut of a knife, came into my department at La Pitie ; on applying compression to the hemorrhage she Avas apparently cured. At the end of fifteen days the blood reappeared, and obliged me to tie the brachial artery. B. On the other hand, the disease may be sIoav in its progress, and scarcely incommode the patient who is the subject of it. "There occurred," says Saviard, (Nouv. Recueil d'Observ., p. 272, Obs. 61,) " an aneurism of the size of a walnut, at the bend of the elbow, in a man, after bleeding; he carried it Avith him during sixteen years, and without ceasing to labor in the coal mines." Pa- tients have thus lived along for thirty years, (Senert,) and even fifty, (Preuss. Helwich.) M. Ribes, (Gaz. Med. de Paris, 1835, p. 161,) who has collected these cases, cites one which continued for twenty-eight years. Nevertheless, as this aneurism, sooner or later, Avith a few rare exceptions, ultimately compromises the life of the patient, the surgeon is not to be influenced by any of those consi- derations. In ordinary cases, if compression should not appear to the surgeon to ansAver the object, or if he has tried it Avithout ad- vantage, he Avould be censurable not to have recourse promptly to the ligature. C. Operation.—It Avas for aneurisms at the elboAv only that the methods of Aetius and Guillineau were employed, until Keisler, and the surgeons of Italy, had ventured to treat in the same man- ner the aneurisms of the popliteal space. It Avas in that region also that Anel cured one of these tumors without touching it, con- fining himself to tying the artery above it; a process which Mi- rault, (Bulletin de la Faculte, t. III., p. 312,) of Angers, was the first among us to imitate, in 1787. I. Though it be generally conceded, that the method of Anel suf- fices here, the operation is sometimes performed by the method of Keisler, in diffused aneurism, for example, also in varicose and in circumscribed aneurism Avhere the walls are very much at- tenuated or disorganized. The reason given for it in the first place is, that by confining ourselves to tying the upper end, we incur the risk of having the hemorrhage return by the lower end; that in the second place, by obliterating the artery above, the blood will nevertheless continue to pass into the vein by the communicating aperture ; in the third, that in this state it is impossible to obtain re- 192 NEW ELEMENTS OF OPERATIVE SURGERY. solution of the aneurismal sac; and that it is necessary to open it and empty it of its clots, to prevent gangrene ; and that in every case we preserve a greater number of anastomosing branches. II. These motives, in reality, do not demonstrate the absolute ne cessity of the ancient method in such cases. If the tumor does not shrink upon itself after the operation, or threatens to suppurate, nothing prevents our treating it as a purulent collection. To put a stop to the hemorrhage, supposing that it continues after the liga- ture above a recent traumatic aneurism, compression, even though moderate, rarely fails to succeed. Though it be true, that in'a pa- tient operated upon by the new method, at the Hotel Dieu, the pro- gress of the aneurism did not yield to the opening of the sac and the ligature upon the tAvo ends of the vessel, it is not clear from the details of the operation, that the humeral artery was actually in- cluded in the ligature at the time of the first operation. Neverthe- less, M. Guthrie, though a warm partisan of the method of Keisler, relates a fact on this point which affords room for reflection. A man had the artery punctured by a lancet. It is tied above. The hemorrhage reappears, and it is tied higher up. The hemorrhage takes place again. Amputation is performed and the patient dies. It was necessary, says the author, to have tied not only the brachial, but also the origin of the radial and of the ulnar. III. As to varicose aneurism, (aneurisme variqueux,) it must be admitted that a certain number of facts seem to justify the recom- mendation of treating it by the ancient method. In the operative surgery of Sabatier, Ave find four cases of Dupuytren in support of this opinion. In the first, in spite of the ligature by the mode of Anel, it became necessary to have recourse to amputation of the limb; in the second there came on a stiffness and false anchylosis of the fingers, with other accidents, which also rendered amputation necessary; in fine, in the third and fourth, the patients were ulti- metely restored by a second operation, which allowed of tying the artery above and beloAV the wound. In a patient, Avhose case is related by M. Alquie, (Gaz. Med. de Paris, 1837, p. 347,) it was tied above : upon hemorrhage recurring, a second ligature was placed above : the hemorrhage returned, and compression Avas used; another hemorrhage recurred ; rest in bed, and compression, effected the cure. Nevertheless, a case has since been reported, where a ligature upon the brachial alone sufficed (Archiv. Gen. de Med., 2e serie, t. VI., p. 576) to cure a varicose aneurism at the bend of the arm. But there is a previous question to be solved here. Is varicose aneurism, in itself, of a nature sufficiently serious to justify such operations ? What I have said above, and a recent case of M. PI. Portal, (Clin. Chir.,X. L, p. 203,) and that of M. Brown, (Arch. Gen. de Med., 2e serie, t. X., p. 370,) may authorize us to doubt if it is. I Avould not, therefore, decide upon this course, unless the functions of the limb were disturbed to so great a degree as to ex- pose the patient to imminent peril. ARTERIES OF THE THORACIC LIMB. 193 § HI.—Operative Process. When Ave have once decided upon tying the brachial artery at the elboAV, Avhatever be the motive that influences us, the folio Aving is the manner in Avhich it is to be performed:— I. The fore-arm being extended, and separated to a greater or less distance from the body, is turned back upon its dorsal surface, and kept in a state of supination. An incision is made three inches long, parallel to the radial, or upper border of the pronator radii teres muscle, commencing at near an inch above the internal con- dyle, and terminating in the middle of the bend of the arm. Under the skin are found the superficial veins, particularly the median- vasilic vein, and the branches of the cutaneous nerve which accom- pany it. An assistant is charged Avith holding them aside Avith a blunt hook, or the end of a curved sound. When some of their branches incommode too much, or cannot be conveniently kept out of the way, Ave should divide them between two ligatures, or even Avithout this precaution, Avhen they are of small size ; Ave then come to the aponeurosis, Avhich Ave must divide upon a grooved sound. Even though Ave might preserve the bandeletteof the biceps, it is better to sacrifice it; Ave are then much more at our ease for the rest of the operation. After having freed the artery of the lamellar and adipose tissue Avhich surrounds it; and after having isolated it from the vein, or the deep veins, as Avell as from the ' median nerve, Ave pass between it and this last cord, the extremity of a sound, Avhich is then carried behind it to raise it up, Avhile with a nail of the other hand Ave prevent the veins from accompa- nying it, or from getting on the point of the instrument, after Avhich there remains nothing more to conclude the operation, than to ap- ply the ligature and dress the wound. II. The course of the blood, though temporarily interrupted, is soon established by tAvo anastomosing circles, Avhich the internal and external collateral arteries of the brachial form around the ex- ternal and the internal condyles, by uniting Avith the recurrent branches of the radial and ulnar. Thus it is by no means indis- pensable, as has been long supposed, (Monro, Med. de Chir., etc., 1826, p. 354,) in order to explain this phenomenon, that the artery at the elbow should be divided into two trunks above the point obliterated. As this caprice of nature, however, happens quite often, the surgeon ought not to forget it. A young man receives a cut from a knife in the lower part of the arm. Having tied the tAvo ends of a large artery, I believe the operation to be terminated, and prepare for dressing. But the hemorrhage reappears. A second artery of the same size as the first was found at the distance of more than half an inch upon the outside of it, and obliged me to tie also the two ends of that. 13 194 NEW ELEMENTS OF OPERATIVE SURGERY. Article IV.—The Brachial Artery, properly so called, § I.—Anatomy. It is in the middle of the bicipital internal groove that the bra- chial (humerale) artery is situated ; its course is indicated by a line draAvn from the hollow of the axilla to the middle of the bend of the arm; the median nerve Avhich runs along side of its radial border above, soon covers its outer (or cutaneous) face and crosses it very obliquely in order to get upon its ulnar border far beloAV. Two satellite veins ordinarily accompany it, or sometimes cover it, and thus separate it from the median nerve ; the ulnar nerve and the internal cutaneous nerve Avhich approach it above, separate them- selves from it more and more as they descend to reach the internal portion of the fore-arm. Resting against the humerus between the coraco-brachialis muscle and the tendon of the latissimus dorsi out- side of it, it soon arrives upon the brachialis internus behind the biceps which it accompanies to its termination. In thin subjects the aponeurosis is almost contiguous to it. The whole is covered as elseAvhere by the common integuments. Its anomalies are so fre- quent that no one is ignorant of them. I have seen it divide itself into tAvo trunks near the bottom of the axilla, at some inches loAver doAvn, at the middle of the arm, above the elboAV—in a Avord, at all parts (hauteurs) of the limb. In one subject one of the branches bifurcated at two inches from the inner condyle to form the ulnar and posterior inter-osseous. In another this last was independent of the radial and of the ulnar. The tAvo trunks sometimes lie side by side Avith each other down to the fore-arm ; at other times they cross each other once or several times; it is not uncommon to see one of them, most usually the ulnar, pierce the aponeurosis and place itself immediately under the skin, while the other Avhich then fur- nishes the radial and the inter-osseous, preserves its natural relations. § II.—Indications. The brachial artery may become the seat of aneurismal affections at every part of its extent almost indifferently ; but it is infinitely less disposed to them elsewhere than at the bend of the arm. As nothing interferes with their development, the tumors, to Avhich these diseases give rise, are generally regular, acquire great size in quite a short time, and rest frequently at their central portion over the opening of the artery. A. Before recurring to the ligature it is sometimes alloAvable to attempt compression and refrigerants; the humerus here offers a point d'appui Avhich signally favors the advantageous application of these means. It Avas to a Avound of the brachial artery at its upper third that Chappe employed compression Avith success. M. Lisfranc speaks of a patient Avho has four aneurisms in the arm, and who,during the space of a year, restricted their growth by means of a laced stocking (bas lace.) The Queen of Bavaria and another personage of the north Avere cured of an aneurism of this kind by arteries of the thoracic LIMB. 195 M. Winter, by means of a compressing bandage. Also it Avas not until lately that the practice Avas determined upon of tying the brachial artery, properly so called. Cheselden scarcely believes the surgeons Avho told him they had done it. It appears, hoAvever, that Lanfranc (Portal, Hist. Anat. et Chir., t. I., p. 191) had already recommended it; Morel, (Jour, des Nouv. Decouv., t. III., p. 212,) going still farther, performed it in 1681, and S. Formi, (Riviere, Obs. de Med., p. 628,) as well as Tassin, (Chirurg. Milit., etc., p. 35,) each relate a curious instance of it. We should do Avrong, however, to deny the dangers of this ligature. Palsy, says Schmucker, Avas the consequence of it in one case, though the nerve had been avoided. In a patient of M. Kraemer (Sprengel, t. VII., p. 348, 349) it gave rise to tetanus. A patient whom I operated upon at La Charite, in 1838, Avas seized with paralysis at the mo- ment of the operation ; but it is necessary to remark that in him the Avound had seriously implicated the soft parts of the neighbor- hood. M. Arbey, (Dissert. Citee, Strasbourg,) Avho, for a wound from a ball, placed his ligature in the upper third of the arm, found gangrene supervene, and Avas obliged to amputate. B. It is nevertheless upon the humeral artery that the operation for aneurism is most frequently performed, and upon Avhich ago- pression, devised by M. Giaccich, (Agopressure, fyc., Mai 1837,) might be made trial of. There the vessel is superficial, easy to seize and surrounded by parts that are sound and not changed, Avhile in front of the articulation the presence of the aneurism so masks its position that Ave sometimes have much difficulty in identifying it. Nevertheless Ave ought, as a general rule, to apply the ligature here as low doAvn as the disease will permit. No circumstance appa- rently Avith the exception of a diffused aneurism and a fresh bleed- ing Avound would justify a preference for the ancient method. If the aneurism extended too high up we should decide rather upon tying the axillary in the hollow which bears its name, unless it should be judged advisable to put into practice the method of Brasdor. § III.—Operative Process. A. The limb being placed as before described, and properly kept apart from the body, the operator seeks for the groove of the biceps, carries the bistoury, in the direction of the arterial line from above dowmvards, if it is the right arm, and from beloAV upAvards if it is the left, and makes an incision of from tAvo to three inches through the integuments. Immediately after, he places his left fore-finger in the Avound, endeavors to feel the median nerve Avhich presents itself under the form of a rounded cord of considera- ble firmness, and to distinguish it from the artery which is recog- nised by its pulsations; afterwards dividing successively upon the director, the aponeurosis and the sheath Avhich it gives to the nerve, he tears, and ahvays with the point of the sound the cellulo-fibrous envelope of the vessels ; isolates the artery from the veins which surround it, and applies the ligature. This operation 196 NEW ELEMENTS OF OPERATIVE SURGERY. can only become difficult in consequence of an anomaly or change in the relations of the parts Avhich it is important not to confound. The median nerve is the first cord that presents itself behind the biceps muscle ; I have but once seen it under the artery, betAveen that and the brachialis internus muscle. When we have once identified it, we may be sure the vessels are not far off. B. Since in a young man who came to La Charite, in 1837, it was found sufficient to compress the brachial artery for the space of twelve hours to avoid the necessity of a ligature upon the ulnar which had been Avounded ; and since, in the case of M. Wythe- roeven, a strangulation of thirty-six hours produced the same re- sult after a lesion of the arteries of the arm, Ave may understand hoAV the temporary ligature has in such cases succeeded Avith M. Malago (Bull, de Ferussac, t. XVIIL, p. 82,) Avho removed it upon the fourth day; Avith M. Bologna, (Jour, des Prog-res, t. XVII., p. 248,) Avho left it on only three days ; and Avith M. Dolcini, (Bull de Ferussac, t. II., p. 334,) who also removed it on the fourth day. C. Shall I add that Formi used only the indirect ligature, and that Buron (Tassin, Chir. Milit., p. 35) succeeded in the same manner Avith the folloAving case ? In a sword-cut the artery Avas opened betAveen the tAvo Avounds, that is, at the middle part of the arm. It Avas eight days before it was perceived that the artery was Avounded. At the expiration of this period, during a fit of passion of the patient, the artery bled afresh, (s'ouvre,) and all the remedies proved unavailing. Buron pierced the arm in the belly of the biceps near the bone, with a carlet threaded with a double ligature, Avhich he tied tightly upon compresses. To prevent mor- tification he slackened the ligature on the day after, and so on suc- cessively on the folloAving days. The patient Avas cured. D.—When the brachial artery is obliterated, the circulation is re-established beloAV it, by means of the muscular branches Avhich it gives off throughout its whole length, by the great collateral or external collateral artery, and by the great anastomosing branch, when it has not been sacrificed. [Aneurismal Varix and Varicose Aneurism. Simultaneous Existence of Aneurismal Varix and Varicose An- eurism from Venesection, and their Successful Treatment by Liga- ture.—Diagnostic Marks, by which they may be distinguished from each other, and from other Aneurisms.—Aneurismal Varix, (Vance Aneurysmale,) and Varicose Aneurism, (Aneurysine Variqueux,) being two distinct affections of a traumatic character, resulting most usually either alone or together, from Avounds of the brachial artery in the operation of bleeding, and being phrases also that are frequently confounded together, Ave avail ourselves, in further illustration of what has been so clearly stated in the text of the author, of a recent memoir on the subject by M. Auguste Berard, read Aug. 15, 1843, to the Societe de Chirurgie of Paris, and pub- lished in the Archives Generales de Medecine de Paris, (Janvier, 1845, p. 38, et seq. ARTERIES OF THE THORACIC LIMB. 197 It is necessary to premise, before proceeding to the observations /of M. Berard, that, Avith English and American surgeons, the phrase varicose aneurism is noAV very frequently applied to that peculiar congeries of dilated branches of vessels, including chiefly the veins, and probably also the minute arterial and venous ca- pillaries, Avhich, in common parlance, is called a ncevus maternus, and by some a species of erectile tumor. In French, hoAvever, va- ricose aneurism, or aneurysme variqueux, has generally, as Ave shall see, a very different signification. 1. Of Varice Aneurysmale, or Aneurismal Varix.—In this case, the brachial artery, for example, being Avounded and opened by the same perforation, Avhich Avas made through one of the veins in its immediate vicinity, the blood effects a passage directly from the artery into the vein. This last undergoes a dilatation which occu- pies the neighborhood of the Avound, or extends itself to a greater or less length through the wounded vein and the branches Avhich it receives. 2. In other cases, a tumor is formed which is bounded by the cellular tissue, and into which the arterial blood penetrates in a manner similar to Avhat takes place in false consecutive aneurism, but Avith characters peculiar to it. This is called varicose aneu- rism, or aneurysme variqueux. " These characters, as described by authors, are," says M. Berard, " as follows : A canal of greater or less length, from the artery to the vein, establishes the commu- nication betAveen these tAvo vessels. On some point of this canal there is a dilatation formed at the expense of the cellular tissue : sometimes this sac occupies the entire circumference of the canal; at other times it is confined to a portion only of its periphery." This kind of lesion, Avhich is much less frequent than aneuris- mal varix, has, M. Berard asserts, not been submitted to dissection, except by two or three persons ; and all authors who have treated of it, have repeated the description Avhich has been given by their predecessors. From Avhence it is natural to conclude that the pathological anatomy of varicose aneurism is not as yet perfectly understood, as it is easy to conceive that other forms of this disease may be presented. As an example, he gives a modification which he thinks has hitherto escaped observation. A patient aged 40, Avho had been accustomed to be bled frequently for pains in the head, had the brachial artery Avounded April 13, 1840. A com- pressing bandage, applied by the physician in attendance, proved of no avail, and the next day the patient experienced acute pains in the bend of the arm, with a burning sensation along the track of the vessels. On relaxing the bandage, the limb soon began to swell, the tumefaction extending to the shoulder and Avrist, and the skin successively assuming first a yelloAvish, then a broAvn and violet, and finally a black color. Pulsations soon became percepti- ble at the bend and loAver part of the arm. For many days the suffering was acute from the axilla doAvn to the fingers, requiring opiates externally and internally, and rendering the arm heavy and incapable of obeying its voluntary movements. The tumefaction 198 NEW ELEMENTS OF OPERATIVE SURGERY. now began gradually to diminish; but in proportion as it subsided, it became easier and easier to define at the bend of the arm and at the inner and anterior part of the biceps, a soft fluctuating tu- mor, with pulsations isochronous Avith those of the arteries, and partially reducible Avhen pressure was made on the brachial ar- tery. The pulsation then began to cease in the middle of the tumor, and the sac to become filled Avith coagulated blood ; more- over, there was no vein running from (ne faisant suite) this tumor. The entrance of the blood into the pouch (or sac) Avas accompa- nied by a rasping sound, (bruit de frottement,) Avhich Avas readily perceptible on applying the ear to it. Outside of, and under the tumor tOAvards the fore-arm, there Avas also perceptible an audible similar sound, (bruissement analogue,) Avhichwas propagated along the veins to the distance of 8 to 10 centimeters. An analogous sound, though of less strength, could also be detected along the brachial vein as far as the loAver third of the arm. The patient was also conscious of this sound, Avhich could be recognised by the surgeon Avith the greatest ease, by exploring it Avith his finger. If the ear Avas applied to these several points, there Avas then heard the pathognomonic bruit of the passage of the arterial blood into the veins—a sound Avhich has been compared to that of a spinning wheel, (rouet a filer,) the hum of a bee, (bourdonnement de l'abeille,) or the murmuring (susurrus) of a stream, &c. This bruit Avas en- tirely different from that heard at the tumor at the bend of the arm. •• It was impossible for me," says M. Berard, "to misunderstand these symptoms as those of aneurismal varix combined with those of varicose aneurism. The last mentioned lesion particularly ex- cited my attention, and I in vain endeavored to arrest its progress, by compression, repose, &c." The tumor from day to day acquired additional size, and on the 13th of May, (that is, a month after the accident,) he performed the operation for aneurism. Notwithstanding the difficulties of the ancient method, which are augmented by the communication of the artery Avith the veins, he decidedly prefers it to the inadequate and dangerous method (as he denominates it) of Anel and Hunter in cases of this descrip- tion. The brachial artery having been compressed at the upper third of the arm, in such manner as to intercept the passage of the blood into the tumor, an incision of 7 to 8 centimeters Avas made at the bend of the arm in the track of the artery. The anterior part of the sac and the aponeurosis of the fore-arm Avere laid bare and divided to the same extent as the skin. At the instant of opening the sac, there floAved out from it fluid blood mingled with a large quantity of fibrinous clots, some of which Avere dense and adherent to the internal surface of the sac. " I then searched," says M. Berard, " for the upper end of the artery, Avhich I found behind the poste- rior Avail of the sac, and Avhich I easily succeeded in separating from the A^ein, Avhich Avas found lying betAveen the artery and the sac." This first ligature Avas applied at about the distance of two cen- ARTERIES OF THE THORACIC LIMB. 199 timeters from the point from Avhich the blood was seen to escape from the bottom of the wound. Though the ligature Avas tightened, the blood continued to flow; it was black Avhen the brachial artery was compressed at its ori- gin, and became both arterial and venous Avhen this compression Avas taken off. This fact left no doubt of the reflux of the blood from the loAver end of the artery, by means of the internal and ex- ternal collateral and the articular arteries. I sought for the loAver end of the vessel, but experienced the greatest difficulty in finding it. The cellular tissue Avas thick, indurated, and red, and the vein closely united to the artery. In order to separate them Avith more ease, I tried to insert a probe into the last mentioned of these two vessels. For that purpose, I applied the instrument to the bottom of the sac Avhere the blood made its escape, and made it pass through the wound Avhich the lancet had made in the A^ein. The probe Avas passed from above doAvmvards in this vessel. I made a new effort to insinuate it into the artery, and I found that, in or- der to effect this, I had to pass through the vein from one side to the other. In fact, the situation of the parts was as folioavs : deep down the artery presented on its anterior surface a large and almost transverse Avound, Avhich occupied more than half the circumfe- rence of the A'essel; in front of the artery Avas the vein, Avhich Avas closely (immediatement) united to it; this last (the vein) presented, on its posterior surface, a wound similar to that of the artery Avith which it Avas in exact coaptation ; on its anterior surface Avas an- other wound of the same form and dimensions ; finally, in front of the vein Avas the aneurismal sac, which communicated with the vein by the anterior wound of this vessel, so that it received indi- rectly only (que mediatement) the blood Avhich came to it from the artery. The Avails of the vein appeared thick, especially a little below (au dessous) the puncture. The adhesion of the vein with the artery at this point was so close, that I found it impossible to sepa- rate them, and Avas obliged to include both vessels in the same liga- ture. As soon as this Avas done, the blood ceased to Aoav, and I ascer- tained again that the condition of the parts Avas such as I have just described them. The consequences of the operation presented nothing remark- able, but Avere very simple. The circulation Avas re-established the day after, in the radial artery. The two ligatures came away, the upper on the thirtieth, and the loAver on the thirty-fourth day. Finally the wound Avas completely cicatrized at the expiration of six Aveeks. There remained afterwards only a slight weakness in the limb, and some inconvenience in the movement of extension of the fore-arm, both of which soon entirely disappeared. This case, continues the Professor, exhibits varicose aneurism in a different point of vieAV from that under which it has hitherto been considered. The artery and the vein Avere completely agglutinated (entitlement collees) together, and communicated with each other 200 NEW ELEMENTS OF OPERATIVE SURGERY. by an opening of no greater length than that Avhich belonged to the thickness of their united (adossfie) Avails. But on the other side of the vein, between this vessel and the integuments, Avas an aneurismal pouch occupying the bend of the arm and extending itself (upAvards) to the loAver region of the arm. This sac, which was full of arterial blood, and which had all the characters of false consecutive aneurisms, communicated Avith the vein by an opening which was situated directly in front of that which united the vein to the artery. Though this arrangement differs totally from the descriptions that have been given up to the present time, the manner in which it Avas brought about seems to me susceptible of easy explanation, one much more simple also than that Avhich authors have given. What in truth is the lesion caused at the moment of bleeding'/ A simultaneous wound of the artery and the vein; the latter is pierced through and through ; one of its Avounds, viz., that Avhich is made in its posterior (profonde) wall, remains gaping and becomes united with that of the artery : if the first [i. e., the external Avound on the anterior surface of the vein—T.] should cicatrize, an aneurismal varix only is produced ; but if the projection of arterial blood into the vein is energetic, this fluid traverses the calibre of the vein, penetrates through the anterior (opposee) wound of this vessel, and the Avound of the integuments, however little compression may be made upon it, heals, Avhile the blood at the same time holloAvs out for itself a pouch in front of the vein and at the expense of the cel- lular tissue which envelopes it; and in this manner there is estab- lished an aneurismal sac Avhich will present the symptoms and progress of false consecutive aneurism. It differs hoAvever from this last, in these particulars; 1, that its walls are not formed by the external coat or cellular sheath of the arteries ; and 2, that the opening by Avhich it communicates Avith the arterial system, is not made in a direct manner, but through the intervention of the vein. I have remarked, says M. Berard in conclusion, that the mechan- ism of the formation of this kind of varicose aneurism Avas more easily explained than the other ; in fact in this last we are obliged to admit that a canal of greater or less length exists between the artery and the vein: but a condition Avhich is considered, if not in- dispensable, at least very usual in the formation of an aneurismal varix, is the agglutination (l'accollement) of the vein Avith the artery at the point Avhere the tAAro vessels are wounded. Now if a varicose aneurism should make its appearance at a later period, we are forced to admit that the two vessels are separated and de- tached from each other ; a result not easy to be explained. From these considerations, I am induced to believe that the form of vari- cose aneurism which I have discovered, is not new, and that it must have passed unnoticed in other cases. Having noAV pointed it out to the attention of surgeons, future dissections will invalidate or confirm the ideas which I have submitted to the judgment of the society. Remarks.—There is a precision of language, a clearness of ana. ARTERIES OF THE THORACIC LIMB. 201 tomical description, a force of reasoning in the communication ot M. Berard, Avhich are of themselves calculated to carry conviction to the mind, as to the accuracy of all his conclusions ; and Ave mis- take greatly, if a contribution like this upon a common yet hitherto almost unexplored point in surgical relations, pathology and treatment Avill not be generally deemed by the profession of the highest va- lue. It Avas for such reasons that Ave have endeavoured to incor- porate the whole substance of this surgeon's remarks with the text of this Avork. The distinctions between several phrases, but little or very imper- fectly understood, will Ave trust no longer lead to any confusion of the mind, especially as to the duty to be performed when young practitioners, already presumed to be thoroughly acquainted Avith the anatomy of the parts shall be suddenly called to such exigen- cies as they must expect to be from the carelessness and ignorance too often manifested in venesection; an operation, which even in this country, at the seat of its first great medical school (Philadel- phia,) is still often performed by respectable medical men Avith a rude instrument called the spring lancet, used by veterinary prac- titioners, and which is so Avell calculated to divide both vein and artery as well as other deep-seated and unseen parts with one clip of its uncontrolled blade. The student should always keep before the mind the exact ana- tomy of the parts and the anomalous course which the vessels sometimes take ; (Vol. I. and II.;) and Avith such advantages as the precautions so forcibly inculcated in the text by M. Velpeau, and with the important auxiliary information to be derived from a mo- nograph like that of M. Berard above, we cannot conceive how he can hereafter fail to comprehend with all the distinctness required : 1. What constitutes (a) an aneurismal varix; (b) a varicose aneurism; (c) a false consecutive aneurism; or (d) a false diffused aneurism, and how all of them may be contradistinguished from (c) a legitimate spontaneous aneurismal sac or pouch, Avhatever may be the shape or situation of this last, or what its apertures or modes of communication Avith the arterial trunks involved. 2. Nor find any difficulty in understanding how an aneurismal varix may exist alone, or at the same time and place with a vari- cose aneurism, or hoAV a traumatic aneurism may involve the wound of a principal artery only, and form a false consecutive diffused, or a false consecutive circumscribed aneurism—the first similar to the varicose aneurism, and the last differing from it in the charac- ters, as pointed out by M. Berard ; and both differing again from varicose aneurism properly so called, in this—that the contained fluid in all false aneurisms is almost exclusively arterial, and not as in true varicose aneurism, and also more strictly in aneurismal varix, a combination of venous and arterial blood. There is another important point to be attended to by the prac titioner, as Avell as by the student in the memoir of M. Berard: that is, the admirable opportunity Avhich diseased organic struc- tures so superficially placed, so isolated and so perfectly at our 202 NEW ELEMENTS OF OPERATIVE SURGERY. command, as it Avere, furnish, (as is seen in his lucid description of the various kinds of bruit of these aneurisms,) to put auscultation to the test, and extract from it all the real value it may possess as a guide for our researches, for example, into substernal and thoracic aneurisms—to say nothing of the light it may throAv on the still more obscure and contradictory, though so often examined subject of auscultation as applied to diseases of the lungs. Varicose Aneurism at the bend of the arm in bleeding, cured by pres- sure.—Mr. Liston, (See his lectures, London Lancet, Dec. 21,1844, p. 361,) says he has seen several cases of aneurism at the bend of the arm from the operation of bleeding, [Avhether varicose aneurism or aneurismal varix, or both, he does not specify. T.] completely cured, if acted upon immediately, and before the blood is much ef- fused into the cellular tissue. This cure consists in strong com- pression, beginning Avith the roller bandage upon each finger sepa- rately, and passing around the hand, in the palm of Avhich must be placed a compress. You proceed firmly with the turns upAvards, till you reach the Avound, over Avhich. after having properly adjusted upon it, first a small, and then three or four other compresses in or- der to obtain a proper elevation for them, you twist the remaining turns tightly over these, and in all probability, he says, you will pre- vent an aneurism. But Avhen aneurism is formed, it will do so speedily by the as- tonishingly rapid condensation of the cellular tissue, by Avhich means a regular cyst is produced. I have, says Mr. Liston, a preparation of an aneurism of two or three days' growth, Avith as regular and beautiful a cyst, as you Avould Avish to see in any aneurism. Cure by Pressure.—Mr. Liston believes that such aneurisms are sometimes cured by pressure ; Avhich should be made by bandag- ing the loAver part of the limb, by Avhich means the patient will be enabled to bear the pressure of a sort of ring-tourniquet on the brachial artery, maintained by a proper apparatus, Avhich admits of being regulated by the patient himself. In conformity with the sound vieAvs of pathology adopted by the Dublin surgeons, in the cure of aneurisms by compression, (See our note on compres- sion,) Mr. Liston says, it is only necessary to retard the flow of blood into the tumor, so as to favor coagulation of its contents ; and this is to be effected by continued but not violent compression. Mr. Liston says, he has seen more than one aneurism disappear in consequence of the application of pressure. One Avas a case of brachial aneurism, Avhere the pressure Avas made on the tumor itself, (See similar case in our note on Mr. Luke's case of tubular femoral aneurism.)—Mr. OldknoAV, according to Mr. Liston, (Ib. loc. cit.) a surgeon of Nottingham of extensive practice, had a similar case cured in the same Avay. There is no doubt, says Mr. Liston, that much is to be done for aneurism, in some situations, by pressure Avell applied. Where hoAvever, you have for such accidents to resort to ligature on the brachial on the arm above, be careful to ascertain, Avhile the artery is raised up from the edge of the biceps, that it is the trunk ARTERIES OF THE THORACIC LIMB. 203 which you will knoAV by pressure upon it suspending pulsation in the tumor. Otherwise from the occasional high division of the bra- chial you may tie only the ulnar. But Avhere the tumor from the anastomosis being so strong is not diminished, the ligature on the trunk of the brachial itself will not ansAver, and Ave are then to cut down on the tumor itself, and tie both ends of the wounded vessel, (See M. A. Berard's lucid ac- count of these aneurisms, above.) This M. Liston thinks the best plan in a recent aneurism in this part; also Avhere pressure had been imperfectly made on such aneurism, or ulceration had taken place over the tumor, producing alarming hemorrhage. In Avounds of the hand, laceration or evulsion of the thumb, or one or more fingers, where the superficial palmar branch has been wounded, and pressure proves ineffectual in preventing extensive tumefaction of the parts, inflammation, diffused aneurism, abscess, severe and repeated hemorrhages, &c, from effusion and infiltra- tion of blood from the Avound, M. Liston thinks, (London Lancet, Dec. 21, 1844, p. 362—363,) the best plan is to tie the brachial at once. It will not do to tie the radial or ulnar or both, for blood will still be furnished from the deep-seated palmar arch, by means of the inter-osseous. The Brachial Artery Ruptured.—A case is related, (Lond. Med. Gaz., May 16, 1845, p. 130,) in Avhich the brachial artery AA^as found ruptured and the upper extremity of the divided vessel re- tracted high up in the axilla. This accident occurred in a young man aged 18, from fracture of the head of the humerus and glenoid cavity, Avith protrusion of this extremity of the bone, caused by the arm being caught, in machinery. The patient was received into the infirmary of Newcastle-upon-Tyne, and died of erysipelatous symptoms occasioned by the injury, without any attempt being made to disarticulate the bone or to place a ligature on the upper extremity of the ruptured vessel. Spontaneous aneurism at the bend of the arm.—Mr. Liston, (Lond. Lancet, Dec. 21, 1844, p. 361,)'has seen but one case of true spontaneous aneurism, (i. e., Scarpa's, he means, or the giving way of the internal coats and dilatation of the external ones,) at the bend of the arm, viz. : in a stout middle aged man who attributed it to the use of the arm in wielding a mallet in driving bolts. From incautious blood-letting aneurism formerly occurred here quite often, and it does occur still from that cause. T.] Article V.—Axillary Arteries. § I.—Anatomy. Under the name of axillary artery I shall speak only of that por- tion of the arterial trunk, Avhich extends from the clavicle to a level with the loAver border of the great pectoral muscle. We may re- gard it in two points of vieAV, either in the hollow, or on the ante- rior surface of the axilla. 204 NEW system of operative surgery. A. In the first it is separated from the skin, only by the two roots of the median nerve, this nerve itself, the axillary vein, a cel- lular filamentous and adipose layer of tissue, increasing in thick- ness as we approach the apex of the axilla, and by the aponeurosis and a second cellular layer. The thoracic, sub-scapular, &c, cross it, and conceal it at different points ; the other nerves of the brachial plexus, at first situated in front of it, soon pass behind it to reach the ulnar side of the arm. Outwardly it rests against the tendon of the sub-scapularis muscle, and the scapulo-humeral articulation, the head and neck of the humerus, between the ten- don of the teres major, which is behind, and the pectoralis minor, or the coraco-brachialis, which are in front. B. In its other portion, (i. e., on the anterior surface of the axilla,) it is situated at a much greater distance from the skin ; the pectora- lis minor crosses it at tAvo or three inches in front of the clavicle; a fibro-cellular membrane, (toile) sometimes quite dense, conceals its position, (plan,) and separates it from the pectoralis major mus- cle. The vein is situated upon the inside, and tOAvards the chest, and the anterior root of the median nerve upon the outside and tOAvards the shoulder, so that both, in part, cover the artery, which is in the interval, and a little behind ; an arrangement nearly con- stant, and which may prove of the greatest assistance in the ope- ration. The cephalic vein, as Avell as those Avhich go from the stump (moignon) of the shoulder, to empty themselves into the axillary vein, beloAV the clavicle, are obliged to cross its anterior surface. It is the same Avith one or tAvo thoracic branches of the nervous plexus : the axillary artery gives off the acromial artery, and the principal external thoracic artery, before passing under the pectoralis minor muscle. C. Lower doAvn the median nerve is, in front, the ulnar outside, the radial behind, and the vein on the inner side of the artery, so that it is found almost completely surrounded by those parts, to which it is also united by a cellulo-fibrous sheath of considerable firmness. § II.—Indications. Aneurisms and wounds of the axillary artery claim the most se- rious attention. Though less frequent than at the ham, groin, and bend of the arm, they are more so than on any other points of the limbs ; Avhich is explained by the position and size of the vessel, its relations Avith the articulation, and its proximity to the heart. All kinds of aneurisms are found on this artery, even varicose aneu- rism has been seen hereby M. Larrey, (Clin. Chir., t. III., p. 142,) Dupuytren, and M. PL Portal, (Op. Cit., p. 204.) The reaction which they produce on the nerves, veins, and ganglions, and on the articulation, and on all the surrounding parts, make aneurisms of the axilla a serious disease, Avhich has long been a source of apprehen- sion to surgeons, and Avas generally looked upon as beyond the re- sources of art, until at the conclusion of the last century. ARTERIES OF THE THORACIC LIMB. 205 A.—Van Swieten, (Comment., t. I., § 161,) however, had already mentioned a traumatic aneurism in this region, Avhich got well spontaneously, Avithout necessitating the loss of the limb. M. S. Cooper also mentions a patient in St. BartholoineAv's hospital, who Avas cured of an aneurismal tumor in the axilla, Avithout any assist- ance. Sabatier effected the dispersion of another by the method of Valsalva, and refrigerants. But the patient was less fortunate in the folloAving case reported by Chabert: (Obs. de Chirurgie, p. 95 ; Obs. 41, 1724, in-12,) from the cut of a sAvord a slight hemor- rhage took place an hour after the Avound; a second hemorrhage on the eighth day, and a third on the eighteenth; the treatment Avas incision, compression, vitriol, &c. On the tAventy-fifth day a fourth hemorrhage, to a considerable extent; on the twenty-ninth day a fifth hemorrhage. The jet of blood equalled the size of the thumb, and Avas followed by instant death. The artery being laid open lengthAvise, Avas found dilated and engorged xvith coagulated blood up to the first rib. Hall, about the middle of the last century, and Keate, in 1801, tied the axillary artery Avith entire success. This operation, Avhich was then thought new, AAras not so. A surgeon of La Charite, Morel, (Jour.desNouv. Dccouv., 1681,t. UL,p. 70-75, Zodiac,M A.—Within the scaleni muscles, the subclavian artery, which is extremely short on the right side because of the brachio-cephalic trunk, has on its posterior surface some filaments of the great symphatic, then the pneumo-gastric, the phrenic and the branch of the pneumo-gastric which connects the second Avith the third cer- vical ganglion, cross its anterior surface—all which organs are then covered by the sterno-thyroid and sterno-hyoid muscles, various cellular lamellae, the internal border of the sterno-mastoid, the aponeurotic layers of the neck, and the common integuments. BeloAV, the recurrent nerve embraces it, Avhile its concavity is sepa- rated from the lung only by the pleura or cellular tissue. It is in this short space that it gives off the vertebral, the internal mam- ARTERIES OF THE THORACIC LIMB. 211 mary, the thyroid, the transverse cervical, the ascending cervical, the deep cervical, and the superior intercostal. On the left side the subclavian within the scaleni ascends almost vertically from' the arch of the aorta to the border of the first rib, separating itself bv degrees from the corresponding carotid. The pneumo-eastric nerve descends on its inner side ; the recurrent nerve does not cross it behind, because it is not until after it has embraced the arch of the aorta, that it ascends upwards tOAvards the trachea. The tho- racic duct lies very near its posterior surface, and ordinarily bridles it above, before emptying itself into the left subclavian vein. This vein, which is separated from it by a very considerable space crosses it at a great distance, Avhile on the right side the artery is principally covered by the termination of the internal jugular. [Ligature on the Subclavian Artery, within the Scaleni Muscles for Aneurism of the Subclavian—From a remark of Mr Liston' (See his Surgical Lectures at the University College Llospital Lon' don Lancet, No XL, Vol. IL, 1844, Dec. 7, p. 307, &c.,) we are led to infer that he has recently twice tied the subclavian on the inside of the scalenus muscle for aneurism. He considers the ligature upon the subclavian outside the scalenus, for aneurisms a little be yond this point and which are still situated above the clavicle as impracticable from want of room, owing to the crowding of the'tu- mor in such cases upon the sterno-mastoideus muscle. (Ib. Ib ) The subclavian portion of the brachial may be tied for aneurisms in the axillary portion ; but this is often exceedingly difficult from the size of the tumor and its extending so far upwards that you have perhaps, to trench on the scalenus muscle, and thus wound the phrenic nerve The advantage of pressing down the shoulder ff11°l beJobtfined Wlth lhe ^me facility as in the subject; and on ^(^p.^^ ^ ^ ^^ "^ ^ ^ ^ In all these and other aneurisms, Mr. Liston says he has found the common aneurism needle, like that of Weiss, quite sufficient, as he has put a ligature with it on all the vessels of the neck and a!l t7$J?TtremUlrS> (Ib,' ib" P- 3°8') but considers those of Gib- son, Mott, &c., complicated. (Ib. ib.) T.] B — Having become horizontal, the subclavian presents the same relations on both sides, andlies naked on the first rib ; the loAver Tt! nH ^Gn °J the anten°r SCalenus m"scle seP*ra^ * from the vehi and this latter separates it from the sternal portion of the sterno-mas- toid muscle ; all the nerves of the brachial plexus are above wd behind so as to form, in prolonging themselves on the anterior sir face of the posterior scalenus muscle, a kind of net-Avork, (gullT) of which the artery constitutes the first radius, (rayon ) g '' C _Outside the scaleni muscles, the subclavian artery corres ponds to the supra-clavicular depression, and rests against the" first intercostal space, the second rib, and the first bundle of he serratus magnus muscle. The vein Avhich approaches iL covers it while descending a little towards thSlavic£ receives there the sub-scapular vein, the external jugular, and soiSe 212 NEW ELEMENTS OF OPERATIVE SURGERY. the acromial veins. It is accompanied on its superior border by the united branches of the last cervical pair of nerves, and of the first dorsal; then, a little farther on by the other branches of the bra- chial plexus, Avhich soon pass behind; so that it is constantly found in the triangular space formed by the omo-hyoideus muscle upon the outside, the clavicle beloAV, and the anterior scalenus muscle on the inside. D. Anomalies.—I should remark that Ave sometimes find the vein with the artery betAveen the scaleni muscles and the artery, occa- sionally taking the place of the vein, and that I have myself observ- ed these two anomalies; Avhen the little scalenus muscle exists, it may, as Robert remarks, while attaching itself upon the rib, separate the two inferior cervical nerves from the superior branches, incline them forward and push them towards the vessels ; at other times it completely isolates the artery from all the nerves. The vein may be higher up than usual above the clavicle, or double, as Morgagni has seen it, and entirely conceal the artery, which latter is found more- over in certain cases, though rarely, surrounded on all sides by the brachial nerves ; the presence of a small muscle attached by itshvo extremities upon the clavicle, the insertion of the sterno-hyoid muscle on the inside of the sterno-mastoid, the insertion upon the clavicle of a second root, or of the inferior Avidened border sent off, (devie) from the omo-hyoid muscle to the clavicle, are also anoma- lies which the surgeon ought to be aAvare of. § II.—Indications. The subclavian artery being protected by the clavicle, and partly enclosed in the chest, or at least sheltered by the Avails of this cavity, is but little exposed to external agents. Exempted also from those alternations of flexion and extension which the axillary and popli- teal are obliged to assume, this artery is consequently disembar- rassed of a frequent occasional cause of spontaneous aneurisms. It is nevertheless, not invulnerable, and the diseases to Avhich the other arteries are exposed have often affected this. M. Larrey, (Clin. Chir., t. III., p. 142,) relates many examples of its Avounds from SAvords, &c. ; he has even seen tAvo cases Avhere they Avere followed by a varicose aneurism, (Bulletin de la Faculte,t. III., p. 27.) The subclavian artery hoAvever is tied not so much for the diseases that are proper to it, as for those of the axillary artery. Should, for example, an aneurismal tumor be developed in the su- pra-clavicular depression, though it may augment ever so little in volume, it will not be long before it will be impossible to place a ligature on the trunk which produces it, betAveen this tumor and the heart: let an aneurism on the contrary in the hollow of the axilla, enlarge in size and increase upwards to such extent as to raise up the shoulder, and the ligature must be applied above the clavicle. A. Spontaneous Cure.—Aneurisms Avhich a ligature upon the subclavian may cure, may like others disappear spontaneously in certain cases, as has been shoAvn by a case published by M. Ber- ARTERIES OF THE THORACIC LIMB. 213 nardin, (Archiv. Gen. de Med., t. VI., p. 511.) The method of Val- salva, refrigerants, &c, Avould also, Avithout doubt, arrest some of them. M. Richarme cites in his thesis an example of a cure obtained in this manner. A case is also mentioned (Jour, de Med. et Chir. Pratique, Septembre, 1830, t. I., p. 268.) of an arterial hemorrhage, from a sabre wound above the clavicle Avhich was arrested by pled- gets of lint, (bourdonnets,) dipped in Binelli water (eau de Binelli.) But as it is dangerous to let them take their course, and as the utility of these means is ahvays problematical, the wisest plan is to operate as soon as possible. B. Method of Brasdor.—The ancient method is not applicable in these cases. If it should not be practicable to employ the method of Anel, that of Brasdor is the only one that could be used in its stead. In that case, for a supra-clavicular aneurism it Avould not be upon the subclavian, that Ave Avould apply a ligature, but upon the axillary. Dupuytren is the first Avho attempted it upon living man. The patient it is true died at the expiration of nine days, on the 20th of July, 1829 ; but in the place of increasing in size as it was apprehended it Avould have done, the tumor had on the con- trary, diminished in volume, and in a great measure lost its pulsa^ tions; finally, repeated hemorrhages and one from a supplementary branch, and Avhich was at first attributed to the division of the prin- cipal artery, seem, much more than the operation itself, to have been the cause of death. The patient of M. Laugier, operated upon in the same Avay, lived a much longer time, and seems to have been the victim to accidents equally disconnected Avith the ope- ration. It must, hoAvever, be conceded that the axillary is one of those the least adapted to the method in question. The numerous branches that are given off from it constitute so many [collateral T.] chan- nels, through which the blood Avill continue to Aoav, and Avhich Avill prevent the aneurism from being consolidated, (se resoudre) unless they should have been previously obliterated by depositions of fibrine, or the progress of the disease. [The author doubtless means here, as one of the most frequent causes of such obliteration of the collaterals, the pressure of the increased size of the aneurismal sac itself on those collaterals. T.] The branches Avhich the subcla- vian gives off Avithin the scalenus, Avill constitute an obstacle not less formidable to the success of this mode of operating, so often as the disease shall have extended to that part. But as it is practicable to apply the ligature very near the sac; as it is possible that the in- ternal concretions of the aneurism may have diminished, or even closed up the calibre of these arteries, and as the least resist- ance sometimes to the course of the blood suffices to produce coagulation in the sac, I am of opinion, that Ave ought to make trial again of Avhat Dupuytren has done. C. Method of Anel.—In folloAving out the principles of Anel the ligature upon the subclavian has been applied at three different points of its course, Avithin the scaleni, betAveen the scaleni and on the outer side of these muscles. 214 NEW ELEMENTS OF OPERATIVE SURGERY. § HI.—Operative Process. A. Within the Scaleni. I. Process of Colles.—M. Colles, (Rev. Med., 1834,1.1.,p. 438.—Gaz. Mcd., 1834,p. 119,) M. Mott, (Gat. Med. de Paris, 1838, p. 600,) and M. Liston, are the only persons to my knowledge Avho have ventured to lay bare the subclavian artery between the trachea and the anterior scalenus muscle. A great difficulty Avas experienced in placing the ligature around the vessel, and it was supposed in one case that the pleura had been slightly Avounded. Before the thread Avas tied, the respiration became laborious, and the patient complained of a feeling of com- pression near the heart. These symptoms became so alarming in the patient of M. Colles, that it was not thought advisable to tighten the ligature before the fourth day. The patient did very well up to the ninth day ; at this epoch he again experienced strangulation and an acute pain in the cardiac region ; delirium supervened and death took place nine hours after the commencement of these symp- toms. On opening the body the aorta as Avell as the whole extent of the subclavian Avere found diseased. The case of M. Liston did well up to the ninth day, though at the time of the operation a li- gature had been placed also, upon the corresponding primitive carotid, after an unsuccessful attempt at electro-puncture. II. Process of the Author.—To arrive upon the arterial trunk, if we should not wish to folloAv the process of M. King, (These No. 15, Paris, 1828,) it would be necessary to cut transversely upon the sound, the root of the sterno-mastoid muscle, to de- press the internal jugular vein towards the trachea, the subcla- vian vein doAvmvards and forwards upon the clavicle, and also to push back the carotid, the phrenic nerve and the pneumo-gas- tric. On the left, moreover, Ave should run the risk of Avounding the thoracic duct (canal thoracique,) and should be obliged to penetrate much deeper; but it would not be impossible to place the ligature between the origin of the mammary and vertebral arteries, &c, and the heart, Avhile on the right, the proximity of the brachio-cephalic trunk would render such an attempt one of the greatest danger. III. In Avhatever manner performed, the ligature of the subcla- vian betAveen the anterior scalenus muscle and the trachea, will be a laborious and formidable operation. As on the other hand we can scarcely conceive that it Avould suffice, when carried farther out- ward it should have offered no chance of success, I cannot see Avhat could authorize its application. B. Between the Scaleni Muscles.—Nor should it ever be per- formed betAveen these tAvo muscles, unless the state of the parts should absolutely forbid our applying the ligature outside of them. It is not that its execution is very difficult or that it might not suc- ceed, but that the advantages it procures may be otherwise ob- tained, and that the section of the scalenus in itself an inconveni- ence, exposes us besides to the risk of wounding the internal jugu- ARTERIES OF THE THORACIC LIMB. 215 lar, or the subclavian vein itself, as well as the two nerves of re- spiration. The ligature applied upon the axillary artery, in the holloAv of the axilla, and according to the method of Brasdor, Avould offer more prospect of success, less danger, and infinitely fewer difficul- ties. I. Process of Dupuytren.—This is the manner in Avhich Ave would reach the trunk of the subclavian between the scaleni, in following the process of Dupuytren. We make at the base of the neck a transverse incision, Avhich extends from the anterior border of the trapezius muscle, to the inner border of the sterno-mastoid, and Avhich is prolonged even a short distance upon the outer side of this last muscle. After having satisfied ourselves that Ave have come down to the anterior scalenus, we insinuate betAveen its pos- terior surface and the artery the extremity of a grooved sound, upon Avhich Ave divide the muscle. By this section alone the ar- tery is laid bare and completely isolated. The posterior scalenus serves as a guide to the eyed probe which bears the ligature. C. Outside the Scaleni.—It is in the omo-clavicular triangle, or on the outside of the scaleni muscles, that the subclavian artery should be and has more especially been tied. I. Process of Ramsden.—A transverse incision an inch and a half long, is first made above the clavicle ; a second is then made two inches long, parallel to the outer border of the sterno-mas- toid muscle, and which falls at a right angle upon the first; after having depressed the shoulder, M. Ramsden continues the dissec- tion of the tissues in order to lay bare the border of the anterior sca- lenus ; the artery is then easy to reach. Having isolated it Avith the nail he Avished to pass a ligature around it; numerous difficulties presented themselves ; it Avas found necessary to resort to a variety of movements; and it was not until after a very great number of trials and a considerable lapse of time that he succeeded in termi- nating this operation, Avhich had been begun so auspiciously; the patient died on the sixth day. II. Another Process.—M. T. Blizzard made an incision three inches long, parallel to the external jugular vein, at the loAver part of the neck and tOAvards the acromion. Post commencing his inci- sion at the outer border of the sterno-mastoid, divided the tissues in the direction of a line slightly oblique in relation to the clavicle. M. Porter made a horizontal incision above the clavicle, then a vertical incision outside the sterno-mastoid muscle, and turned back the triangular flap thus formed. M. Dubled on the contrary pro- poses that the incision of the skin should be directed obliquely from above dowmvards and from Avithout inwards, to make it terminate near the sterno-clavicular articulation. According to M. Hodgson the Avound should be altogether transversal, and it is this last pre- cept Avhich unquestionably offers the greatest number of advan- tages. I do not think that the advice formerly given by a member of the Academy of Surgery, to include in the same ligature both the artery and the clavicle, should ever be folloAved. I have diffi- 216 NEW METHODS OF OPERATIVE SURGERY. culty also in comprehending Avhat reasons could have induced M. Cruveilhier (Etud. Anatom., t. II., p. 609) to say, that it Avould be advantageous to saAV this bone in order to tie the subclavian Avith greater security. III. The Process to be followed.—The patient should be placed upon his back, Avith his chest a little elevated; his head and neck should be turned to the sound side, Avhile an assistant depresses the shoulder as much as the aneurism Avill permit, by raising (en ecar- tant) the arm from the body. A. First Stage.—The integuments are then divided in a trans- verse direction at an inch above the clavicle, and from the anterior surface of the sterno-mastoid muscle doAvn to the trapezius ; we divide in the same direction the cellular tissue, the fibres of the platisma myoides, and the external jugular itself, after having tied it above and below, if we cannot keep it out of the Avay by push- ing it by means of a blunt erigne, either fonvards (en avant) or backwards ; Ave soon arrive at the aponeurosis Avhich in its turn is also cut; then the fore-finger may feel the border of the scalenus immediately below and on the inside of the sterno-mastoid. B. Second Stage.—After having torn apart or separated the cellular tissue, and the lamellae, filaments, and ganglions, at the bottom of the wound, with the extremity of the sound or a good dissecting forceps, Ave apply the finger near the root of the scalenus to identify the tubercle of the first rib. This tubercle is a sure guide here, so much so, that if the pulp of the fore-finger without being taken off from it is carried a little outAvard and back- wards, it almost constantly falls upon the vessel. Being once found the eye is no longer indispensable. The nail applied against its posterior and outer side serves as a director to the curved sound or to the needle Ave are using. C. Third Stage.—By making the point of one of these instru- ments pass from before backAvard, and slightly from Avithout in- ward, you soon get it under the artery Avhich you raise up, at the same time that the finger placed between it and the first fasciculus (faisceau) of the brachial plexus, assists in supporting the vessel, and preventing its escape. When the shoulder is not too much deformed, or too much raised up by the tumor, or Avhen it is possible to depress it Avithout in- convenience, any person possessed of tolerably accurate anatomical knoAvledge may succeed in applying this ligature with much less difficulty than is supposed. IV. The section of the omo-hyoideus muscle proposed by some persons, and of the external border of the sterno-mastoid, as still practised by M. Mayo and M. Liston, is altogether useless. The assistance of the sound Avhich should be preferred after the division of the aponeurosis, enables us to avoid the plexus formed by the confluence of the small veins of the shoulder and neck when they empty into the subclavian. To avoid also at the same time this latter vein nothing more is ever required than to pass the end of the director under it and near to the scalenus before directing the ARTERIES OF THE THORACIC LIMB. 217 point of the instrument backward Avith the view of hooking up the artery. Finally, inasmuch as the subclavian artery in the normal arrangement of the parts is constantly the first moveable cord that is felt by the finger on leaving the tubercle of the rib, and that the nerves moreover are distinguishable from it by their rounded form and their solidity, Ave cannot see Avhat can lead to any mistake on the part of the operator. I). Method of Brasdor.—M. Wardrop has tied the subclavian artery, by the method of Brasdor, for an aneurism of the brachio- cephalic trunk, in a patient whose corresponding carotid obliterated by the tumor soon after recovered its permeability. The success at first appeared complete, but after a certain time the aneurism began to enlarge again, and Madame Desmarest, Avho was the patient, died on the 13th of September, 1829. I will return to this case a little further on, and will confine myself to remarking, that it A\rould be better in the event of our wishing to treat a lesion of the subclavian by this method, to place the ligature upon the artery immediately under than above the clavicle. E. Consequences of the Operation.—The mortification of the limb Avhich seems to be dreaded so much after the obliteration of the subclavian, is a circumstance that rarely occurs. In the patients of MM. Ramsden, Colles, Blizzard and Mayo, the phenomena noticed Avere suffocation, delirium, symptoms of cerebral affection, and implication of the heart or its envelope. After death there Avere found traces of pericarditis, diseased condition of the aorta or heart, and inflammation of the brain, but no gangrene. In some cases the circulation is re-established even Avith a remarkable rapi- dity ; in the patient of M. Roux the pulsations reappeared in the radial and ulnar arteries tAvo days after the operation. The blood is brought back into the axillary or the brachial, by the anasto- moses of the internal mammary Avith the thoracic and the circum- flex, and of the acromial and common scapular Avith the posterior cervical and the supra-scapular. If the ligature Avas placed Avithin the scaleni beyond the vertebral and mammary arteries, the fluids could not arrive in the diseased side but by the communication of its vessels with those of the sound side. F. History and Appreciation.—M. Ramsden, who performed his operation in November, 1S09, appears to have been the first Avho actually tied the subclavian artery. Some time before him, M. A. Cooper had tried, but in vain, to seize this vascular trunk; he tied a nerve instead of it, and the patient soon died of hemorrhage. The same misfortune happened afterAvards, under another form, to M. Lallemand, (Dubreuil, Gaz. Mid. de Paris, 1837, p. 563.) To re- lieve a hemorrhage of the axilla, this professor Avished to tie the subclavian artery, but could not succeed; the patient died on the day after. The vein Avhich was between the scaleni Avas at the dis- tance of nine lines beloAV the artery. In the month of April or May, IS 10, a woman, aged about sixty years, Avas admitted into the Hotel Dieu of Paris, for an enormous aneurism in the axilla. Dupuytren believed that the operation of the ligature of the sub- 218 NEW ELEMENTS OF OPERATIVE SURGERY. clavian could and ought to be performed ; Pelletan (Dubreuil, Gaz. Med. de Paris, 1837, p. 563) Avas of an opposite opinion, and the patient died after a lapse of a few days Avithout having been oper- ated upon; a sufficiently long time, hoAvever, after the attempts of MM. Cooper and Ramsden, to prevent our making any claim to priority in this matter. A very aged and debilitated subject, operated upon in 1811, by M. W. Blizzard, also died on the fourth or fifth day. The same happened Avith the patient of M. Galtie in 1814. M. Th. Blizzard and M. Colles were not more fortunate in 1815. But complete success attended the operation of Post in 1817, and afterAvards those of Dupuytren, MM. Liston, Bullen, Green, Gibbs, Key, Roux, Lan- genbeck, Mott, Porter, 1838> P« 60°- Total, 43—cured 34, dead 7. 238 NEW ELEMENTS OF OPERATIVE SURGERY. II. For Wounds, Ulcers, and Hemorrhage. Guthrie - dead - Op. Cit., London, 1830. Duffin - id. - The Lane, Vol. I., p. 587, 1829, Vol. IL, p. 638. Michon - cured - Lane. Jr.,t. XII., p. 475. Roux - cured - Wounded of July, 1830. Larrey - cured - Clin. Chir., t. IL, p. 120—130. Mayo - cured - Bull, de Ferussac, t. XXL, p. 123. Arch. Gen. de Med., t. XXII.) p. 117. Gaz. Med., 1827, p. 329. Syme - cured - Ed. Med. fy Surg. Jour., 1833. Arch. G., 2e serie., t. II., p. 108. Sisco - cured - Annal Univ. de Med., 1829. Bull de Ferussac, t. XXII., p. 446. Forner - cured - American Jour, of Med. Sciences, 1832 ; Arch. Gen., 2e. ser.,t. I., p. 572. - cured - Arch. Gen. de Med., t. VIIL, p. 45. - cured - Rev. Med., 1836, t. IL, p. 423. - cured - Med. Chir. Trans., Vol. III., p. 2. - cured - West Journal Med. fy Surg., Vol. I., p. 425. - cured - Hodgson, t. III., p. 25. - cured - Guthrie, p. 326. - cured - Ed. Med. <$• Surg. Jour., t. XIV., p. 106. - cured - Jour. Hebd., t. III., p. 451. - cured - Trans. Med., 1833, p. 360. - cured - Med. Chir.'Trans-, Vol. VII., p. 107. - dead - Surg. Obs. Jour., p. 115. - cured - Presse Med., t. I., p. 73. - dead - Hodgson, t. IL, p. 39. - cured - Jour. Hebd., t. II., p. 7. - dead - Hodgson, t. IL, p. 44. - cured - Bull, de Ferus. t. X., p. 286. - dead - Hodgson, t. II., p. 45. - cured - Arch., 2e ser., t. IL, p. 108. Total, 27—Cured, 21—Dead, 6. HI.—For Erectile Tumors. Fungus. - Cured Hodgson, t. IL, p. 15, Mid. Ch. Trans., vol. VI. - dead Jour, des Prog., 2e sgr., t. IL, p. 262. - dead Tarral. Arch. G., 2e ser., t. VII., p. 22. - dead Unpublished, 1835. - unsuccessful Jour. Hebd. Univ., t. II., p. 117. Boileau Tyerman Flemming Miller Hebenstreit Luke Brown Dacrux Garrey Collier Abernethey Bedor Dupuytren Maurin Marjolin Travers Giroux Cheyne Dalrymple Mussey Walther Velpeau Willaume ARTERIES OF THE NECK. 239 Wardrop unsuccessful Pattison cured Clellan cured Kuhl dead Delpech unsuccessful Travers cured Bernard cured Hall cured Rogers cured Mayo dead Arendt cured Dupuytren unsuccessful Busk cured Bushe cured Davidge dead Maunoir unsuccessful Roux cured Peyrogoff, in-fant 9 mos £ dead Zeis, infant of > dead 15 months Jameson imsuccessful Machlachlan dead Hodgson, t. IL, p. 82. Burns, Surg. Anat., p. 465-476. The Lancet, 1828, vol. I., p. 715. 2 cas, a 3 m. de dist., Ency. Med. 1836, p. 131. Tarral, Arch. Gen., 2e ser., t. VI. Med. Chir. Tr., vol. L, p. 222, or vol. II. Rev. Med., 1833, t. III., p. 26, Tarral, Op. Cit.; Burns, Op. Cit., p. 485. Amer. Jour, of Med. Sc, 1833. Quarterly Rev. Jour., 1834, p. 411. The Lancet, vol. XV., p. 116. Sec. Oral. Rep. d'Anat. et Ph., t. VI., p. 232. Med. Chir. Rev., April, 1836, p. 184. The Lancet, 1828, vol. IL, p. 413. Burns, p. 481. S. Cooper, Art. Aneur. Berard, Diet., t. VI., p. 422. Ann. der Ch. de Dorpat, 1837, Rev. Med., 1838, t. III., p. 422. Rev. Med.,1838, t. III., p. 404. Burns, Surg. Anat., p. 480. Glasgow Med. Jour., 1828. Total, 26—Cured, 11—Dead, 9—Unsuccessful, 8? IV.—For the Removal of Tumors, fyc. dead cured Langenbeck Fouilloy Mayer Stedman AavI Eckstrum Beclard Warren Scott Tarle Gibson Flaubert Arch. Gen. de Med., t. XIX., p. 118, Diet, de Rust, t. IL, p. 11. Arch. Gen. de Med., t. XXVIIL, p. 599. cured The Lancet, vol. XIV., p. 174. cured Gaz. Med., 1S32, p. 529. cured West. Med. and Surg. Jour., vol. I., p. 423. unsuccessful Bullet de Ferussac, t. VIIL, p. 204. dead Arch. Gen., t. IV., p. 62, Berard, Diet. t. VI., p. 434. cured On Tumors, p. 292. dead Lond. Med. Gaz., vol. IX., p. 951. cured lb., p. 374. cured Amer. Jour, of Med. Sc, v. XXVI., p. 505. cured Voranger, These, No. 85, Paris, 1836, Arch. Gen. 2e ser., t. XII., p. 343. 240 NEW ELEMENTS OF OPERATIVE SURGERY. Goadlad Magendie Palmi Kuhl Baravero Lisfranc Gensoul Fricke Graefe Mott Mott Mayo Seutin Widmer Total, 26- Preston Liston Total, 3. Wardrop 2 Busch Montgomery cured cured dead Fearn cured Morrison Rigen Tillanus Lembert Evans dead dead dead dead cured Mott Key dead Total, 12—Cured, 4- cured Med.-Chir. Trans., vol. VII., p. l.,p. 112. unsuccessful Bull, de Feruss., t. XII., p. 253. dead Kock, Dessert., &c., 1831. dead Peters, These, Leipsic, 1836. unsuccessful Bull, de Feruss., t. XII., p. 234. dead Arch. Gen. de Med., t. XIV. p, 112- 114, Rev. Med. These, 1S34. dead Lett. Chir., &c, 1833. dead The Lancet,vo\. IL, p. 670. cured Mag. de Rust, et These de Koch. cured Arch. Gen. de Med., t. XXVIL, p. 246. dead New York Med. and Phys. Jour., v. 11., p. 401. unsuccessful Lond. Med. Jour., 1827, Nov., p. 408. cured Jour. des. Sc. Nat. de Bruxelles, Nov. 18, 1829. cured L'Exper., t. II., p. 336. -Cured, 12—Dead, 10—Unsuccessful, 4. V.—For Diseases of the Head. 1,'2 Gaz. Med., 1833, p. 76. unsuccessful Ed. Med. and Surg. Jour., v. XVI, p. 73. VI.—Method of Brasdor. 1 M. Vilardebo, These, 1831. The Lancet, 1828, No. 2, p. 149. Berard, Diet. 6, p. 418, The Lancet, June, 1833, p. 421. Arch. Gen., 3e ser., t. II., p. 364,recid. 1838. Arch. Ibid., p. 369. Lettre Privze de M. Kerst. Ibid. Arch. Gen. de Med., t. XV., p. 441. The Lancet, 1828, vol. I.,et Vilardebo, t. IV., p. 58. Amer. Jour, of Med. Sc., IS30, Jour. des Progres, t. II., p. 262, 2e sir. Lond. Med. Gaz., July, 1830. -Dead, 8. dead VII—The Arteria Innominata. Mott Graefe dead Burns, Surg. Anat., edit., 1823. dead Jour, de Graefe et W., t. III., et IV. ARTERIES OF THE NECK. 241 Bland dead Amer. J. of the Med. Sc, 1833,rp. 509. Hall dead Arch. Gen ,2e ser., t. VI., p. 267, Bal- timore Med. Journ., vol. L, p. 125. Kuhl dead Peters, Dissert,&c, 1836. Lizars dead The Lancet, June, 1837, p. 600. Total, 6—Dead, 6. General Total, 143—Cured, 82—Dead, 46—Unsuccessful, 13— Doubtful, 2. § III.—Operative Process. The ligature upon the trunk of the carotid is generally of easy execution, and the mode of doing it varies but little. A. Ordinary Process.—The patient should be laid upon his back, with his chest slightly elevated, the neck a little extended, and his face turned tOAvards the healthy side. I. First Stage.—The surgeon, placed on the diseased side, first seeks for the anterior border of the sterno-mastoid muscle, which is indicated to him by a slight depression, and then makes, in the direction of this border, an incision of about three inches in extent, which commences on a line with the cricoid cartilage, and termi- nates near the sternum, provided Ave wish to lay bare the artery in the omo-tracheal triangle. This incision, on the contrary, is pro- longed a little higher, and not quite so low, Avhen the disease ad- mits of our applying the ligature in the omo-hyoid triangle. A second cut of the bistoury divides the platisma myoides, and the cervical aponeurosis, and lays bare the fibres of the sterno-mastoid muscle. The assistant draws the inner lip of the Avound tOAvards the median line. The operator having drawn its external and mus- cular lip to the outside, by means of the left fore and middle finger, omits the extension, inclination, or throAving back of the head, and then divides the fibro-cellular layer, Avhich extends from the sterno- hyoid and thyroid muscles, to the posterior surface of the sterno- mastoid, and upon the fore part of the vessels. II. Second Stage.—The omo-hoideus muscle is uoav seen under the form of a reddish bandelette; if it interferes too much Avith the action of the instruments, Ave divide it upon the director; but Ave can generally save it by draAving it out of its place to one side or the other; above and below are seen the vein and the artery, en- veloped in their common sheath, Avhose anterior Avail encloses the descending branch (filet) of the ninth pair. This sheath should be first perforated opposite to the artery, and not the vein, by means of the point of the director, then divided upon the same instrument with the bistoury, to the extent of an inch or two. When the jugular swells so much during the inspirations as to conceal a part of the carotid, and to embarrass the operator, Ave compress it near the upper angle of the Avound, and it immediately shrinks, (s'affaisse.) III. Third Stage.—The sound, held as a writing-pen, is then 16 242 NEW ELEMENTS OF OPERATIVE SURGERY. passed between the two vessels; one or tAvo fingers of the other hand hold the artery fast and prevent it from slipping tOAvards the trachea, while, by gentle movements forwards and backwards, Avhile making pressure on the point of the instrument, Ave reach its posterior surface, in such manner as to raise it Avithout effort, and without being obliged to touch either the pneumo-gastric nerve, the great sympathetic, or any of their branches. B. Remarks.—If we Avere to strike at first within the sterno- mastoid muscle, Ave should run the risk of confounding this fleshy bundle Avith the sterno-hyoid, and of being thus led astray; it is therefore better to cut upon its outer surface, and at the distance of some lines outside of its border, Avhich latter it is ahvays easy to bring afterwards upon a line Avith the wound of the integuments. If, unfortunately, the jugular vein should happen to be opened, I do not knoAV Avhether it would be better to tie it or to stop the hemorrhage by tents, (le tamponnement.) MM. Simmons and Miller (Western Med. fy Surg. Jour., vol. I., p. 425,) have, it is true, applied the ligature to it Avithout difficulty, and the tents Avould oblige us to leave the Avound open; nor had M. Gibson, in 1830, M. Stevens in 1832, nor M. Dugas (Gaz. Med. de Paris, 1837, p. 298) since, any fear in surrounding it with a double ligature. The liga- ture has also been applied to it by M. Warren, (Communicated by the Author,) and by M. Widmer, (Experience, t. IL, p. 336,) with- out difficulty. But to say nothing of phlebitis, which in this case is the most formidable consequence to apprehend, who would not hesitate in suddenly obliterating so large a vein at the same time with the principal artery of the head ? If the wound Avere small, it would be prudent to pinch it with the forceps, and to bring its lips together and secure them with a ligature laterally, in such manner as not to shut up the calibre of the vessel. The patient upon whom M. Guthrie (Oper. Cit., p. 328,) operated in this man- ner, died in consequence of a ligature which it was afterwards found necessary to place upon the carotid. C. Process of M. Sedillot.—In order to come down perpendicu- larly upon the artery, and to have a wound more neat and of less depth, and which will give a more easy egress to the discharges, M. Sedillot (Nouv. Bibliot. Med., 1829, t. IL, p. 63,) has proposed a neAV process for tying the carotid at the loAver part of the neck. This incision, carried much further outwardly than in the ordinary mode, falls upon the outer side of the sterno-mastoid muscle, the whole substance of Avhich, betAveen its two roots, must be divided; the lips of this wound being held apart Avith the fingers by intelli- gent assistants, or by hooks, we come immediately in front of the vein and artery, which we have nothing more to do than to isolate. This process is practicable and ingenious; but it Avould be, if I do not deceive myself, less easy and less sure than the pre- ceding. Consequently I do not think it should be exclusively adopted, but that it should be reserved only for particular cases. D. Consequences of the Operation.—When the carotid is oblite- rated, the circulation is soon fully re-established in the correspond- ARTERIES OF THE NECK. 243 ing side of the neck and head; the voluminous and almost innume- rable anastomoses which it contracts in the brain, with the verte- bral and internal carotid of the opposite side ; those Avhich are es- tablished by the temporals, occipitals, supra-orbitars, facials, Un- guals, thyroids, superior and inferior ; in a Avord, by all the branches of the external carotids,—form too vast a net-Avork to allow of our having the least uneasiness on this subject. We should rather have to fear that these resources, so valuable and for so long a time over- looked, might not jeopardize our success, by bringing too much blood into the tumor after the operation. This is, in fact, an in- convenience which we meet Avith; we have seen the pulsa- tions in the aneurism at first diminish, and soon after reap- pear and be kept up for several weeks. In the patient operated upon by M. Walther, for aneurism of the external carotid, they con- tinued for two months. We should, indeed, have difficulty in com- prehending, if observation had not demonstrated the fact, how the ligature upon the primitive carotid could cure aneurismal affec- tions as remote as those, for example, of the orbit, the face, and ex- terior of the cranium ; but it is proved to-day that this reflux does not always hinder the tumor from being dispersed—that refrigerant applications and compression, morever, co-operate in promoting this resolution, or, at least, in accelerating it when it is too tardy. The successful results enumerated in the preceding table sufficiently establish this point. We are not, however, to conclude, therefore, that the oblitera- tion of the carotid artery involves no danger. If M. Tuson, in advancing the proposition that it ought in some sort to be pro- scribed in sound surgery, has extravagantly exaggerated its danger, we must also admit that most surgeons impute too little importance to it. The patient of M. Gonnet Avas attacked with serious acci- dents before being cured. That of Abernethey died in delirium and convulsions. One of those of Dupuytren died from prostration, (adynamie,) probably from purulent infection, like one of mine. In- flammation of the sac, caused the death of those of Cline, A. Cooper, and M. Key. Another, operated upon by M. Key, and one of the patients of M. Langenbeck, died in less than tAvo days from the destruction of the functions of the brain. Incipient paralysis took place in the cases of MM. Mayo, Sisco, Molina, and Zeis. The patient of M. Horner was seized with aphonia. An actual and complete hemiplegia took place in at least five cases, (Magendie, A. Cooper, Baravero, Vincent, and Macauley,) and one of the pa- tients operated upon by me was also attacked Avith it. Abscesses and hemorrhages from the upper end, (le bout superieur,) as in the case of M. Lisfranc and in one of mine ; phlebitis, inflammation of the air passages and the viscera of the chest, are also among the consequences calculated to make the ligature upon the carotid a serious operation. \ 244 NEW ELEMENTS OF OPERATIVE SURGERY. Article IV.—Ligature upon the Trunk of the Carotid, ACCORDING TO THE NATURE OF THE DISEASE. § I.—Wounds.—Hemorrhages. In cases of wounds the ligature of the carotid cannot in respect to the mode of operation be subjected to fixed rules. The opera- tion should then be performed after the method of Keisler, or ac- cording to the rules laid doAvn in the chapter on diffused aneurism and arterial Avounds in general. It is consequently upon the bot- tom of the Avound itself or opposite to the Avounded point of the artery, that Ave are to operate in order to seize the vessel, and not upon the region Avhere it Avould be most easy to reach it. Another peculiarity of Avounds of the carotid and its branches is, that unless it is found wholly impracticable to do so, there must be a ligature placed both beloAV and above the division. Otherwise the hemor- rhage in fact might be kept up, by means of anastomoses from the upper end of the artery; under this point of vieAV Avounds of trie carotid may be compared to those of arteries of the hand or fore-arm and of the foot or leg. Because a single ligature has suf- ficed for the cure in certain cases, we are not therefore to conclude that it is generally unnecessary to apply tAvo. § II.—Aneurisms. If the aneurism which renders a ligature upon the carotid neces- sary, should be situated in the neighborhood of the parotid region, the operative process Avhich I have described above is applicable to it in every particular. But Avhenever it is of large size or descends down to a level Avith the larynx, the manipulation can no longer be so simple. In that case we are obliged to commence the incision loAver doAArn and to prolong it to near the sternum or even upon the anterior surface of that bone. M. Mayo in fact in one of his pa- tients Avas obliged to divide the inner portion of the sterno-mas- toid muscle, in order to arrive at the trunk of the carotid artery. In such cases also the larynx or the muscles are displaced to such extent as to change in part the relations which I have pointed out above. We cannot expect to find therefore in such cases any other guide than that Avhich is to be obtained from a profound know- ledge of the anatomy of the region, and from the, carotid tubercle of the sixth vertebra. § III.— Varicose Aneurism. The examples of varicose aneurism observed by M. Larrey, (Clin. Chir., t. III., p. 149, 154,) M. Willaume and M. de Noter (Mem. de la Sac de Med. de Gand., p. 192,) and lastly by M. Kuhl, (Encyclog. Med., 1S36, p. 131,) M. Jorret, (Private communication, 1S3S,) and M. Rufz, (Private letter, March, 1S3S,) prove that the ARTERIES OF THE NECK. 245 -carotid like all other arteries is liable to this disease. Only that the position of the head appears to me to render varicose aneurism in this region less inconvenient even than upon the limbs. In other respects, if it should produce symptoms so alarming as to oblige us to attempt a radical cure, it Avould be proper as in those of the arm, to tie the artery both above and beloAV the point of communication, if the operation should not be found too difficult. In the contrary case there Avould be room to hope that a single ligature beloAV Avould in most instances suffice. § IV.—Erectile Tumors. When a ligature is to be placed upon the primitive carotid artery for erectile tumors of the head, Ave may proceed exactly in con- formity to the rules laid down for the operative process. As all the organic tissues of the carotid region retain in that case their na- tural position, Ave are enabled to make choice of the place Avhere the artery can be reached Avith the greatest ease. But then the ques- tion may often arise Avhether Ave should rather tie the primitive or the external or the internal carotid. Whether in place of tying one of the common carotids, it Avould not become necessary after the example of MM. Mussey, Kuhl and Langenbeck, to tie both. As these questions in no respect change the operative process itself, I shall not discuss them until I come to the chapter upon erectile tumors. § V.—Various Tumors. The preceding remarks are applicable also to the various tumors whichjhave been thought to require a ligature upon the carotid trunks. It is in fact readily perceived that these tumors Avhen situ- ated upon the head, leave the sub-hyoid region perfectly free, and in no manner interfere Avith the manual of the operation. On the supposition that they should exist in the neck, in the body of the thyroid or parotid gland for example, they would require the same precautions as for an aneurism in those regions. I cannot however understand Iioav a ligature upon the carotid should be had recourse to with the vieAV of arresting the development or nutrition of a fun- gus, or of any cancerous tumor whatever. § VI.—Operations on the Face or Neck. When the carotid has been tied in operations upon the face, the parotid region or the thyroid body, Ave have been governed by the rules Avhich belong to two different conditions of the parts. If, as happened to Beclard and M. Warren, the artery has been unavoidably wounded during the operation, Ave must proceed as in the circumstances for wounds in general, that is, Avhile an assistant makes compression between the Avound and the heart, we must 246 NEW ELEMENTS OF OPERATIVE SURGERY. immediately seek for the lower end and then the upper end of the divided vessel, and in this manner apply the two ligatures. Upon the supposition on the contrary that we Avish to tie the artery previously, as I have done in a case Avhere I had to remove an enormous cancerous tonsil, as MM. Graefe, Palmi, Mott, Awl, and a great number of other practitioners have done, before extir- pating the thyroid, disarticulating the lower jaAV, or removing paro- tid tumors, the operation Avould be quite simple, and would be regulated by the rules of the general operative process. § VII.—Neuralgia. Supposing that any one Avere disposed to follow the suggestion of M. Preston or M. Liston, and tie the carotid for nervous affec- tions of the head, it would be a case Avhere the operation evidently would present the greatest degree of simplicity ; but as hemiplegia not unfrequently results from the operation itself, we cannot com- prehend why M. Preston should have tied the carotid for the cure of hemiplegia. The patient operated upon by M. Boileau, and Avho Avas epileptic, continued nevertheless to have paroxysms after the obliteration of the vessel. Here was a fact ascertained which should have deterred M. Preston from unnecessarily exposing the life of an epileptic, in whom he vainly attempted to effect a cure by a ligature upon the carotid. The failure of M. Liston, also, shows hoAV irrational it was to place a ligature upon the carotid for the purpose of relieving a simple neuralgia. § VIIL— Method of Brasdor. If, in place of applying the ligature upon the carotid by the method of Anel or by the ancient mode, we should choose that of Brasdor* this process has nothing in addition peculiar in its ma- nipulation, except that the incisions should be made a little higher up than in the preceding cases, and that Ave must lay bare the ar- tery in the omo-hyoid triangle, and in the neighborhood of the great horn of the os hyoides. We shall see, moreover, in the fol- lowing articles, what we have to expect from this method when applied to aneurisms at the apex of the chest, and at the loAver part of the neck. [Ligature on the Primitive Carotid. Primitive Carotid tied near the Innominata.— A large tumor in a boy, Avhich Mr. Liston considers to have been originally of a scrofu- * As an aid to the memory of the student, it may be remarked, that he will always readily remember the two great processes for aneurism, by minding his A. B. C. D. Thus, Ariel's was the Cardiac and Brasdor's the Distal side of the aneurism ; i c, A. C, B. D. So the late Professor Hossack, in his lectures on midwifery, used to say to his hearers that they could always recollect that there were two arteries and one vein in the umbilical cord, by calling to mind the orthography of the name of the great Boer- haave ; i. e., two A A's and one V. T. ARTERIES OF THE NECK. 247 lous character, occupying the whole space from the arch of the palate behind the angle of the lower jaAv on the right side, and ex- tending near to the sternum, compelled him, after he had decided on the step to take up the carotid close to the innominata. From Oct. 20 to Nov. 3d, things went on Avell, and the tumor had dimi* nished sensibly, Avhen a sudden hemorrhage from the Avound caused death. The artery Avas nearly ulcerated through by the ligature, but had no coagulum. M. Liston is of opinion the ulceration came from Avithout the vessel; i. e., from pus in the tumor making its way into the artery. It is, hoAvever, manifest that the subject must have been a bad one, and that in such cases there is too much pro- bability of arterial degeneration, especially the nearer Ave go to the great trunks about the innominata. (See Lond. Med. Gazette, March 18, 1842.) Carotid tied in two cases, by Dr. Duncan, for Carotid Aneurism.— Dr. Duncan read, at the Medico-Chirurgical Society of Edinburgh, May 1, 1844, (see Cormack's Monthly Journal, Aug. 1844, p. 728,) a case of much interest: a Avoman aged 33, in Avhom a carotid an- eurism had attained such rapid groAvth, in the short space of three weeks, that it extended from the angle of the inferior maxillary bone to about two fingers' breadth from the clavicle. Tavo or three days after,she was seized with spasmodic attacks of dyspnoea, one of which was followed by a state of complete insensibility, the pulse being almost imperceptible, and the respirations only five in the minute. Tracheotomy Avas performed by Dr. Duncan ; and on her rallying, he proceeded, from an apprehension that the sac of the aneurism might give Avay, to tie the vessel. Everything went on Avell until the 12th day, Avhen inflammation of the sac of the aneurism fol- lowed, and a small ulcerated communication with the pharynx formed. The sac was then freely incised, and the coagula turned out, but the woman died on the 15th day. No morbid appear- ances sufficient to account for death Avere found at the post mortem inspection; and it was believed the cause of death Avas spasm of the glottis, induced by irritation of the recurrent nerve, Avhich was involved in the tumor. The obliteration of the artery was found to have been perfectly completed. Dr. Duncan, at the meeting of the same society, May 13,1844, (Cormack's Soc. Cit., p. 733,) stated he had also tied the carotid on account of hemorrhage folloAving extensive ulceration of the fau- ces ; but the patient died the 14th day, in consequence of an attack of bronchitis. In this case, though the interval of time that the pa- tient survived was nearly the same as in the case last mentioned, the distal portion of the artery above Avas found closed only with an internal coagulum of about half an inch in length. The dis- sected ends of the artery Avere separated from each other by more than one third of an inch, and without any effusion of lymph be- tAvixt them. The cardiac end of the vessel Avas patent for about an inch from its divided extremity, and at this point Avas blocked up by a coagulum about three quarters of an inch in length, which alone had prevented the occurrence of secondary hemorrhage. But • 248 NEW ELEMENTS of operative surgery. Dr. Duncan is of opinion that, had the patient not perished as he did, secondary hemorrhage would in all probability have ensued, as softening of the coagulum had already commenced. Both cases, in our opinion, throAV much light on the pathology of divided arteries, proving that an aneurism does not always imply, even in cases not traumatic, that an aneurismal degeneration of the arterial coats has proceeded to any great extent beyond the sac; not to such extent, in fact, as in cases of general vitiation of the constitution, Avhich probably Avas the condition of the last patient. The death in both cases from accidental pulmonic causes, also shows hoAV important it is, in such as in all other cases, that a sound therapeutic should be kept constantly in vieAV, and be promptly resorted to after surgical operations ; Avhich, skilfully as they may be performed, too often fail to complete the cure, unless medical treatment as the adjunct of the knife, is carefully and vigi- lantly attended to. Such cases shoAV also Iioav dangerous, not to say preposterous on its very face, is the too prevailing notion that surgery should aristocratically disdain to meddle with medical practice strictly so called, or to look beyond the mere adroitness and rapidity of cutting; in other Avords, the mere carpentry or mechanical part of the profession, Avhen, in fact, every department of the healing art is so closely blended Avith, and dependent upon all others, that no one branch can be separated from the rest with- out endangering the Avhole superstructure. The left common carotid Avas tied on May 29th, 1842, by Mr. James Spence, surgeon at Edinburgh, (Cormack's Lond. and Edinb. Monthly Journ., May 1843, p. 439, &c.,) for a hemorrhage from ulceration of the face in a man aged 38. This patient had had a running from the left ear from childhood. In March, 1842, when first seen by the surgeon, the Avhole of the left side of the face over the parotid and temporal regions, and upper part of the neck, Avere greatly SAvollen and discolored, hard and tense, and with a deep- seated fluctuation over the zygoma, while the temporal artery was seen pulsating on the surface of this sAvelling in the temporal region. A thin, sanious discharge came from the left ear, the ex- ternal meatus of Avhich Avas nearly filled up by a large fungous excrescence. From inability to eat solid food, and from the severe pains at night, he Avas greatly exhausted. These symptoms seemed to be relieved by evacuating a quantity of foetid pus from the fluc- tuating region mentioned, by means of a free incision over the zygoma. Abscesses, hoAvever, soon re-formed there, and Avere opened, but continued to emit foul discharges, and exhibited pale and flabby edges, the zygoma itself being iioav bare. A slight ar- terial bleeding, in April, from one of the incisions, Avas arrested by compression; but the patient became daily weaker from night sweats and diarrhoea. The surgeon apprehended, from the condi- tion of the parts, hemorrhage from ulceration of the branches of the external maxillary artery, or the superficial temporal. The patient Avent into the country, applied caustic to the ear,which only made the fungoid growth there spread more rapidly and more ARTERIES OF THE NECK. 249 malignant in character. Again, on May 29th, a violent bleeding ensued, to the quantity of two or three pounds of fluid blood, from one of the old incisions on his face, which, threatening a fatal issue Mr. Spence, Avhen reaction took place after the exhaustion, properly proposed, Avith the approbation of Sir George Ballingall, a ligature on the common carotid as his only chance. From the SAVollen, infiltrated state of the upper part of the neck, the incision Avas directed in such a manner as to reach the vessel below the omo-hyoid, and to have no greater extent than a quarter of an inch. The Avant of light, and of proper instruments to hold open the edges of the Avound, (as it was at the patient's residence,) prolonged the operation, Avhich, however, was carefully completed by cautiously separating the artery in its sheath, and passing the aneurism needle under it from Avithout to the tracheal side, bringing its point out with the dissecting forceps, without raising up the artery. Both ends of the ligature Avere left outside the Avound, which Avas brought together by three stitches of interrupted suture, when the patient Avas laid in bed with his head raised, and a pledget of lint, dipped in cold water, kept over the part. The operation was per- formed at quarter past eleven a. m., and at 2 p. m. there had been no bleeding from the face. The pulse was 98, and tolerably full, there Avas some pain in the Avound on swalloAving, but the respira- tion Avas easy and natural, and without cough. The favorable symptoms continued, and on May 31, the stitches Avere removed, and the edges of the wound Avere nearly united, and in a healthy state. The swelling of the face had diminished, but the ulceration of the ear continued to spread. On June 5, hoAvever, secondary hemor- rhage supervened to considerable extent; it Avas found that the ligature had not completely separated, and the bleeding seemed to come from the lower part of the artery, the wound itself being Avithout extravasation or purulent deposit, but pale and flabby. Compression Avas thought preferable to tying the vessel nearer the heart, and thus endangering more ulceration and secondary hemor rhage. A dossil of lint Avas passed over the bleeding point, secured by a graduated compress and a roller obliquely across the neck, and under the arm-pits. This completely arrested the hemorrhage, and the next day his pulse was 98 and soft, and he felt easy. On June 14, there having been no more bleeding, the compresses were removed, and the edges of the Avound brought together by adhesive straps. The wound gradually contracted, but the fungous ulceration of the external ear, Avhich was noAV half destroyed, spread Avith frightful rapidity, laying bare the articulation of the lower jaAV. On June 25th, coma came on, and a profuse discharge of dark blood from the ear, Avhich was arrested by plugging with lint, as the fungous groAvth in the meatus had entirely disappeared. Some relief en- sued, and the patient Avas rational and talked, but on July 4, coma returned, and ended in death. A post mortem Avas not permitted, but the carotid was examined. Granulations Avere found at the bottom of the Avound, the divided ends of the vessel, connected by a quantity of firm lymph, effused 250 NEW ELEMENTS OF OPERATIVE SURGERY. around them, and the parvagum and internal jugular of their natu- ral appearance. The internal coats of the artery Avere found fairly divided, and their ends retracted to some distance from each other, and adhering to the external cellular coat. There Avas no appear- ance of a clot in the vessel, either above or beloAV the ligature, so that the lymph effused around and betAveen the cut ends of the cel- lular coat seemed the only obstacle to hemorrhage taking place. In remarking upon the fatal issue, Mr. Spence Arery naturally asks himself the question :—" Hoav far might a cautious use of nu- tritive diet, Avith a vieAv to increase the plasticity of the blood, have been a preferable mode of treatment to the exhibition of antimon- iah and the other means (Avhich were) used to diminish the force of the circulation ; as it appears to me that in this case the second- ary bleeding Avas owing to the Aveakened powers of the patient being inadequate to effect the healthy changes necessary to pro- cure obliteration of the artery." This is unquestionably the sound doctrine, and the facts since disclosed by the neAV and successful treatment of aneurism by compression by the Dublin surgeons, (vid. our note above,) prove its truth as common sense does. Mr. Luke [see his case of Tubular Aneurism in a note above. T.] also leans to this pathology. But the fungoid cancerous ulcer of the ear, and the general condition of the face, shoAved that there was internal vitiation of the fluids which no surgical operation, nothing in fact but constitutional therapeutic means could repair. The hemorrhage, however, antecedent to the operation, Avas a bare justification of the knife in so extreme a case of general vitiation of the system and parts affected. The compression by pieces of sponge impacted into the wound by Dr. Mott's process, (see note above,) Avould have been preferable; but the other mode answered, as the force of the cir- culation was exceedingly feeble. Dr. Mott invariably makes it a practice on the carotid, subclavian, &c, gently to raise up the artery alone from out of its sheath at the bottom of the Avound, by means of the blunt hook, so that it may be distinctly seen to be perfectly separated from all its important connections, and its pulsations and arterial character satisfactorily demonstrated to the operator and others, by pressing the point of the finger moderately upon the ar- tery while it is upon the hook. From the failure of this case, M. Spence Avas induced to make a series of experiments on the ligature of arteries, and the mode in which obliteration is effected. He detailed his vieAvs (Cormack's London & Edinburgh Monthly Jour., May 1843, p. 492,) before the Edinburgh Medico-Chirurgical Society, accompanied Avith pre- pared specimens. The results lead him to believe that too little at- tention had hitherto been bestOAved on the lymph effused external to the canal of the vessel, and which he thought was of service in two ways : 1st, by surrounding and pressing upon the vessel for some distance above and beloAV the ligature, so as to diminish the calibre of the artery, and to lessen the impulse of the blood at that part; 2d, he considered it to be of still greater and more direct use at the period of the separation of the ligature, at which time as the pre- ARTERIES OF THE NECK. 251 paration showed, the lymph had begun to connect the divided ends of the artery, and continued to be effused between the ends of the vessel in the track made by the ulcerative process for the separation of the ligature. (This goes to confirm the learned and ingenious experiments Avhich have been made by M. Velpeau and others, at Paris, on the subject, to determine the nature of the process in the formation of the material interposed in the space left by the retracted ends of tendons subjected to the sub-cutaneous division ; to which great salutary, reparative, or recuperative organic action of nature, the formation of the substitute material deposited in the interval made by the division of arteries, veins, &c., is very analogous, if not precisely the same.—See Vol. I.) M. Guerin, (Gaz. Mcd. de Paris, t. XII., 1844, p. 659,) doubts entirely the reasoning of M. P. H. Berard, (Diet, en 25 vol., t. VI., p. 430,) Avhich attributes to cerebral hemorrhage the hemiplegia which sometimes follows a ligature upon one of the carotids. M. Guerin cites the case of a dissecting aneurism on the aorta, innomi- nata and right carotid, in Avhich the last vessel Avas obliterated a short distance from its origin. The patient (See Dublin Medical Press, April, May, and June, 1844,) Avas aged 37, robust and ple- thoric, and Avas suddenly seized with fainting and died in 11 days after having suffered much distress about the loins, suppression of the urine and paralysis of the left side. The brain Avas found soft- ened and exsanguined—Avith no evidence whatever of effusion of blood, says M. Guerin. The brain he supposes is paralysed for want of the stimulus of blood, not from too much of it—in the same Avay as Stenon and Legallois found the hind legs of rabbits soon paralysed by a ligature on the abdominal aorta, for want of the stimulus of blood upon the nervous centres. Ligature on the Primitive Carotid for Aneurism of a secondary branch of the External Carotid.—Mr! Kerr (Edinburgh Med. and Surg. Jour., January, 1844) relates the case of a remarkable tumor on the right side of the neck in a woman aged 67, and which had existed 30 years, but only in latter years had increased to such size as to extend from the angle of the jaAV to the sternum andcla vicle. It had the same diffused expanded strong pulsations of all aneurisms, and these Avere synchronous with those of the heart. Gangrene took place folloAved by occasional slight hemorrhages ; when the external parts having sloughed and healed, the hemor- rhage ceased, and the tumor at the end of a month was found to have sensibly diminished. Great doubts existed if it was an aneu- rism, and if so, it was supposed to be of the primitive carotid near its bifurcation, as the trunk of this artery had been croAvded to the outside by the tumor, and its pulsations were distinctly felt, and when arrested by compression, caused also those of the tumor to cease. The primitive carotid was tied at its upper part; the pulsations of the tumor ceased, and its volume at the end of nine months Avas diminished to half its original size ; when an attack of pneumonia came on and proved fatal. On dissection the carotid artery being carefully exposed from its origin to beyond its division, was found 252 NEW ELEMENTS OF OPERATIVE SURGERY. obliterated to a certain extent; but the tumor had no communication with this vessel, and did not present those concentric layers Avhich are found in ancient and obliterated aneurisms. It Avas found in communication only Avith a secondary branch of the external caro- tid, and appeared to be formed of cellular tissue and vessels mixed with blood. This may perhaps be considered a good specimen of circumscribed false aneurism, or the varicose aneurism of A. Berard, but not aneurism by anastomosis nor erectile tissue, (See note on M. A. Berard's cases, supra.) Wounds of the Carotid causing Aneurismal Varix and Varicose Aneurism.—Veterinary surgery again comes to the aid of our art in relation to some neAV pathological results noticed by M. Rey, Professor at the Royal Veterinary School of Lyon, (See Jour, des Connaiss. Med.co-Chir., Paris, Janvier, 1843, p. 20, et seq.,) in puncturing the carotid while opening the jugular vein for bleeding. Tavo cases have fallen under his observation, the lancet in both having been used instead of the fleam (flamme.) 1. In the first a mule aged 15 years, the carotid alone OAving to a sudden move- ment of the animal Avas punctured. The professor immediately applied to it the twisted suture with three pins; a large tumor formed immediately afterAvards, Avhich, in confirmation of the present re- vived mode of healing aneurisms by compression, and also Avounds of the brachial artery in the human subject in bleeding, Avas en- tirely dispersed, and a perfect cure effected in two day shy a containing bandage, vigorous compression, acidulated lotions and diet; 2. In the second case the aneurism Avhich the application of a ligature to the vessel could not prevent [the ligature must have been on the distal side of the artery, Ave presume. T.] was cured by refrige- rants. Both the cases were probably aneurismal varix of the ar- tery, (See the diagnosis of this in our note on M. A. Berard.) In another case Avhich is the most important of all, arteriotomy (i. e., of the carotid) Avas performed as an experiment, and Avas fol- lowed by no unpleasant result, though the animal was left to him- self. T.] Article IX.—The Trunk of the Innominata. When aneurisms are situated upon the lower part of the carotid, it is no longer practicable to treat them by the method of Anel, un- less by placing the ligature upon the trunk of the innominata; and should this last-mentioned trunk itself be affected, it would seem at first that the disease Avas beyond the resources of art. When, on the other hand we consider that in a great number of cases, the pre- cise seat of the aneurismal tumors in the loAver part of the neck, and in the supra-clavicular region, and at the apex of the thorax, is exceedingly difficult to determine, it is easy to conceive Avhat must be the embarrassment of surgeons, under such circumstances, when the question comes up of applying a ligature upon the artery which is diseased. arteries of the neck. 253 § I.—Method of Brasdor. As a remedy, in part, for these difficulties, the method of Bras- dor has been, at the present day, often had recourse to upon the neck. It is a method also Avhich numbers noAV a sufficient number of trials to require that it should be examined with care. Though all the surgeons who have made trial of it have done so, upon the supposition that it Avas for an aneurism at the origin of the carotid; they have frequently found, hoAvever, that they had to do Avith quite a different affair. Thus, one of the patients of M. Wardrop had an aneurism of the brachio-cephalic trunk, and this surgeon, not per- ceiving the pulsations of the carotid, placed the ligature upon the subclavian. There is reason to believe, also, that the arteria inno- minata Avas the seat of the aneurism, in the cases of M. Evans, M. Key, and M. Mott. M. Montgomery, who supposed he was operating for an aneurism of the carotid, Avas enabled to ascertain, four months later, that the disease was seated in the arch of the aorta. We may add, that in another case, Avhere M. Wardrop had supposed that he had embraced the carotid in a ligature of the in- testine of a silk-worm, this artery, at the end of three months, was found perfectly free, Avithout its being possible to say exactly Avhat had become of the aneurism. Nevertheless, one of the cases of M. Wardrop, that of M. Evans, and also that of M. Bushe, demon- strate, unquestionably, that certain aneurisms, at the apex of the thorax, may be cured in this manner. It might seem a priori that the ligature in the hyoid region might suffice Avhenever the aneurism is situated upon the carotid only ; but that it Avould be necessary to combine Avith it the liga- ture upon the subclavian also where the trunk of the innominata itself is affected. But M. Kerst of Utrecht has communicated to me tAvo facts Avhich, Avith those of MM. Evans (Vilardebo, These, etc., p. 58) and Montgomery, prove indisputably that the ligature upon the carotid alone may not only arrest the development of aneurisms upon the trunk of the arteria innominata, but also those of the arch ot the aorta. A man Avas received into the Civil Hospital of Amsterdam Avith an aneurism which projected above the sternum. M. Tillanus supposing it an aneurism of the left carotid, tied this artery a little higher up. The patient got Avell. Five months after he suddenly died. The aneurism, Avhich Avas seated upon the arch of the aorta itself, Avas completely filled Avith a Avhite coagulum, (caillot blanc.) The specimen is preserved in the cabinet of pathological anatomy at Amsterdam. In the other case the aneurism Avhich Avas on the point of bursting (s'ouvrir) Avas found in the same situation. Be- lieving also that it Avas an aneurism of the left carotid, M. Rigen of Amsterdam tied this artery at some inches higher up, on the 21st of February, 1829. The dangerous symptoms disappeared, and the size of the tumor diminished considerably. It became necessary to operate upon this man for a strangulated hernia on the 9th of 254 NEW elements of operative surgery. May folio Aving ; but he died on the 13th of June with symptoms of spasm or asthma. The autopsy showed that the aneurismal sac occupied the arch of the aorta betAveen the left carotid and the trunk of the innominata. As in the case of M. Tillanus, it was filled with a Avhite coagulum and considerably diminished. We see therefore that the ligature upon the carotid artery, by the method of Brasdor, deserves to be tried even in cases where the aneurism appears to have extended to the aorta. Nevertheless the question constantly presents itself to my mind Avhether the chances of success Avould not be greatly increased by the simulta- neous or subsequent ligature upon the subclavian artery. Only that there remains a doubt Avhether the internal mammary, the vertebral and inferior thyroid artery, &c, might not be sufficient to keep up the circulation in the root of this vessel and thus destroy all the effect of the ligature in reference to the aneurismal sac. § II.—The Ligature upon the Brachio-Cephalic Trunk itself. A. Anatomy.—The trunk of the innominata, which is about two inches in length, and which reaches from the right antero-superior portion of the arch of the aorta to the level of the sterno-clavicular articulation, Avhere it bifurcates to give origin to the right subcla- vian and carotid, takes a direction slightly oblique from below up- wards, from within outAvards and from before backwards. The pleura covers its outer side ; behind it rests against the front and right side of the trachea ; its anterior face is crossed above by the left subclavian vein, andloAver down by the vena cava descendens, which is parallel to it and separates itself more and more from it, as it approaches the right auricle. It is afterwards covered only by the cellular tissue, the root of the hyoid and sterno-thyroid muscles, the upper portion of the right side of the sternum and then to a small extent by the sterno-clavicular articulation upon the same side. Anomaly.—This remarkable artery presents numerous varieties; it may be wanting altogether or be found on the left side ; be long- er or much shorter ; give off at the same time both the right and left carotid; or it may originate from the left side of the aorta, cross the whole breadth of the trachea and nevertheless pass to the right side. I have once seen it, and two similar cases Avere shown to me in the pavilions of the School of Practice, pass to the left, across the trachea, turn round this canal from before backwards, and crossing the posterior surface of the (oesophagus and the vertebral column, reach the line of the first rib, and then divide as usual. (Anat. Chir., 1.1., Reg. Sous-hyoid: Sommet de la Poitrine; region sous-claviculaire.) B. Indications.—Aneurisms of the brachio-cephalic trunk have been observed in a great number of instances. Sharp, A. Burns, MM. Mott, Graefe, Wardrop, Devergie, Vosseur, &c, have pub- lished several examples of them. Spontaneous aneurism either by dilatation or by rupture of the internal and middle coats, is, never- theless, almost the only one which is to be met with in this artery. ^arteries of the neck. 255 It was an aneurism of the trunk of the innominata, which, opening into the trachea, strangled the individual mentioned bv Malouet, (Bibl de Planque, in 4to., t. V., p. 278.) The case that'M. Focke (Dissertatio Med., etc., 1835,) published, included also the arch of the aorta. M. Genest, (Arch. Gen. de Med., t. XXVI., p. 205,) de- scribes one which extended up as high as the chin. In a patient of M. Martin Solon, (Arch. Gen., Mars, 1836.—Gaz. Med. de Paris, 1836, p. 357,) an aneurism of the aorta had obliterated the brachio- cephalic trunk as Avell as the vena cava; yet the circulation, not- withstanding, continued in the arm. A case of Pelletan, in Avhich it is seen that the subclavian, the right carotid, and the termination of the arteria innominata Avere obliterated during life Avithout causing any serious symptoms; the case related by M. W. Darrach, in Avhich it is seen that the trunk of the innominata and the left carotid had completely closed, prove that the circulation may be kept up in the upper limb, though the bra- chio-cephalic artery has ceased to be permeable to the blood. Sur geons have been emboldened by this to attempt a ligature upon it when the aneurisms of the neck are situated too Ioav doAvn to allow of its application to the carotid itself. C. Appreciation.—M. Mott, (A. Burns' Surgical Anatomy, edit. Pattison, 1823, p. 433-456,) Avho was the first to perform it, in the case of a man aged 27 years, on the 11th of May, 1818, for a mo- ment indulged the hope of seeing the operation crowned with com- plete success. Death did not occur till the tAventy-sixth day. The circulation had re-established itself in the limb. On the twen- tieth day the patient was so well that he was enabled to walk in the garden of the hospital; but on the twenty -third day, repeated hemorrhages ensued, and the man died in a state of extreme ex- haustion. There Avas neither inflammation in the aorta, the lungs, nor the pleura; a firm and adherent coagulum filled a part of the trunk of the innominata below the ligature ; an ulceration, situated upon the other side of the artery, was the cause of the accidents. In 1822, M. Graefe, (Edinburgh Medical fy Surgical Journal, vol. XLIX., p. 471.—Jour, de Graefe et Walther, t. III., c. IV.—Dic- tionnaire de Chirurgie, de Rust, t. IL, p. 81,) repeated the ope- ration of the Professor of NeAV York; his patient lived sixty- eight days, and died only from his having made imprudent efforts which gave place to an abundant hemorrhage ; the ligature came away on the fourteenth day. Though not conclusive, these two results nevertheless demonstrated that the ligature upon the trunk of the innominata presents some chance of success, and that it might be made trial of, if art possessed no other resources, in cases where the patient seemed doomed to an inevitable death. Thus has it been repeated at least four times since; the issue has been un- fortunate ; the four patients died. That of M. Bland, (The Lancet January, 1837, p. 607,) died of secondary hemorrhage, on the' eighteenth day, and the aneurism Avas situated upon the right sub- clavian artery ! In the case of M. Hall, (American Journal of Med. Science, No. 22, p. 509,) death took place on the sixth day, and was 256 new elements of operative surgery. preceded by dyspnoea, acute pains and an issue of black blood from the Avound; that of M. Lizars, (Baltimore Medical Journal, Vol. I., p. 125.—Arch. Gen. de Med., 2e serie, t. VI., p. 267,) operated up- on the 31st of May, 1S37, died on the 21st of June, in conse- quence of hemorrhage. There were twenty ounces of blood in the chest, and the subclavian artery, Avhich was the seat of the aneu- rism, might have been tied betAveen the tumor and the carotid ! In the sixth example, in the case of acancerous tumor in the neck, the roots of the carotid and subclavian were tied together, on the 26th of September 1836, at the Hospital of Leipsic, under the impression that the carotid alone Avas tied. The case is too remarkable to omit giving the account of it in this place. The patient, Avho Avas forty-three years of age, having been pro- perly seated in an elevated chair, the head inclined to the left side, and held by assistants, M. Kuhl (E. 0. Peters, Dissert. Inaug., in the appendix at the end. Leipsic, 1836) made his first incision on the anterior border of the sterno-cleido-mastoid muscle, from the cricoid cartilage to the sternal portion of the clavicle. After having divided the skin, platisma myoides and fascia of the neck, he perceived the sterno-cleido-mastoid muscle; the external jugular vein Avas wounded and tied. The lips of the Avound being kept apart by Arnault's hooks, the operator readily reached the bottom to separate, by means of the finger, the parts in the neighbourhood of the artery, to Avit: the internal jugular vein, the par vagum, the descending branch of the hypo-glossal nerve, and the omo-hyoideus muscle. After all these difficulties, we Avere astonished, says M. Kuhl, not to find the division of the common carotid near the la- rynx ; I found it, finally, near the clavicle, Avhere I tied it. The pa- tient died on the third day. Half of the arteria innominata, a portion of the carotid, and a portion of the subclavian artery, were surrounded Avith a layer of plastic lymph. We found the right carotid and subclavian tied to- gether at three lines above their origin from the trunk of the inno- minata ; their coats Avere ruptured, and their canal in part ob- structed. Six trials, by six different surgeons, of different countries, have ended in six fatal results ! Is it not enough to enable us to pronounce an inexorable verdict upon such an operation? At the present day therefore I do not hesitate formally to proscribe it, not only because of the dangers Avhich accompany it, but also because the aneurism which requires it is often of a difficult diagnosis, and especially be- cause, as I have said above, the ligature beyond the tumor and by the method of Brasdor, presents at the same time less difficulty and more prospect of success. This however is the mode of operating. § III.—Operative Process. A. Process of M. Mott.—M. Mott made an incision about three inches above the clavicle, and Avhich extended from the outer part of the sterno-mastoid muscle, to the fore part of the trachea; then arteries of the neck. 257 another of the same length upon the inner border of the sterno- mastoid muscle, making it fall upon the inner extremity of the first. He afterwards divided all the sternal portion, and a great part of the clavicular attachment of the same muscle, in order to turn it back outwards and upAvards. After having separated Avith the handle of the scalpel, the jugular and subclavian veins and several small vein's, together Avith the surrounding nerves, M. Mott laid bare the carotid; observing that it appeared diseased, he proceeded down to the brachio-cephalic trunk, around which he passed and tied a simple ligature of silk. B.—M. Graefe proceeded nearly in the same manner, with this difference, however, that he left in the Avound an artery compres- sor to tighten the knot, (un serre-naeud-artere-presse.) This, more- over, was the course that M. Porter thought proper to follow at Dublin in 1829, to tie the carotid very Ioav down, in a man who recovered perfectly. C.—Others have thought, I do not know for what reason, that we should succeed better by trephining the sternum; but the best process, and that Avhich is performed Avith the most ease on the dead body, is the following, which differs, hoAvever, but very little from the method proposed by M. O'Connell of Liverpool, and which M. King has described in his Thesis. D. Combined Process of the author.—I.—First Stage.—The operator being placed on the left, makes in the supra-sternal de- pression of the neck, an incision of about three inches upon the inner border of the left sterno-cleido-mastoid muscle, obliquely from without inAvard or from left to right; he thus divides successively the skin and sub-cutaneous tissue, the superficial layer of the fascia cervicalis, the adipose cellular tissue, and a second fibrous layer. Encountering behind, the sterno-thyroid muscle, the thyroid plexus, and the thyroid artery of Neubauer, when it exists, he separates these vessels or causes them to be pushed aside by an assistant; or even applies the ligature to them, if he cannot avoid them, and thus arrives at the trachea. II. Second Stage.—Then are seen the left subclavian vein and the right internal jugular, which must be carefully turned aside to the right and upwards by means of the director. The sur- geon causing his patient to bend his head a little, endeavours to identify the artery between the trachea and the right sterno-hyoid muscle ; he first isolates its concave part, by inserting from before backwards, between it and the superior cava vein, the point of a slightly curved director ; and isolates it in the same manner on the side of the trachea, in order to separate its posterior surface and to raise it up. III. Third Stage.—Increasing a little the curve of the directoir which serves to guide the ligature probe, whether he introduces it from before backwards, and from right to left, or from behind for- wards, and from left to right, he takes care during all this maniput- lation to avoid tearing the pleura, or touching the nerve of the par vagum, which he leaves on the right, or drawing too much on the 258 NEW ELEMENTS OF OPERATIVE SURGERY. subclavian vein, Avhich perhaps, it Avould be more convenient on the living subject to raise up or depress, in order to pass the direc- tor between it and the trachea, than to push it aside (que de la re- tirer) as I have just mentioned. IV.—This process, unquestionably, more simple and less danger- ous than any other, has moreover, this advantage, that the same incision would admirably serve for either of the subclavians within the scaleni, or for either of the carotids near their origin. V. Consequences of the Operation.—After the obliteration of the brachio-cephalic trunk, the blood is returned first by the ramifica- tions and branches of the carotids and left subclavian, which pour it into the corresponding vessels on the left side; afterwards, these, that is, the thyroids, cervicals, &c, transmit it to the supra- scapulary, external thoracics, acromial, common scapulary and cir- cumflex, and consequently, to the Avhole upper limb, Avhich also re- ceives some through the medium of the intercostals and the internal mammary. Thus, it is not the want of circulation Avhich we have most to fear, as a consequence of such an operation; but the sec- tion and the ulceration of the artery, rendered almost unavoidable by the proximity of the heart and the size of the vessel; and the effusions into the pleura, the inflammation of the aorta, of the peri- cardium, and even of the cavities of the heart. VI.—On the supposition that the trunk of the innominata itself is diseased, no one would think of surrounding it with a ligature; the operation beyond the tumor, is then the only resource that can be attempted, and when the disease is confined to the carotid, how- ever low down it may be, this last operation seems to suffice. Therefore, I see only tAvo conditions that can make the ligature upon the brachio-cephalic trunk justifiable : 1, Avhen an aneu- rismal tumor sufficiently developed to cover the secondary caro- tids up to their origin, nevertheless leaves space enough above the sternum to enable us to reach them, and that without being dilated, this trunk is diseased nearly up to the aorta; 2, Avhen the subcla- vian alone being affected, the alteration of its coats extends too far toAvard its root to venture to surround it Avith a ligature, inasmuch as the method of Brasdor Avould then probably fail. The ligature then upon the trunk of the innominata, is an operation, in fact, which should rarely be put in practice, if in truth it is ever indis- pensable. [On Aneurisms of the Large Trunks near the Heart. Dr. Peacock, (Cormack's Lond. and Edinb. Month. Journ. of Med. Science, October 1S43, p. 871, &c.,) after a series of experiments, fifteen in number, made Avith the intention of illustrating the mode of formation of dissecting aneurisms, and Avhich consisted of injec- tions into the aorta and its principal trunks, after securing their ter- minations by ligatures, and rupturing or not the two principal coats of the aorta, the vessels being all healthy, feels himself authorized to come to the following conclusions : 1st. That the coats of the ARTERIES OF THE NECK. 259 aorta in a healthy state, cannot be ruptured by the application of any ordinary force from Avithin ; AArhich accords Avith the experi- ments of Dr. Davy, (Ib.) Such in fact, is the great strength of the internal coat, that the fibres of the middle or muscular coat split or give Avay transversely under the pressure of the finger from within, thus allowing the internal coat to protrude through the muscular, constituting a true hernia of the internal tunic, as cor- roborated by Laennec, Dubois, Dupuytren, and Liston. 2d. That when the internal coats are divided directly by an incision, or by a force acting from Avithout, [meaning, doubtless, by a ligature, &c. T.] the fluid injected, readily penetrates between the middle and external coat, distends the latter for a great distance along the course of the vessel, and never forms a tumor bearing any re- semblance to a circumscribed aneurism, and that this effect is equally produced, Avhether the aperture be of considerable extent or a mere puncture. 3d. That the external coat alone, does not in these cases possess sufficient power to resist permanently the pressure of the extravasated fluid, Avhich, therefore, escapes into the adjacent texture, either by transudation or rupture. 4th. That when the middle coat is partially divided, its different layers admit of being separated by the current of fluid over a greater or less extent, but that the canal thus formed, tends rather to re- open into the original vessel, than to burst externally. 5th. That this separation between the lamin;u of the middle coat is less readily effected than the diffusion of the fluid beneath the ex- ternal coat; it being necessary, in order to accomplish that pur- pose, that the fissure should follow a transverse direction, so as to be opposed to the course of the injected fluid and that its edges should be separated, so that the current may bear directly on the outer laminae. This separation does not take place so readily in the pulmonary artery as in the aorta, because the middle coat in the former, possesses [for a very obvious wise provision, as Ave think, from the immediate connection of this artery Avith the respiration T.J so much greater elasticity than that of the latter. Therefore in most cases of dissecting aneurisms: 1st. The arte- rial tunics in various places present decided proofs of diseased lacerability. 2d. That the sac of the aneurism would be more likely to be situated between the laminae of the middle tunic, than as has been usually supposed, in the space betAveen the external and middle coats; Avhich is, he says, corroborated by a recent case of Dr. Henderson, and by that of Drs. Pennock and Goddard in the American Journal of Medical Sciences. Dr. Peacock thinks that in a healthy artery it is only Avhen the fissure between the laminae of the middle coat, affords a direct opposition to the current, that a separation is effected ; yet this has occurred Avithout any extensive extravasation between the coats, in cases Avhere the internal coats of the aorta have been ruptured during life. Therefore, says Dr. Peacock, it is most probable that a dissectin« aneurism can only take place in arteries, of which the coats are as suggested by Dr. Henderson, rendered more readily separable'by 260 NEW ELEMENTS OF OPERATIVE SURGERY. disease, as Avhen, to use the language of Dr. Henderson, " the outer coat with an adherent lamina of the middle, admitted of being de- tached with a facility not much less than that Avith which two moistened pieces of paper may be separated," (Edinb. and Lond. Med. Jour., August, 1842.) In a case at the Edinburgh Infirmary, says Dr. Peacock, (Loc. Cit., p. 87«,) the coats Avere separated from the commencement of the abdominal aorta to the heart. Difficulty of Diagnosis in Sub-sternal Aneurism. Aneurism of the Arch of the Aorta mistaken for Chronic Laryngitis.—No fact calls so imperatively for the grave attention of stethoscopists, or more significantly points out the utter impossibility of making those pre- cise and minute diagnostic discriminations of the position, form and character of sub-sternal and thoracic aneurisms, and pulmonary dis- organizations and degenerations than the one related Avith great candor by Dr. Janssens of Ostende, (See Annales de la Societe Medico-Chirurgicale de Bruges, 1842; also Jour, des Connaiss., de Paris, Mars, 1843, p. 116-117,) to Avit: A seafaring man ex- ceedingly robust and vigorous, aged 52, of irregular habits, on his relurn from a hot climate to reside in Europe, became subject to constant attacks of bronchitis with hoarseness, Avhich finally obliged him, January 4, to enter the hospital at Ostende. The general health, and every function except those of the larynx, seemed to be normal. No pain or swelling in the neck, but more or less cough and abundant mucous expectoration. There was however difficulty in the deglutition of solids immediately behind the upper part of the sternum. Leeches to the neck, fumigations to the lungs, and every other medicament almost Avas had recourse to without any result. The patient returned to his occupation, Avent a voyage to the north, and soon came home much worse. He now had constantly a loud sharp shrill suffocating cough, continual dyspnoea and inability to lie down without strangling in some of these paroxysms. The ex- pectorations became muco-sanguinolent. Upon the strength of, and especially guided, says Dr. Janssens, by M. Cruveilhier's pathog- nomonic sign of a hoarse stifled cough, &c, he diagnosed nothing else but laryngitis, and therefore freely cauterized the glottis with a solution of nitrate of silver. This and other means all proved useless, and the patient died, May 4 following, during a suffocating paroxysm, ending in coma. On dissection, the larynx was found perfectly unaltered from the healthy state; but in the pos- terior mediastinum Avas found a large aneurismal tumor, croAvding on both lungs and the upper part of the trachea, an$ seated upon and communicating with the arch of the aorti! No mention is made of the stethoscope; but if it had been used as a means of interrogating the phenomena, would not the ansAver have been decidedly some morbid alteration in the respiratory passages? What but the slight difficulty of deglutition alone shadowed forth this terrible disorganization of the very foundations of the vital fabric ? Diagnosis of Aneurisms.—Professor Miller (See his late work on the Principles of Surgery, p. 439) furnishes some plain and use- ARTERIES OF THE NECK. 261 ful rules to be kept always in mind for the diagnosis of aneurisms: Thus, aneurisms are first soft and then solidify ; abscesses on the contrary are generally first hard and then soften; Avhether abscesses (as lymphatic) are soft from the beginning or not, they want on pressure the resiliency of aneurisms; Avhen a tumor (not aneurismal) over an artery is raised and held by the sides, its pulsations are faint or altogether absent; when these tumors are small they are separate from the artery and have no pulsation, but Avhen large they become attached to it and thus receive its impulsions, but they never have those diffused expansive pulsations under the pressure of the hand, Avhich aneurisms have, nor have they like aneurisms the thrill to the touch and bruit to the ear, both combined, but may have the bruit alone; in tumors over arteries the vessel, if it can be traced, will always be found free ; while in aneurismal tumors it is the reverse. Aneurism of the Pulmonary Artery.—Mr. CroAvfoot of Beccles, (Eng.,) (at a meeting of the Royal Medical and Chirurgical Society of London, April 11, 1843, vide Cormack's Journal, Oct., 1843, p. 945,) describes the case of a medical gentleman aged 3 6, av ho, after re- peated attacks of pulmonary disease, tending to symptoms of phthi- sis, finally died from successive attacks of hemoptysis. The upper part of the left lung Avas occupied by a cavity containing half a pound of grumous blood, Avhich Avas traced to a small aperture in a dilatation of the left branch of the pulmonary artery nearly of the size of the aorta. Mr. Liston considered this ulceration, as in simi- lar cases, to have resulted from pressure of matter contained in encysted abscesses—(Vide an extraordinary case of ulceration thus produced in the internal jugular vein, ending in death, under the head of veins, below in this present volume.) Mr. Syme, in a communication to Mr. Liston, states that he had seen cases of hemorrhage from the ear and throat, Avhich he con- sidered as originating from some large vessel opening into an ab- scess—(See note on one of these cases below, under veins, and in which Mr. Syme found the hemorrhage to proceed from an abscess in the lateral sinus.) Dr. Arnott related the case of a man in the Middlesex Hospital, in whom an abscess behind the angle of the jaAv burst through the ear and neck and into the throat, Avith copious discharge of blood, ending in death. The cavity of a large abscess was found, and at the bottom of this a large opening into the facial artery just at its origin from the external carotid. He considered cases of this kind readily explicable by the isolated and unsupported state in which the parietes of the artery were left by the destructive and dissecting progress of an abscess. Both Mr. Liston (Loc. Cit.) and Breschet (Ib.) relate each a case of an artery ulcerating and bursting into an abscess, and M. Cheyne (Loc. Cit., p. 946) one of a boy aged 6, in Avhom a suppuration of some large glands between the oesophagus and aorta was followed by perforation of the oesophagus, and finally by ulceration and per- foration of the aorta close to the going off of the subclavian, ending 262 NEW ELEMENTS OF OPERATIVE SURGERY. in effusion of blood into the oesophagus and stomach, which proved fatal. Diagnosis of deep-seated Aneurismal Tumors.—M. Gendrin (Revue Medicale de Paris, for December, 1844. See also Lond. Lancet, May 17, 1845, p. 548, et seq.) adds the folloAving diag- nostic marks of deep-seated aneurismal tumors of the large arteries that may be examined, to those usually given: Each impulsion isochronous to the arterial diastole, is followed by a retraction of the tumor, easily appreciated by the hand, Avhich retraction is ac- companied by a tremor (fremissement) quite distinct from that which corresponds to the diastolic shock. In aneurisms of the large arteries, the retraction is nearly always folloAved and terminated by a second impulsive shock, Avhich corresponds exactly to the systole of the artery. It consequently follows that on these tumors, two alternate shocks may be distinctly appreciated, the first of which corresponds to the diastole of the artery, and the second takes place betAveen it and the following diastole. These double pulsations always exist in aneurisms of the large arterial trunks and are pathognomonic. Tumors receiving their impulsive motion from voluminous neighboring arteries present, he says, only one impul- sion isochronous with the arterial diastole. Pressure beyond an aneurismal tumor (i.e., on the distal side) Avill shorten the pulsations, and give of course a greater shock to the hand, followed by an ap- preciable retraction. If the pulsations are double, the second dis- appears completely. These are best studied on the descending aorta by making pressure on the abdominal aorta. The second impulsion sound to the stethoscope is ahvays greater in proportion as the artery is larger—slight in middle sized and wanting in small aneurisms. In large aneurisms, the friction sound which usually folloAvs the first impulsion sound, is sometimes ab- sent, or if present often double. The friction sounds heard on stethoscoping the artery above and below the tumor, and which are isochronous Avith the arterial diastole, are the result, he thinks, of lesions in the tumor as they are fainter as Ave recede from it either Avay. The intensity and extent of the expansive pulsations and retractions of the tumor are modified by the size of its cavity, and by the stratified fibrinous clots Avithin it. Hence the great dif- ferences of the extent and form of the impulsion, &c. in various aneurismal tumors and the same tumor at different epochs. The rugous filaments, fibrinous lamella?, &c, often protruding from the margin of the orifice of the sac, greatly modify the sounds and sonorous vibrations. These produce the harsh friction sound, the tremulous sensations communicated by the tumor, &c, both in its retractions and expansions, thus prolonging the friction sound and sometimes also the tremulous motion Avhich accompanies the re- traction. If the arterial reaction is powerful, it driAres back the blood Avhich is returning from the more sloAvly contracting or re- tracting systole of the tumor, and hence the second shock; for the blood diffused into the large cavity of the tumor cannot return from it through its narrow orifice in time to be synchonous with the sys- ARTERIES OF THE NECK. 263 tole of the artery, and thus encounters the neAV impulsion of the artery. This second shock is more marked in aneurisms of the aorta and its first subdivisions, from the middle tunic above and below the tumor becoming hypertrophied. With all this and other similar minute descriptions Avhich have been given of the auscultic phenomena of aneurisms, Ave must con- fess that Ave see in M. Gendrin's rules as Avith others, when applied to latent aneurisms as those that are sub-sternal and thoracic, so much frittering and splitting up of distinctions, and such confused and contradictory subdivisions, as the double or quadruple percus- sion sound, the friction as well as the rugous sounds of the artery or the sac, or both, &c., all of Avhich may be still rendered so much more obscure by displacements in the chest, co-existing destruction of the bones and other tissues, the presence of tumors Avithin or disease of the heart and its valves, a varicose state of the large venous trunks from pressure of the sac, &c, &c.,asAve have elseAvhere said that it leaves the whole subject at the present time in a state of almost as much mystification as ever. Aneurism of the Brachio-Cephalic Trunk or Arteria Innomi- nata.—M. P. E. V. Guettet, in a late thesis (Determiner si I'on peut tenter la cure de I'aneurisme du Tronc Brachio-Cephalique, avec quelques chances de succes. La Ligature du Tronc Brachio- Cephalique, est-ellepraticablel These supported,Dec. 31st, 1844,be- fore the Faculty of Medicine of Paris. See Gaz. Med. de Paris, Mai 3, 1845, tome XI1L, p. 286, &c.) attempts to revive the now gene- rally rejected method of Valsalva for the treatment of aneurisms, by applying it to those of the brachio-cephalic trunk, upon princi- ples more minutely rigid as to regimen, rest, food and exercise, &c, than those adopted by the Italian surgeon. That debilitating and exhausting plan Ave may repeat en passant, is now generally con- sidered obsolete and at Avar Avith the more sound pathological and physiological views Avhich should govern the therapeutics of such affections. It has been Avell remarked by MM. Syme, Llenderson, and others, that such an enervating and exsanguinating process by abundant bleedings, Ioav refrigerating regimen diet, &c, must neces- sarily deprive the blood of its essential elements, and defeat the very object in vieAv by depriving it of the poAver of furnishing the quantity of fibro-plastic lymph requisite to establish an adherent permanent clot in the sac ; Avhich verdict has been fully confirmed by the more or less opposite course of treatment adopted in the ex- traordinary cures by compression recently effected by the surgeons of Dublin, and by M. Liston and others Avho have imitated the pro- cess of the Irish practitioners. (See our note on compression in the cure of aneurisms, supra.) M. Guettet, in SAveeping terms, reiterates the perhaps too un- measured denunciation or proscription Avhich has been fulminated chiefly at Paris, against the method of Anel in aneurisms of the brachio-cephalic trunk, Avhich question will be found fully consi- dered and discussed in the Remarks of Dr. Mott, infra, Avhose opin- 264 NEW ELEMENTS OF OPERATIVE SURGERY. ions, coming as they do from the first person that ever tied this trunk, may be thought to be entitled to some weight. Nevertheless M. Guettet has furnished in his thesis some useful and original information of an anatomical character, to show why aneurisms in this trunk are so much more frequent than any where else except at the arch of the aorta. He lays it down as an axiom, from Avhich Ave see no reason as yet to dissent,that in the brachio-ce- phalic trunk, the impulsion of the column of blood (I'ondee sanguine) has much greater force than in any other trunk in the supra-aortic system. Thus : so great is its Avidth, and so little the curvature of the aorta from its root (origine) to the point Avhere the innominata is given off, that a straight tube of six millimeters in diameter, being introduced into the aorta by one of its extremities, will pass in a direct straight line Avithout any impediment into the orifice of the brachio-cephalic trunk. M. Guettet has also frequently passed a tube in this manner on the dead body, from the middle of the brachio-cephalic trunk to the sigmoid valves, and in tAvo subjects to the bottom of the left ventricle Avithout making any traction on the vessels. From Avhich he concludes that much of the column of blood projected from the heart into the innominata, to Avit, the central portion Avhich corresponds to Avhat in hydraulic tubes is called the thread of the current, (le fil de l'eau,) or that which has the greatest velocity, (le fil de plus grande vitesse,) must reach the latter vessel directly and in a straight line, and without having undergone any [sensible] diminution of its momentum from the fric- tion of the arterial walls. In conforming also to another principle in hydraulics, this velocity in the column of blood in the innomi- nata, must he remarks be still farther augmented by the fact that the united calibres of its two great bifurcating branches, the right subclavian and right carotid, greatly surpass that of the parent trunk. Thus he found on making their section that the area of the calibre of the innominata was 74.64 square millimeters, that of the right subclavian 60.03, and the right carotid 35.07. Thus the aggregate of the two last is 95.10, and that of the common trunk as above stated 74.64. Hence the impulsion of the blood is greater in the last than beyond its bifurcation. Again in the same subject he found that the sum of the areas of the left carotid and left sub- clavian Avas only 57.87—another cause of a predominant afflux of blood to the brachio-cephalic trunk. Hence, says he, the great fre- quency of aneurisms in the innominata, greater than any Avhere else except at the arch of the aorta, because of the greater afflux and direct and uninterrupted impulsion of the blood from the heart upon this point;—and therefore according to the obliquity of the inno- minata to the aorta, this impulse and consequently the relative fre- quency of aneurism, will be either at its origin, middle portion, or distal extremity; Avhich results, M. Guettet affirms, are conform- able to the observations Avhich have been made in practice. In according, Avhere a surgical operation should be resorted to, an unqualified preference to the method of Brasdor over that of Anel, M. Guettet proposes a neAV or retrograde revolution in the modifi- ARTERIES OF THE NECK. 265 cation to which the minds of the Brasdorean partisans seem now tending: to Avit, he is not for tying both the subclavian and carotid, either simultaneously or at any time, but only one of these two trunks, as the most efficacious in the cure, and the most sound in principle. Thus, suppose for example, the inferior aortic orifice of the innominata is dilated to such extent by an aneurism as to re- ceive more blood than the upper orifice can give egress to; then the innominata Avould become a sort of funnel with a Avide mouth, whose walls will share in the pressure and distension which are experienced by the aorta, and Avill also be more exposed than any other part to the action of the sanguineous current coming from the heart. In consequence therefore of the relative narrowness of cali- bre of the upper extremity, the column of blood will exercise its greatest percussion upon the walls of this infundibulum; making the vessel in fact in itself a sort of infundibuliform aneurism of the aorta. These aneurisms therefore at the cardiac extremity of the innominata, would be aggravated by a ligature on the two branches, because the force of the impulsion would be vastly augmented by the total occlusion of the trunk, and lead to the inevitable destruc- tion or expulsion of the clot. But even the method of Brasdor must be abandoned Avhere the aneurismal dilatation is at the cardiac extremity of the innominata. If hoAvever, the dilatation is at the middle part, and one of the branches is tied and both its extremities through Avhich the passage of the blood continues to be made, be supposed to be of like calibre, the actual median position of the aneurism between those narrow openings under such circumstances must favor the stagnation of the blood, and the deposit and formation of the clot. Of the two branches he prefers, (and upon the presumed data we suppose, Avhich we have just given,) the carotid to the subcla- vian ; the ligature on this latter, after that on the carotid, having in his view hastened the death of the cases of Fearn and Wickham. At the sitting of the Academy of Medicine of Paris, Sept. 8, 1840, the illustrious Larrey took occasion to give as his opinion, (Gaz. Med. de Paris, No. 37, p. 589,) that the method of Brasdor should be totally rejected in any case Avhatever. M. Diday, in taking opposite ground and to illustrate the preference of this me- thod in supra-clavicular aneurisms, indulges in a latitude of expres- sion which is not wholly justified. He goes so far as to say, (See his memoir on this method, and on the ligature upon the Brachio- cephalic trunk and the origin of its branches, Gazette Medicale, Feb. 22, 18 15, p. 116, &c.,)that " if there is any principle in Opera- tive Surgery established irrevocably, it is the absolute prohibition of a ligature on jhe arteria innominata for aneurisms of this artery," (See on this subject the general remarks of Dr. Mott on aneurisms, infra.) The resource by the method of Brasdor, M. Diday also deems perilous and uncertain, but the only one there is between the patient and certain death from the disease. And moreover, con- trary to the opposite opinion of Mr. Wickham, an English surgeon, (Gaz. Med. 1841, p. 365,) he deems this method more positively 266 NEW SYSTEM OF OPERATIVE SURGERT. indicated in the class of aneurisms of which this memoir above men- tioned treats, than in those of any other region. He considers this method based on physiological principles that are incontrovertible, though not as easy of application as other methods. The little suc- cess hoAvever Avhich has attended it shows, as M. Diday very pro- perly remarks, that it requires revision and modification, (See re- marks of Dr. Mott, infra.) M. Diday considers it impossible that any aneurism involving the brachio-cephalic can ever be radically cured except by the obliteration, either by surgical means or spon- taneously, both of the subclavian and primitive carotid. At the time that the memoir of this surgeon first appeared, viz., in 1842, (Read before the Academy of Medicine of Paris, Sept. 13, 1842 ; but not published until in the Gaz. Med., Fev. 22, 1845, p. 115,) the method of Brasdor for aneurisms in the supra-clavicular space (creux) had been performed, he says, seventeen times, not one of which he contends militates against the truth of the foregoing pro- position. In addition to the ten cases only enumerated by M. P. H. Berard, under the article Aneurism in his Dictionary, (t. III., p. 72,) M. Diday gives the following seven not contained in that work :— 1. That by M. Laugier, (Bullet, de la Societe Anat., 1835.) 2. M. Morrison, (Gaz. Med., 1837, p. 583.) 3 M. Dolhoft, (Gaz. Med., 1839, p. 57.) 4. M. Fearn, (Gaz. Med., 1838, p. 601, & 1839, p. 253.) 5. M. Colson, (Gaz. Med., 1840, p. 589.) 6. M. Wickham, (Gaz. Med., lS41,p. 365.) 7. M. Fergusson, (Annal. de Chir., 1841, p. 484.) Of these operations there Avere tAvo only in which both the sub- clavian and primitive carotid were tied ; but not at the same time, which M. Robert like most surgeons Avould consider too hazardous an attempt, and one that Avould almost render it impossible to re- establish the circulation in the right arm,(Loc. Cit., Gaz. Med., Fev. 22,1845, p. 116,andThesedeConcours: Des Aneurismes de la re- gion sus-claviculaire, by M. Robert, p. 122.) M. Diday however does not accord Avith M. Robert, in his apprehension of danger to the circulation of the limb. " If," says M. Diday " after the liga- ture upon the trunk of the innominata itself, M. Mott and Graefe have seen nutrition maintained uninterruptedly in the arm for the space of 26 and 58 days, it is more than probable that the oblitera- tion of its two branc^--:, would not in this respect be attended with more serious consequences." On the contrary might not M. Diday and others who believe in the practicability of the operation and the fair prospect of success Avhich would attend it, on both the great trunks of the brachio-cephalic, on the principle of Brasdor, confidently maintain that this double interruption would in fact be far less hazardous to the circulation of the right arm, the neck, and entire thorax on that side, than the ligature on the innominata only? By the report made by M. Blandin on the memoir of M. Diday at the time it Avas read to the academy (Vid. sup.) it appears, that that surgeon entirely accords Avith the views of the author as to the ARTERIES OF THE NECK. 267 propriety of the ligature both upon the subclavian and carotid. Mr. Liston, in fact, at London in July 18, 1838, (See Gaz. Med., 1838, p. 600,) tied both at the same operation and the man died on the 30th day from secondary hemorrhage. M. Diday and most other surgeons would scarcely think it pru- dent to tie, unless under very peculiar circumstances as stated by Dr. Mott, (see infra,) both arteries at one operation. The subclavian, according to M. Diday, should be tied as near the tumor as possible ; because, in proportion as the ligature should be more remote, the greater, naturally, Avould be the number of, and the greater certainly the chance of obliterating, branches that might be given off in this interval between the ligature and tumor; and therefore to the same extent Avould there be more danger of producing mortification of the arm, the more the collateral circula- tion would be deprived of the branches Avhich Avere gradually to re-establish the course of the blood betAveen the branches of the right subclavian and those of the left carotid and left subclavian. [See Dr. Mott's remarks beloAV, Avherein it will be seen that he entertains an opinion the reverse of that of M. Diday, as respects the point on the subclavian to be selected for a ligature.] Although the surgeon, says M. Diday, might feel greater confi- dence of success if he found one of the tAvo great branches of the innominata already spontaneously obliterated to his hands, and might therefore suppose that the ligature on the other would cer- tainly complete the cure ; yet that this is not always so ; for it has been found (in proof of Avhich he gives the cases of MM. Wardrop, Mott and Wickham) that the operation of the ligature then is to have in some cases the disastrous effect of re-opening a large pas- sage for the blood through the interior of the sac, and thus to give a neAV impulse and greater activity to the disease, showing that the obliteration Avhich had been supposed to be permanent Avas only temporary. In the examples cited, M. Diday appears to have sup- posed that the operators labored under a misconception of this kind. Surgeons, therefore, should not, according M. Diday, to con- clude, because no pulsation may be felt in the carotid for example, that that artery is obliterated. We believe there are none profess- ing any knoAvledge of the subject who have ever allowed them- selves to be deceived by any such illusion. Suppose in such a case this cessation of pulsation in the carotid had been OAving, as he thinks it might be, to the size and pressure of the aneurismal sac itself upon the artery, this latter, on tying the subclavian Avould immediately diminish and the blood return to the carotid. Thus, also, in the case above cited of Mr. Wickham, (Loc. Cit., supra,) the carotid Avas tied first and the tumor diminished, but then augmented in volume and prolonged itself in a new direction outwardly and along the clavicle, because, no doubt, according to M. Diday, the pressure of the tumor being at first taken off from the subclavian as Ave are to suppose, the latter vessel Avas as it were re-opened, and in this manner gave vent to the then pent-up 268 NEW ELEMENTS OF OPERATIVE SURGERY. blood of the aneurism and actually augmented its volume—all of which reasoning, as it appears to us, is someAvhat contradictory upon the principle laid doAvn by M. Diday that the augmentation of the volume or size of the sac has just produced a temporary sus- pension of the pulsation, i. e., an apparent obliteration of the calibre of the carotid or subclavian. Notwithstanding which obscurity, M. Diday thinks Ave may overcome the difficulty of the diagnosis on this point of permanent or temporary obliteration by attending to the following rules : — 1. To ascertain if the vessel in question corresponds at its origin or at its middle portion only, to the most prominent point (point le plus saillant) of the aneurismal tumor ; in the first case there Avould be more probability of obliteration ; in the second, of compression. 2. To ascertain if the movements made in the shoulder, arm and head do not cause some pulsation in the branches of one of the tAvo trunks in question—thus in the radials or temporals for ex- ample. 3. To ascertain if these same pulsations may not be made to re- appear, by displacing the aneurismal tumor with the fingers,-and endeavoring to shift it (la detourner) from off the arterial trunk which Ave may suppose to be compressed by it. 4. To mark the dilatation Avhich is sometimes noticed in the veins contiguous to the tumor ; we may, from this sign, conclude that the tumor presses forcibly on the neighboring parts, Avhich will be an additional reason for supposing that the cessation of the pul- sations in one of the arterial trunks is attributable only to the pres- sure made upon it at its origin. M. Diday considers it a laAv, positive and incontrovertible, that whenever one of the tAvo great trunks of the innominata is either totally obliterated or has undergone an organic contraction (or di- minution) in its calibre, the ligature must first be applied to the other trunk. Among the minor points Avhich become enhanced in importance where both trunks are found permeable, are :—the direction of the great axis of the tumor, and that in which it appears to make the most rapid progress; that in which its pulsations act with the greatest force, and the changes produced in the size of the sac by making alternate compression upon one or the other of the two trunks in question ; all of Avhich may be of service in determining the surgeon upon which artery he should first apply the ligature. The last test is the best, but not decisive, for in a case in Avhich Wardrop (These de Villardebo; 3e serie, 1 observ.) found compression on the subclavian produced no change in the tumor, he nevertheless tied that vessel, and found that immediately after the operation the size and pulsations of the sac disappeared ; and the respiration became more free. So in the case of M. Morrison, (Gaz. Med., 1837, p. 583,) the tumor did not sensibly diminish in volume, though pressure Avas made Avith great force upon the carotid; yet he tied this vessel and the tumor disappeared entirely, so that the patient continued well for more than sixteen months. ARTERIES OF THE NECK. 269 Where there are no indications to guide us it is best, M. Diday thinks, to commence with the ligature upon the carotid. He con- siders Wardrop to have established the fact that the constriction of this vessel diminishes to a much greater degree the blood which traverses the sac than that of the subclavian possibly can do. So, also, are the dangers of the operation incomparably less ; on Avhich account, doubtless, it is that all the surgeons Avho have tied the tAvo branches have begun with the carotid. The statistical results also fully confirm the correctness of this decision. Up to the present time, surgeons have not proceeded to a liga- ture on the remaining trunk, until that on the other has been found to have failed in effecting a cure. Though it is an established truth, that whatever branch has been tied, the sac has, without a single exception, says M. Diday, experienced a certain diminution in its volume and pulsations, yet a preference has perhaps been given to the ligature on the carotid first, from the impossibility of distinguishing with certainty an aneurism of the innominata from one at the origin of the carotid. This has led to the hope of a cure by tying this artery only, and thus, by procrastinating the period of tying the subclavian, the aneurismal tumor has been permitted to obtain a neAV growth. To this circumstance M. Diday imputes many of the failures. The second operation should be performed, he thinks, as soon as it is ascertained that the tumor no longer decreases, and especially if the pulsations which have been temporarily suspended by the first operation, begin to reappear. Thus, in the case of M. Wick- ham, (Loc. Cit.,) the tumor, by the ligature on the carotid, had at first diminished; but, at the end of a month, it had acquired its primitive volume. The patient resisted the operation on the sub- clavian for another month, when the tumor having noAV acquired an enormous size, the ligature on this vessel resulted soon after in rupture of the sac and death. One motive for retarding the second operation, should that be on the subclavian, undoubtedly has been the fear that the circulation might not be re-established in that ves- sel, because of the anastomosing branches to it from the carotid being now cut off. This M. Diday thinks an inadequate reason for delay ; moreover, it is possible, he thinks, to establish, by the pul- sations in the temporal and facial arteries, and even by those of the tumor, that the circulation of the carotid is restored, and therefore that there is no danger in proceeding to the subclavian. Mont- gomery has seen the pulsations of the temporal and facial arteries reappear in ten days after a ligature on the carotid. Until the second ligature is decided upon, gentle and moderate compression should be made on the sac. This we think one of the most im- portant suggestions of the author, especially after the remarkable success Avhich has resulted at Dublin from treating aneurisms by oompressing moderately the trunk of the vessel above the sac ; (see note on the subject above;) also, by direct pressure upon the sac itself, (see Mr. Luke's case, note above.) Could compression to the tumor and its neighboring connecting trunks be efficiently apr 270 NEW ELEMENTS OF OPERATIVE SURGERY. plied, and conjointly Avith a ligature on one of the great branches, so as to effect a cure, it would indeed be another masterly and bloodless triumph for surgery. This compression, says M. Diday, in the interval mentioned, Avould become indispensable Avhere it is the size of the sac Avhose pressure has suspended the pulsations in a neighboring artery. We thus, in taking off the pressure on the ar- tery and applying it to the sac, aid its natural contraction. In regard to the place to be selected for a ligature, it is to be re- marked that all the hemorrhages which have followed the ligature on the carotid by the method of Brasdor, have come from the upper, i. e., the peripheric end of the vessel, in both the cases published, viz., that of Lambert and that of Montgomery, (Vilardebo, ut sup ) M. Diday considers that such hemorrhages are OAving to surgeons not paying sufficient attention to a point of surgical anatomy which he deems of great importance, viz.: to tie the trunk at a sufficient distance above a collateral, provided that collateral be of large size, and goes off in a retrograde direction from, and at an acute angle with, the main trunk, i.-e., has its sinus (sinus) turned towards the capillaries, (sous un angle aigu a sinus tourne vers les capillaires;) for, in that case, the column of contained blood in the collateral, though diminished by passing through the capillary, circulation may still have so much force as to break up the clot above the liga- ture. To this cause, viz., an ulceration of the peripheric end of the artery, he imputes the hemorrhage Avhich proved fatal to Dr. Mott's case of ligature on the innominata, 1818, and that of M. Crampton on the primitive iliac, 1828. He cites also a case he saw at the Hospital of Saint Louis, Paris, in 1839, in Avhich fatal hemorrhages super- vened from the loAver end, in a patient in Avhom the femoral had been tied a little above the origin of the profunda, (Gaz. Med., 1839, p. 681.) M. Diday considers that all these conditions of hemorrhage from the peripheric extremity, exist to a greater degree in the primitive carotid than elseAvhere, to Avit, the proximity, size, and retrograde direction (la direction retrograde) of the collaterals ; for, in the only two cases where hemorrhage took place in this vessel from the pe- ripheric end, the ligature Avas placed too high up on the artery; thus diminishing not only the length of the contained clot, but its poAver of resistance to the reflux current of blood. Thus Mont- gomery, in his case, remarks that the ligature Avas placed very near the bifurcation of the carotid. In that of Lambert, he states that the ligature Avas placed above the point Avhere the artery is crossed by the omo-hyoid muscle. Therefore, says M. Diday, tie the carotid as far as possible from its bifurcation ; only that, in thus approximating nearer to the tumor, Ave run the greater risk of constricting a diseased portion of the vessel. Prudence and judgment must decide upon the juste milieu, though M. Diday would, in a case of doubt, prefer approach- ing the tumor than the capillaries. He instances the great number of cures and infrequency of hemorrhages in the ligature on the ex- ternal iliac for spontaneous aneurisms, and in Avhich it has to be ARTERIES OF THE NECK. 271 placed very near the tumor. The danger, therefore, of this method, which Avas that of Kesleyre, he thinks, has been greatly exaggerated by Jno. Hunter. At the bifurcation of the carotid, there is, according to Hodgson, the additional danger that depots of calcareous matter and simple dilatation are more common here than in any other part of its trunk. M. Diday furnishes the folloAving interesting table of the number of cases in which the method of Brasdor has been applied to aneu- risms of the innominata, or the origins of its branches. As his me- moir Avas read to the Academy, Sept. 13th, 1842, but not published in the Gazette Medicale of Paris until Feb. 22, 1845; it may be safely asserted, I think, that there had not come to his knowledge, (as there has not to ours,) up to the time of its publication, (1845, Feb. 22,) any additional case to the seventeen which he enumerates. He considers the case of M. Rossi too exceptional to be added to his list. We think it, however, one of the most important, as es- tablishing the remarkable fact that the functions of the brain Avere sustained for six days by the right vertebral artery alone. The more recent operation of Dr. Campbell Ave shall also add, as illus- trative of the diagnosis, the operation, and its accidents; though not strictly belonging to this table, inasmuch as the whole trunk of the aorta was involved in aneurismal disease, as well as the in- nominata itself. It is too instructive, however, in its bearings on the innominata, to be omitted. This makes, up to the present time, nineteen cases in, all. We have given a more detailed abrege of the useful paper of M. Diday, because of its historical details on most of the operations which have been performed on the brachio-cephalic trunks for an- eurisms, by the method of Brasdor. This method has of late years attracted much attention on the Continent, and M. Diday, a zealous champion of it, has, as we should think, exerted himself Avith all the ability that could be brought to bear in its favor. Consequently, it Avillbe seen that his analyses of several of the fatal cases are made to correspond in favor of his views. We (speaking for ourselves individually) are no partisans of the Brasdor plan ; least of all, in giving it a preference over that of Anel, Avhere that is at all practi- cable. The paper of M. Diday will be serviceable, at least, as a reference for those Avho are investigating this subject, and Avish to treat it with exactitude, as always should be our rule in all matters of science. 272 NEW ELEMENTS OP OPERATIVE SURGERY. Table of the Nineteen Operations performed up to the year 1845, inclusive, on the Distal method, or that of Brasdor, for aneu- risms of the Arteria Innominata, and of the origins of its trunks. No. of Cases. Not operated. Cures. Deaths, times; four of the patients recovered perfectly One died from peritoneal inflammation, in consequence of imprudence in spirituous drink; the other, from secondary hemorrhage. 3 In tying the external iliac artery, Ave have ahvays pursued the plan last recommended by Sir Astley Cooper; and Ave have no hesitation in saying that, in our opinion, it ought always to be fol- lowed as the safest and best method. It is obvious that the great danger in the operation is the Avounding of the peritoneum ; and whoever cuts directly upon this membrane, must always incur con- siderable hazard, either from his OAvn unsteadiness or the motion of his patient. By the method recommended by Cooper, Ave com- mence the incision just above the external abdominal ring, and carry it a little above Poupart's ligament, to within a small dis- tance of the anterior superior spinous process of the ilium. After cutting through the integuments, the superficial fascia, and tendon of the external oblique muscle, we expose the muscular fibres of the internal oblique. Upon detaching a feAV of these from the upper and inner edge of Poupart's ligament, we lay bare the sper- matic cord. Pinching up the cylindrical process of the cord, and dividing it with the knife transversely, the finger is readily passed up the inguinal or abdominal canal, and arrives at the internal ab- dominal ring. We now knoAV that the finger, by being passed into the internal abdominal ring, is certainly beloAV the peritoneum, and that this membrane, with gentleness and care, can readily be pushed upwards, and may be detached to any distance above and below, so as to expose the artery as high up as may be necessary for the ligature. It ought ahvays to be recollected, by an operator, that immediately behind and below this internal ring, the external iliac is to be felt. This mode of operating has always appeared to me to be by far the most safe on this account: that you are sure of get- ting below the peritoneum—and it has, in our judgment, a decided preference over the methods of Abernethy, and others Avho fol- lowed him, by cutting down upon the peritoneum, by means oi a longitudinal incision, more or less in a line Avith the linea alba. In all our operations on the Iliac arteries, we have invariably adopted the kind of incision Ave have above described for the ex- ternal iliac. Our object previously has been to be sure of getting below the peritoneum. This being accomplished, by going through the internal ring, we then, by continuing to push up this membrane, may divide the super-imposed parts in any direction and to any extent we think proper, to enable us to reach either the primitive or the internal iliac; always taking care to keep the peritoneum well pushed up before dividing the parietes. Recollecting alwavs however, that when the finger is in at the internal rin*, the' epigastric artery must always be on the inner side of the finger and that cutting in that direction is therefore to be carefully avoided. " In one of the cases in which Ave tied the external iliac, there 300 NEW ELEMENTS OP OPERATIVE SURGERY. were some peculiar features which make it deserving of particular mention. A man aged about 35 years, of a vitiated habit, presented him- self to me with a true popliteal aneurism on the right leg, and an inguinal aneurism on the left. Both were circumscribed, and each about the size of the fist Avhen he called upon me. I urged him to submit to surgical operations for their cure. He however preferred to postpone any surgical interference until it should be more urgently called for. About a year from the time of my first seeing him, he sent for me to relieve him, saying that he feared he had deferred the matter too long. I found his popliteal aneurism now increased nearly to the size of a man's head, blue, cracked, and Oozing a sanious fluid from the surface, and in the most imminent danger possible of bursting every moment. I immediately tied the artery in the lower part of the upper third of the thigh. In a few days an extensive surface of the aneurism gave Avay, and dis- charged a hatfull of coagula. Nevertheless, Avhen all these latter had escaped, suppuration and granulation kindly took place, and the Avhole of this immense ulcer healed up, leaving him only with a little contraction about the knee joint, and shortening of the limb, not so much, however, but that he could still bring about half the plantar surface of his foot to the ground. About a week after I had applied the ligature to the femoral artery, he sent for me in great haste. Having visited him on the same morning, and found him doing well, I was somewhat sur- prised at receiving an urgent message that he Avas suffering intoler- able torture, and labouring under the greatest anxiety and alarm. This condition, on arriving at the house, I found arose from a sud- den sensation of something giving way in the inguinal aneurism on the other side, which Avas, in the morning, a little larger than an ordinary sized fist, but now I found had attained more than double this volume. The tumor extended upwards and downAvards— reaching upAvards considerably aboA^e Poupart's ligament. In truth, this circumscribed true aneurism had suddenly become dif- fused. No time Avas noAV to be lost. I immediately, therefore, tied the external iliac; every thing Avent on Avell, and the patient perfect- ly recovered of both aneurisms, and is iioav, near twenty years since the operation was performed, enjoying much more robust health than formerly, and with very little impediment in Avalking; re- quiring only the heel of his boot on the limb Avhich had been affected with the popliteal aneurism, to be made a little higher than the other. This curious case has never before been pub- lished. The Femoral Artery.—This artery may be tied in any part of its course. We ahvays prefer, when we have a choice, the lower part of the upper third, as recommended by Scarpa, and noAV called by Professor Velpeau and others, Scarpa's space. The artery here is most superficial, lies directly below the inner edge of the sartorius muscle, and requires that this muscle should be but very DR. MOTT ON ANEURISMS. 301 little disturbed in order to get at the vessel. We have, in our prac- tice, tied the femoral artery forty-nine times.* Some surgeons have doubted the propriety of tying the artery between the going off of the profunda and the origin of the epi- gastric. We have, hoAvever, several times put a ligature here, and in every instance with success. In one instance Ave have tied the popliteal successfully. We have, in a number of instances, tied the anterior and posterior tibial arteries, in different parts of their course. In one case, an aneurism of the anterior tibial on the dorsum of the foot, Avhere it is called the dorsalis pedis, we found it necessary to tie, not only the anterior tibial, but also the posterior. In tying the anterior first, it seemed for a while to promise a cure of the aneurism; but the tumor, after some time, began to in- crease in size. We then tied the posterior tibial artery, and the case resulted in a perfect cure. In wounds of the dorsalis pedis, as Ave have mentioned in a note above, it ought to be recollected that we are ahvays to tie both ends of the wounded artery. In Avounds of the plantar arteries in the bottom of the foot, or in a wound between the great toe and the one adjoining, when the wounded branches cannot be readily found, the best practice is to tie both the anterior and posterior tibial arteries at once, on the same principle, and for the same reasons that we have recommend- ed the arteries of the wrist to be tied in wounds of the palm of the hand. On the Method of tying Arteries, and on Ligatures, Dressing, 6pc. —We would advise all Avho tie large arteries, to bear in mind, that after the edge of a muscle is laid bare, Avhich is the anatomical guide or landmark for the relative situation of the artery, that very little use should be made of the knife. With his fingers, or the handle of the scalpel, the surgeon can readily separate the parts, so as fully to expose the artery. In this way he will be much less troubled with the oozing of blood, from cutting the small vessels, and thereby better enabled to see the principal trunk more distinctly. With the parts held asunder with curved spatulas, the surgeon now seizes the filamentous structure with the forceps, and raises it from the artery. He then cautiously divides the structure per- pendicularly, and upon the anterior surface of the artery only, and should never dissect or use the edge of the knife on the sides of the artery, but introduce the handle of the knife, and separate the struc- ture from the artery on each side, only denuding the vessel to an ex- tent barely sufficient to allow the hook to be passed around it. This rule Ave believe most important, as by using the edge of the knife on the sides of the artery Ave endanger frequently the di- vision of branches, as most of these are given off laterally; and * Since this chapter was prepared, I have tied the femoral again above the profunda. 302 NEW ELEMENTS OP OPERATIVE SURGERY. the floAV of blood where they are divided, obscures and interferes very much with the beauty and the neatness of the operation. Denuding the artery, also, to any considerable extent of its fila- mentous structure must, by robbing the vessel of its connecting media, always be adverse to the salutary changes Avhich we expect from the ligature. For passing the ligature, we have always used the American aneurismal hook, Avhich Ave consider the best that has ever been invented.* To use this most prudently, we always introduce it from thevpin. We prefer the small, strong round ligatures of silk or flax, and we only use one around the vessel. We have come to the conclu- sion long since that one ligature is quite sufficient. Formerly, in many instances, we used two ligatures, about an inch distant from each other. Then, in other cases, we divided the vessel in the inter- space ; again, we adopted the expedient of passing the ligature through the artery, above and beloAV where it was tied, tying it again, and then dividing it in the interspace. In another case we used tAvo remarkably delicate ligatures of raw or flossed silk, each ligature not Aveighing over the sixteenth or twentieth of a grain, and we divided here also the artery in the interspace, and then cut both ends of each ligature close to the vessel. We then healed the wound by the first intention, the first dressing being the only one required. This all seemed very beautiful; but the sequel remains to be told. Some six weeks after the patient had got about, inflam- mation and suppuration took place opposite the points of the two little ligatures, and they were discharged. We have also used animal ligatures of different kinds, as cat- gut, the raw hide, &c.; but we have long since come to the con- clusion1 that the plain simple ligature is the best, and one only. In all my experience for the last forty years in tying arteries, I have only lost one patient from mortification of the inferior extrem- ity. This was a case in which the femoral artery was tied higher up than usual; there being a femoral as well as popliteal aneurism in the same limb. The popliteal aneurism, for some days before the operation, had become diffused from above the knee to the toes, distending the parts to a very painful degree. This inordinate distension of the lower part of the limb, no doubt effectually prevented the inoscu- lating channels from conveying a sufficient amount of blood to pre- serve its vitality. Should I ever meet with another case of this kind, I would amputate the thigh above the femoral aneurism at once. In the case of an old man, partial mortification, to a slight ex- tent in the smaller toes, took place; but it Avas arrested, and he re- covered. My mode of dressing the wound after tying the femoral artery, is * This aneurismal hook or needle was invented by Drs. Parish, Hartshorne and Hewson, of Philadelphia, many years ago. DR. MOTT ON ANEURISMS. 303 to pass a single stitch through the integuments in the centre of the wound. Short straps of adhesive plaster then ansAver to bring the remainder of the lips into contact. I then wrap the Avhole limb in Avadding or avooI ; place the pa- tient in bed, Avith the limb a little flexed and turned a little out- Avard, with a pilloAv under the ham. No bandage of any sort is to be applied on any account what- ever. We even avoid long pieces of adhesive plaster, for fear that by their compression the inosculating circulation might be inter- rupted. Nothing is more dangerous than the application of a tight band- age to an aneurismal limb after the artery is tied; as everything that interferes Avith the collateral circulation must be to the greatest degree hazardous. In order that those Avishing to refer to our labors, in regard to the subject of aneurisms and ligatures upon the great arterial trunks, may have embodied before them an authentic and correct abstract of what Ave have done in these matters, and of Avhat Ave consider as our own surgical property, we have prepared and revised the various publications that have been made of our operations in this department, as they are found scattered in different medical peri- odicals of our country, over the space of the last twenty-seven years. We have arranged them consecutively in chronological order. The account of the attempt to place a ligature upon the left sub- clavian, by Sir Astley Cooper, referred to by me above, and in which I had the honor to assist that eminent surgeon, is as fol- lows :— Ca.se of Subclavian Aneurism, which occurred in Guy's Hospital, London; communicated to Dr. Miller, by Valentine Mott, M.D., Corresponding Member of the Medical Society of London, fyc. (See New York Medical Repository, edited by Drs. Samuel L. Mitchell and Edward Miller, 3d Hexade, Vol. I., New York, 1810, p. 331-334.) On the 20th of August 1809, a man, aged 40, came into Guy's Hospital, in London, with a tumor, occupying the whole of the left shoulder, the greatest part of the clavicle, and extending under the pectoralis major muscle. It Avas not red upon the sur- face, but very hard, and Avithout any distinct pulsatory motion : it was of about six months' duration, and, when very small, A. Cooper said he saw it, and there was no distinct pulsatory motion to be discovered; at least, only such a motion as the subclavian artery beneath might communicate to a tumor situated immediately over it. The tumor, however, A. C. fully believed to be an aneurism of the subclavian artery; and when, upon examination, an aneu- rism was discovered in the femoral artery, just below Poupart's ligament, the smallest doubt did not remain, in the mind of any person present, as to the nature of the tumor in the shoulder, and that it was an aneurism of the subclavian artery. 304 NEW ELEMENTS OP OPERATIVE SURGERY. The situation of the man being truly painful, and it being evi- dent that the disease must prove,in a short time, fatal, if no operation were to be performed, A. C. Avas determined to make an attempt to take up the subclavian artery, just after it had passed betwixt the first and second scalenus muscle. Though this Avould appear to many to be a cruel and umvar- rantable attempt to save life, yet, as A. C. very properly observed to ine, it could only shorten his days a little to attempt the opera- tion, and it was possible it might succeed, though it had never be- fore been performed. The man Avas Avilling to submit to anything that might be thought proper fcr the relief of his distresses. A. C. then pointed out to him the uncertainty of the operation, and promised, if he Avould submit to it, that nothing should be done but what was perfectly proper and safe ; saying, that if, in the course of the operation, he should find it not safe to proceed, he Avould give it up. The man consented, and Avas laid upon the table in the theatre, with his shoulders a little elevated. The operation Avas then begun, in the presence of G. W. Young, Esq., Surgeon, B. Travers, Demonstrator of Anatomy, and a number of other surgeons. The incision was commenced at the outer and loAver edge of the sterno-cleido-mas- toideus muscle, close to the clavicle, and carried, straight ouhvards and backAvards, about three inches. The most careful dissection was noAv necessary, and by means of the edge, and sometimes the handle of the scalpel, the muscles Avere separated, till the nerves, going to form the axillary plexus, were laid bare. The open- ing betAveen the muscles was very small and so deep, (A. C. re- marked that it was like looking down a well,) that the fore finger could but just reach the nerves. The subclavian artery was felt beating very feebly, immediately under one of the large nerves go- ing to the axilla; it could not be felt at all by several that Avere present, and by none constantly ; A. C. was convinced that he felt it at times, and I was certain that I perceived it also. A curved probe was now passed under the artery, and repeated trials were made to draAV it from under the nerve, so as to pass a ligature around it; but these Avere all unsuccessful. Every time the nerve was put upon the stretch, with this vieAV, the patient complained of the most excruciating torture, not only in the shoulder and neck, but extending throughout the whole arm. It Avas not one or tAvo trials, but many, that Avere made, before A. C. could be sa- tisfied to relinquish the operation. After, hoAvever, keeping the man on the table an hour and fifty minutes, he desisted from any further attempts; saying it Avas impossible to accomplish it, and even if it were then possible, after so much violence had been done, and the patient so much exhausted, it would not be safe, as it Avas most probable that it would almost immediately prove fatal. A. C. remarked to me, that the operation, though not difficult in a small aneurism, cannot be performed in one of a very large size. The man did not lose an ounce of blood in the attempt. The wound was now brought together by sutures and plasters; DR. MOTT ON ANEURISMS. 305 the patient put to bed and a large opiate given him. He com- plained of extreme pain all over his shoulder and arm, occasioned, no doubt, by the violence done to the large nerves, going to form the axillary plexus. A considerable degree of fever ensued the day after the operation, which very much increased; attended with high delirium, though venesection, purging, and sudorifics Avere assiduously used; and on the sixth day from the operation he died. Upon examining the body after death, the tAvo first ribs Avere found to be destroyed, and a portion of the upper lobe of the left lung was adhering to the aneurismal sac ; the sac was large, and contained large coagula of blood, Avhich had thrust the clavicle very much upAvards. A. C. took out the part, very carefully preserving all the vessels connected Avith it. Would any but a great mind, conscious of its own poAvers, and the rectitude of its intentions, make the following remarks ?—He said to me, " I am suspicious that, in this operation, the thoracic duct must have been divided, as it was on the left side; though I did not think of it at thctime of the operation, nor before it." I could not learn that any person present had thought any thing about the danger of injuring this vessel; no doubt from its being a vessel which we have never been accustomed to think of in any operation. I regret that it is not in my power, at present, to satisfy the curious on this point, as A. C. had not ascertained the fact when I left London. We are not to despair, though this first attempt* has been un- successful, when we consider the great and splendid chirurgical achievements of the last three years in the British metropolis. The first operation for carotid aneurism Avas performed by that eminent and accomplished surgeon, A Cooper, and Avas unsuccessful; this, hoAvever, did not deter him from a second attempt, in the summer of 1808, Avhich completely succeeded. After this, the carotid Avas taken up by an eminent surgeon of Stockholm, M. Bierken ; but, from some unfavorable circumstances of the case, it failed, as I am informed in a letter from my learned friend Dr. Wegell, Physician to the late King of Sweden, Avho as- sisted at the operation, and accompanied me, when in London, to A. C.'s second operation. In the winter of 1809, Henry Cline, sen., of St. Thomas' Hos- pital, took up the carotid for an aneurism of a very large size, in- volving the posterior angle of the loAver jaAv, and extending down towards the shoulder. The artery Avas secured in the usual way, by that great surgeon, and Avithout any kind of difficulty. The man, in the course of the following night, drank very freely of spi- rits, and became in some measure inebriated, and he died the next day. The parts Avere examined after death, and there Avas nothing unusual about the aneurism, but the brain and its membranes shoAved signs of inflammation. This state of the brain, no doubt, * Keatk, the Surgeon-General of the British army, and one of the Surgeons of St. George's Hospital, is said to have taken up this artery, below the clavicle, in a wounded •oldier, who recovered. 20 306 NEAV ELEMENTS OF OPERATIVE SURGERY. Avas induced by the excessive stimulation, and caused his death; as the brain then from its altered circulation, Avas more predis- posed to inflammation. The carotid Avas again tied in the spring of lS09,by B. Travers, Demonstrator of Anatomy at Guy's Hospital, for an aneurism by anastomosis, situated in the left orbit, which had protruded the eye a little from its socket. He used two small round ligatures, but did not divide the artery betAveen, and secure the ligatures by passing them through the artery, as was done in the other cases, ex- cept A. C.'s first. The ligatures came aAvay in about tAventy days, and no hemorrhage ensued, nor did the brain suffer the least in- jury. The pulsation in the tumor was diminished by the opera- tion ; there Avas, however, but little alteration in its size three months after. Though this operation did not succeed in removing the disease for which it was performed, it is a valuable fact, and proves, Avith A. C.'s case, that the artery may be tied with perfect safety as to the functions of the brain.* Abernethy's operations upon the external iliac, and A. Cooper's upon the carotid and subclavian, must be admitted by every one to be master-strokes of scientific surgery. These, most undoubt- edly, are proud days for London, and particularly Avhen Ave know that they have never been the subjects, even of dream or specula- tion, in the capital of France. Are we not to expect, from these and similar examples, that the lives of many valuable individuals may be protracted far beyond the period in which their diseases have hitherto proved fatal ? They may, indeed, be protracted to a very late age, if we are allowed to judge from similar cases, in which the whole system has not become affected from the disease of a part. No. I.—May 11, 1818. Ligature on the Arteria Innominata. The first publication of this operation, Avas made in a periodical published in NeAV York, and entitled " The Medical and Surgical Register, consisting chiefly of cases in the New York Hospital, by John Watts, M.D., Valentine Mott, M.D., and Alexander H. Ste- vens, M.D., NeAV York, printed and published by Collins & Co., No. 189 Pearl-street, 1818." Part 1., vol. I., p. 9 to 56 inclusive. Also tAvo plates, illustrative of the same Avith explanations, on the 4th page from the title of the Avork. The case is as folioavs :— Reflections on securing in a Ligature the Arteria Innominata. To which is added a case in which this artery was tied by a Surgical operation. By Valentine Mott, M.D., Professor of Surgery in the University of New York, fyc Since the publication of Allan Burns's invaluable Avork on the surgical anatomy of the head and neck, I have been in the habit * The case of Mr. Travers was ultimately successful. See Medico-Chirurg. Trans., iLondon. DR. MOTT ON ANEURISMS. 307 of showing in my surgical lectures, the practicability of securing in a ligature the arteria innominata; and I have had no hesitation in remarking that it Avas my opinion, that this artery might be taken up for some condition of aneurisms; and that a surgeon, Avith a steady hand and a correct knowledge of the parts, would be justified in doing it. I felt myself Avarranted in this, from the singular success which this celebrated anatomist informs us attend- ed his injections, and from my own investigations of this subject. If the right arm, and the right side of the neck, can be filled Avith injec- tion, after interrupting its passage through the innominata, as we be- lieve they can, Avho can doubt the possibility of the blood to find its Avay there also, as it will pass through thousands of channels, Avhich art could not penetrate even by the finest injections '/ The Avell known anastomoses of arteries, and the great resources of the sys- tem in cases of aneurism, encouraged me to believe, that this opera- tion might be performed with reasonable prospects of success. With all this sanction, and the analogy of the other great operations for aneurism, I could not for a moment hesitate in recommending and performing the operation. The following operation, as the steps of it will shoAV, Avas per- formed Avith the two-fold intention : 1st, of tying the subclavian artery before it passes through the scaleni muscles, if it should be found in a fit state ; and 2dly, to tie the arteria innominata in case the former should be diseased or too much encroached upon by the aneurismal tumor. Michael Bateman, aged 57 years, Avas born in Salem, Massa- chusetts, and by occupation a seaman. He was admitted into the New-York hospital on the 1st of March, 1S18, for a catarrhal affec- tion, having at the same time his right arm and shoulder much swollen. At the time of his admission the catarrh being thought the most considerable disease of the two, he was received as a medical patient, and placed under the care of the physician then in attendance. During the three first Aveeks of his residence in the house, the catarrh had greatly yielded to the remedies prescribed. The inflammation, Avhich had produced an enlargement of the whole superior extremity, extending itself to the muscles of the neck on the right side, was also gradually subsiding. A tumefaction, however, situated above and posterior to the cla- vicle, at first involved in the general swelling, and not to be distin- guished from it, began to shoAV itself. This resisted the remedies Avhich Avere effectual in relieving the other, and became more dis- tinct and circumscribed as the latter subsided, at length assuming the form of an irregular tumor. The history which he gave of the case is as folloAvs :—He said about a week before he entered the hospital, Avhile at Avorkon ship- board, his feet accidentally slipped from under him, and he fell up- on his right arm, shoulder, and the back part of his head ; that he felt but little inconvenience from the fall, and after a short time re- turned to his duty. Two days subsequent to this, hoAvever, he felt pain in the shoulder, and the succeeding night Avas unable to lie up- 308 NEW ELEMENTS OP OPERATIVE SURGERY. on it in bed. The whole arm and shoulder then began to swell, and became so painful that he Avas unable any longer to perform his duty as a seaman. The ship having arrived in New York, he Avas admitted into the hospital. For some time after the general swelling had subsided, leaving the tumor distinct and circumscribed, no circumstance occurred which gave rise to a suspicion of its being aneurismal. The enlargement Avas thought to be a common indolent tumor, and Avas repeatedly blistered, Avith a view to discuss it. The tumor gra- dually diminished under this treatment; though a considerable time elapsed before any very striking change took place. At length a faint and obscure pulsation Avas perceived ; still it Avas a matter of doubt whether the tumor was aneurismal, or Avhe- ther the pulsatory motion was communicated to it by the subcla- vian artery, immediately over which it was situated. From its firm unyielding nature upon pressure, the latter Avas considered as the most probable, and the blisters were continued as before. Dur- ing the Avhole of this time the patient had worn his arm in a sling, the motions of it being very limited, and ahvays attended Avith pain. The patient remained in this state for several days, without any marked change either in his feelings or in the appearance of the tumor. On the 3d of May, at 6 o'clock in the afternoon, the patient com- plained that he "felt something give way in the tumor," that his shoulder was very painful, and that he Avas able to raise it only a feAV inches from his side. The tumor at this time suddenly in- creased about one third, and a pulsation Avas distinctly perceptible. Its most prominent part was beloAV the clavicle; at Avhich place the pulsation Avas most distinct. The portion above the clavicle Avas also much enlarged; it still however had its usual firmness, except in one point near its centre. May 4th.—The tumor is evidently increased, that portion of it more particularly which is beloAV the clavicle ; it is not as firm and resisting as it has been. Pulsation is not so distinct as yesterday, but appears to be more diffused. He was this day transferred to the surgical side of the house, and became my patient. The cough having become comparative- ly slight, the tumor appeared to be the most urgent disease, and, in my opinion, to call for prompt attention. The arm is now per- fectly useless, and any motion at the shoulder joint gives him severe pain. The patient is naturally of a spare habit, and from the nature of his disease, and the confinement to which he has been subjected, has become much reduced in strength. May 5th and 6th.—The tumor is still progressing, and the pain in the shoulder is also more severe. During the three last days his medicines have been discontinued, except that he is allowed to rub the parts about the clavicle Avith volatile liniment. On the 7th I directed a consultation of my colleagues to be called, consisting of Drs. W. Post, Kissam and Stevens. I noAV stated DR. MOTT ON ANEURISMS. 309 to them that I wished to perform an operation Avhich would enable me to pass a ligature around the subclavian artery, before it passes through the scaleni muscles, or the arteria innominata, if the size of the tumor should prevent the accomplishment of the former. This I Avas permitted to do, provided the patient should assent, after a candid and fair representation Avas made to him of the pro- bable termination of his disease; and that the operation, though uncertain, gave him some chance, and, as we thought, the only one of his life. Dr. Post, at my request, communicated with him privately on this subject, and after a full explanation of the nature of the case, my patient requested to have any operation performed Avhich pro- mised him a chance for his life, saying that in his present state he was truly wretched. May 8th, 9th, and 10th.—The tumor is acknoAvledged by all to be increasing, and it is thought proper not to defer the operation any longer. I therefore requested that preparation be made for performing it to-morroAv. It is difficult to give an idea of the size of a tumor so irregular in its form, and so peculiarly situated. A thread passed over it, from the loAver part of that portion of it which is below the clavicle, extending upAvard obliquely across the clavicle tOAvard the back of the neck, will measure" five and a quarter inches. Another crossing this at right angles one inch above the clavicle, will measure four inches; two and a half inches of the thread are on the sternal side of the former, and one and a half on the acromial. It rises fully an inch above the clavicle, which added to the depression beloAV the clavicle on the opposite shoulder, will make the size of the swelling above the natural surface about tAvo inches. May 11th.—One hour before the time assigned for the operation, the patient appeared perfectly composed, and apparently pleased with the idea that the operation afforded him a prospect of some re- lief. He Avas directed to take of Tinct. Opii. 70 drops. No difference can be perceived in the pulsation of the arteries in the tAvo extremities ; his pulses are uniform and regular, each beat- ing 69 in a minute. He was placed upon a table of the ordinary height, in a recum- bent posture, a little inclining to the left side, so that the light fell obliquely upon the upper part of the thorax and neck. Seating my- self on a bench of a convenient height, I commenced my incision up- on the tumor, just above the clavicle, and carried it close to this bone and the upper end of the sternum, and terminated it immediately over the trachea: making it in extent about three inches. An- other incision about the same length, extended from the termination of the first along the inner edge of the sterno-cleido-mastoid muscle. The integuments were then dissected from the platisma myoides, beginning at the loAver angle of the incisions, and turned over upon the tumor and side of the neck. Cutting through the platisma myoides, I cautiously divided the sternal part of the mastoid muscle, in the direction of the first inci- 310 NEW ELEMENTS OF OPERATIVE SURGERY. sion, and as much of the clavicular portion as the size of the swell- ing Avould permit, and reflected it over upon the tumor. The inter- nal jugular vein Avas encroached upon by the swelling, which made this part of the operation of the utmost delicacy, from the morbid adhesion of that part of the clavicular portion of the muscle to it, which Avas detached. I separated this portion of the muscle to as great an extent, hoAvever, as the case would possibly alloAV, to make room for the subsequent steps of the operation: only a part of the vein Avas exposed. The sterno hyoid muscle was next divided, and then the sterno-thyroid, and turned upon the opposite side of the Avound, over the trachea. This exposed the sheath containing the carotid artery, par vagum, and internal jugular vein. A little above the sternum, I exposed the carotid artery, and separated the par vagum from it; then draAving the nerve and vein to the outside, and the artery tOAvards the trachea, I readily laid bare the subcla- vian about half an inch from its origin. In doing this, the handle of a scalpel Avas principally used, nothing more being required but to separate the cellular membrane, as it covers the artery. I judged it Avould be very imprudent to introduce a common scalpel into so narroAV and deep a wound, especially as it would be placedbehveen two such important vessels or parts, as the carotid and par vagum, and Avhere the least motion of the patient might cause a Avound of one or the other of them. The proper intrument, in my opinion, for this part of the operation, is a knife, the size of a small scalpel, Avith a rounded point, and cutting only at the extremity; this was used, and found to be very convenient for this stage of the operation. It can be introduced into a deep and narrow wound, among important parts, Avithout the hazard of dividing any but such as are intended to be cut. This knife is contained in a set of instruments admira- bly calculated for this and other operations on arteries deeply seat- ed, and Avhich I shall mention more particularly hereafter. On arriving at the subclavian artery, it appeared to be consider- ably larger than common, and of an unhealthy colour; and Avhen I exposed it to the extent of about half an inch from its origin, Avhich Avas all that the tumor Avould permit, to ascertain this cir- cumstance more satisfactorily, my friends concurred Avith me in opinion, that it would be highly injudicious to pass a ligature around it. The close contiguity of the tumor would of itself have been a sufficient objection to the application of the ligature in this situation, independent of the apparently altered state of the artery. Art in this case could not anticipate any thing like the institution of the healthy process of adhesive inflammation in an artery in the immediate vicinity of so much disease. The Pathology of arteries has long since taught us, that ulcerative inflammation, and all its train of consequences, Avould have been the inevitable result. This was the fate of the only case, in Avhich a ligature has been applied to the artery in this situation. The operation Avas performed by that eminent Surgeon of Dublin, Dr. Colles. While separating the cellular substance from the loAver surface of the artery, with the smooth handle of an ivory scalpel, a branch DR. MOTT ON ANEURISMS. 311 of artery Avas lacerated, which yielded for a feAV minutes a very smart hemorrhage, so as to fill the Avound perhaps six or eight times. It was about half an inch distant from the innominata, and from the stream emitted, Avas about the size of a crow-quill. It stopped with a little pressure. I can scarcely believe this to have been the internal mammary, from the hemorrhage ceasing so quickly: though, from its situation, it would appear so, and if from some irregularity it were not the superior intercostal, it must have pro- ceeded from an anomalous branch. With this appearance of disease in the subclavian artery, it only remained for me either to pass the ligature around the arteria inno- minata, or abandon my patient. Although I very Avell knew, that this artery had never been taken up for any condition of aneurisms, and never in fact tied as a surgical operation, yet with the approba- tion of my friends, and reposing great confidence in the resources of the system, Avhen aided by the noblest efforts of scientific surgery, I resolved upon the operation. The bifurcation of the innominata being noAV in vieAV, it only remained to prosecute the dissection a little loAver behind the ster- num. This Avas done mostly with the round edged knife, taking care to keep directly over and along the upper surface of the artery. After fairly denuding the artery upon its upper surface, I very cau- tiously, Avith the handle of a scalpel, separated the cellular sub- stance from the sides of it, so as to avoid wounding the pleura. A round silken ligature was now readily passed around it, and the artery was tied about half an inch beloAV the bifurcation. The re- current and phrenic nerves Avere not disturbed in this part of the operation. As most surgeons Avho have performed operations upon large ar- teries, in deep and narroAV wounds, complain of the embarrassment which has attended the application of the ligature, I am happy in the present opportunity to have it in my poAverto recommend a set of in- struments, contrived for the purpose, Avhich, in my opinion, are cal- culated to surmount all difficulties. This set of instruments consists of several needles of different sizes and curvatures, Avith sharp andblunt points,and having in each tAvo eyes. The needles screw into a strong handle or shank of steel: there are also tAvo strong instruments in handles, with a ring or eye in the extremity similar to a tonsil iron, and perhaps they may be called ligature irons : a small knife round- ed at the extremity like a lancet for scarifying the eyes, and a small hook at the extremity of a steel shank, also fixed in a strong han- dle. These instruments are the invention of Drs. Parish, Hartshorne, and Hcwson, of Philadelphia. They are the result of investigations made upon the dead body, as to the best mode and place for tying the subclavian artery on the acromial side of the scaleni muscles.* With the ligature introduced into the eye of one of the smallest blunt needles, Avhich was nearest the shank of the instrument, I pressed doAvn the cellular substance and pleura with the convex * See Dr. Parish's Paper, Eclectic Rep., vol. III., p. 229. 312 NEW ELEMENTS OF OPERATIVE SURGERY. part, and very carefully insinuated it from beloAV upAvards, under the artery. The point of the needle appearing on the opposite side of the artery, I introduced the hook into the other eye of it; then unscreAving the shank, the needle Avas drawn through with the utmost facility, leaving the ligature underneath the artery. In the application of the ligature to this artery, I would invite the attention of those who perform it, to a circumstance Avhich, in my opinion, is someAvhat important: it is to pass the ligature from beloAV upwards, in order to prevent the pleura from being Avound- ed. From the use of these instruments repeatedly, I Avould also recommend that the hook be fixed in the eye of the needle before the shank is unscreAved, otherAvise very considerable difficulty will be experienced in finding it, and even Avhen felt, not easily intro- duced, from the Avant of firmness which the handle part of the in- strument Avould afford. I noAv made a knot in the ligature, and with my forefingers carried it doAvn to the artery, and dreAV it a little so as partly to close its diameter and arrest the column of blood gradually. This Avas continued for a feAV seconds to observe the effect produced upon the heart and lungs; when no change taking place, it Avas draAvn so as to stop the circulation entirely, as was shoAvn by the radial artery of the right arm, and the right temporal immediately ceasing to pulsate. The knot Avas draAvn more firmly by the liga- ture irons, and a second knot applied in the same manner. In no instance did I ever view the countenance of man with more fluctuations of hope and fear, than in draAving the ligature upon this artery. To intercept suddenly one fourth of the quantity of blood, so near to the heart, Avithout producing some unpleasant effect, no surgeon, a priori, would have believed possible. I there- fore drew the ligature gradually, and with my eyes fixed upon his face; I was determined to remove it instantly if any alarming symptoms had appeared. But, instead of this, Avhen he showed no change of feature or agitation of body, my gratification Avas of the highest kind. Dr. Post noAv asked him if he felt any unpleasant sensation about his head, breast, or arm, or felt any way different from com- mon, to Avhich he replied, that he did not. Immediately after the ligature Avas drawn tight, the tumour Avas reduced in size about one third, and the course of the clavicle could be distinctly felt. The parts Avere iioav brought into coaptation, and the integu- ments drawn together by three interrupted sutures and straps of adhesive plaster; a little lint and additional straps completed the dressing. Three small arteries Avere tied in the course of the opera- tion : the first Avas under the sternum, and divided Avith the ster- nal part of the mastoid muscle, and from its course may have been a branch of the internal mammary reflected upAvards ; the second, in raising the inner edge of the mastoid muscle, about the upper angle of the longitudinal incision, and must have been the most descending branch of the superior thyroid; and the third,Vasa DR. MOTT ON ANEURISMS. 313 branch of the inferior thyroid, and cut while raising the sterno thyroid muscle. The patient lost perhaps from two to four ounces of blood, most of which came from the ruptured branch of the subclavian. The operation occupied about one hour. The curved spatulas recommended by Dr. Colles, I found of great use in the operation. I provided three for this purpose,' tAvo broad, and one narrow, bent at right angles, and sufficiently firm. After raising the muscles, they Avere of the greatest advantage in keeping separated the carotid artery and par vagum, as likewise the divided muscles; they served also another very useful purpose, that of preventing by their equable pressure the constant oozing from the smaller vessels; and the little room taken up in a small and deep Avound, will give them a great superiority over the fingers introduced. Ten minutes after the operation the pulse is regular, and not the least variation can be perceived ; it beats .69 strokes in a minute ; the patient says he is perfectly comfortable, and has no new or unnatural sensation, except a little stiffness of the muscles of the neck, Avhich he thinks is OAving to the position in Avhich his head was placed during the operation ; the temperature of the right arm is a little cooler than the left; his breathing has not been the least affected by the operation, but is perfectly free and natural. 2 o'clock, P. M.—Patient expresses a desire to eat, and is direct- ed a little thin soup and bread; the temperature of both arms is very nearly the same ; breathing perfectly natural; pulse as before. 3 o'clock, P. M.—There is still a trifling difference in the tem- perature of the two arms ; ordered the right to be wrapped in cot- ton Avadding; not the least unpleasant symptom has as yet made its appearance. 6 o'clock, P. M.—Complains of a little pain in his head, not more on one side, hoAvever, than the other; describes it as a common head-ache : the pain of the shoulder and arm much less than be- fore the operation: no difference can noAV be perceived in the tem- perature of the two arms ; pulse a little accelerated, and perhaps a little full. 9 P. M.—Patient complains of head-ache ; skin is rather hotter than natural; pulse strong and full, and beats 75 in a minute ; the carotid on the left side of the neck is observed to be much dilated and in strong action; tongue moist and clean. 9$ P. M.—Symptoms continuing the same, directed him to be bled from the left arm to I xvj. After bleeding the pulse fell 7 beats, and Avas less full. Complains of some thirst; let him drink common tea. 12 P. M.—Patient has slept a little; is free from pain; pulse full and less frequent, beats 60; skin moist and of a natural tem- perature. Second day, 2 o'clock, A. M.—Patient enjoys a natural and un- disturbed sleep ; respiration free, and performed Avithout the least difficulty. 5 A. M.—He has rested well the last three hours. Says he has 314 NEW ELEMENTS OF OPERATIVE SURGERY. a slight head-ache, and a little pain in the right elbow : the latter he attributes to the position in Avhich his arm has lain during sleep; pulse full, but not so tense as before the venesection ; skin natural and moist; temperature of both arms the same. He states that he can noAV incline more upon the shoulder than he has been able to do since the second day after he received the injury. 9 A. M.—Pain in the head no Avay troublesome ; skin moist and of natural temperature ; tongue clean ; says his neck feels stiff, but is not painful; has no difficulty in swallowing. His cough has thus far been much less frequent than before the operation: expec- toration is also attended with less difficulty; pulse 75, full, but not tense ; has taken a dish of coffee, and some bread ; complains of some thirst; directed a solution of supertartrate of potass to be drank occasionally. 10 A. M.—Symptoms as before ; the veins of the fore-arm and hand since the operation have been as much distended as previous to it, and upon compressing them so as to stop the circulation, and allow the vein to become empty for some distance above, the column of blood is seen to distend the vein immediately upon the removal of the pressure, plainly showing that the circulation is going on with considerable rapidity, although no pulsation has been felt in the brachial or radial arteries. The radial artery can be easily distinguished, by the fingers, and seems to be filled with blood. There is evidently a pulsation in the anterior branch of the temporal artery, just as it is passing a little above the exterior can- thus of the orbit; the left external carotid is beating with increased action, and appears larger than natural. 3 P. M.—Has taken a light dinner, and complains of a little head-ache; pulse has become tense, and is also increased in fre- quency ; skin is considerably hotter than natural; tongue too indi- cates a febrile action: Avas bled to § viij., and directed to drink free- ly of a solution of the supertartrate of potass. 10 P. M.—Since the last report he has become more comfortable; complains of no pain, and says he lies perfectly easy; pulse in- creased in frequency to 78, but of the natural soft feel; the right side of the face has been at times a little cooler than the left, and is so at the present time : it is however, not so much so as to be perceptible to the patient; temperature of the right arm natural; that of the left, and the whole body, is above the natural standard, but it is moist; tongue is clean : having had no evacuation from his boAvels since the operation, is directed to take a saline cathar- tic, in divided doses. 1 A. M.—Complains of nothing; has not slept any ; cathartic has operated twice. Third day, 5 A. M.—Has had no sleep in consequence of the operation of the medicine, it having produced free evacuations in the course of the night; skin not so moist, but of natural tempera- ture ; the tAvo arms have equal Avarmth; pulse full, and rather more frequent than last evening: says his right elboAV is a little painful, and the arm feels tired. The complete flexion of the arm DR. MOTT ON ANEURISMS. 315 at the elboAV is prevented by a little rigidity of the extensor muscles. 9 A. M— He is now comfortable, has slept a little, and feels re- freshed ; pulse is full, and rather more frequent than natural; skin natural and moist: the size of the tumour is considerably dimin- ished ; has taken a dish of chocolate and some rusk. llhA. M.—Patient still free from pain, or any uneasiness; medi- cine has operated seven times; skin not hotter than natural, and moist; tongue clean ; the right facial and anterior temporal arter- ies communicate a distinct pulsation to the fingers: having slept but little during the last night, directed him to take an anodyne of Tinct. Opii. gtt. xxx., and to have the room made dark, and kept quiet, in order to procure him some sleep : let him have sago or panada as often as he inclines to take nourishment. 4 P. M.—Has slept the last two hours, and is still sleeping ; re- spiration free and easy; nothing the least unnatural in his ap- pearance. 10 P. M.—He has slept four hours, and is much refreshed ; is free from pain, except a little in the elboAV ; pulse small and soft, beating 105 strokes in a minute ; tongue clean ; feels a little sore- ness in the Avound when swallowing; has taken a considerable quantity of sago and panada; his appetite is good; temperature natural and uniform in both arms. 12 P. M.—Patient has slept the greater part of the time ; is free from pain, and perfectly comfortable; skin moist and natural; pulse soft, small, and frequent. Fourth day, 6 o'clock, A. M.—Patient has passed a good night; says his right elboAV gives him some uneasiness, but complains of nothing else ; tongue is clean; skin moist and natural; can moA^e the right arm Avith considerable ease : says he takes as much light nourishment as he has been accustomed to for some time past: no unfavorable symptom has as yet made its appearance. 11 A. M.—Symptoms continue much the same ; tongue slightly furred; pulse comparatively small and soft, beats 105, and regular; respiration has been uniformly natural since the operation; sup- puration has begun to appear through the dressings, and is attend- ed Avith a little foetor ; let them be covered Avith a yeast poultice : it is thought that a faint pulsation or undulation is at intervals felt in the radial artery of the right arm: the left external carotid con- tinues its increased action. 6 P. M.—No change is observable in the patient's symptoms ; he still continues comfortable and complains of nothing. Fifth day, 11 § o'clock A. M.—The Avound Avas dressed to-day : on removing the poultice the dressings Avere soft and easily camo aAvay; the suppuration Avas considerable, and of a healthy ap- pearance ; it was found that the extremities of the hvo incisions Avere united as far as the sutures, each about one inch in extent; one suture at the angle of the Avound Avas removed; the Avound was dressed Avith dry lint, gently pressed into it; adhesive straps 316 NEW ELEMENTS OP OPERATIVE SURGERY. and a compress: his pulse beats 110, is fuller and stronger than yes- terday. 6 P. M.—Patient is very comfortable, subject to no pain or un- natural sensation ; pulse still 110, but softer. Sixth day, 6 A. M. —Patient sleeps; respiration not attended with the least difficulty ; skin moist and natural. 9 A. M.—He has rested well during the night, and is perfectly free from pain; pulse 110, and soft; skin moist; tongue clean: having had no alvine evacuation since the 13th, directed to take of sulphate of soda § j, in divided doses. 11 A. M.—The dressings were again removed, and the discharge seemed more considerable than at the former dressing; the sides of the wound are granulating, and appear perfectly healthy; on the ends of the muscles that Avere divided in the operation, there are small sloughs which are beginning to separate, leaving a healthy surface underneath : wound was dressed Avith lint spread Avith Ung. Res. Flav. and adhesive straps : pulsation is now perfectly distinct in the branches of the right external carotid artery: complains a little of the back part of his head, which he says is sore from lying; in other respects is comfortable. 6 P. M.—Has no pain, and is in every respect much as usual; tongue clean ; skin natural; says he feels " no weaker than before the operation." Seventh day, 6 A. M.—He has passed a comfortable night, and is free from pain or any uneasiness; pulse regular and soft, and beats 105 in a minute ; skin moist, and of natural temperature. 11 A. M.—The Avound Avas again dressed : suppuration consid- erable and healthy ; some of the small sloughs came aAvay, leaving a healthy and florid surface beneath: sprinkled the Avound with poAvdered carbon, then filled it lightly with lint, and over this ap- plied the yeast poultice, Avhich was secured Avith adhesive straps: temperature of the two arms is the same, cathartic having pro- duced no effect; habeat enema purgans statim. 9 P. M.—Symptoms have not varied materially ; the enema has produced a copious evacuation: says he feels more comfortable, and desires to set up in bed, which was alloAved, taking care to have him raised up very cautiously, in order to prevent any exer- tion being made with the right arm and shoulder. Eighth day, 6 A. M.—Patient has rested Avell during the night; says he feels some pain on swalloAving, and that Avhen the attempt is made, it gives rise to a fit of coughing, which fatigues him; it also occasions some soreness in the wound: pulse still soft, and less frequent than yesterday : he takes a reasonable quantity of light food every day:—Directed a cetaceous mixture for his cough, and is permitted to set up for a short time, if he feels disposed. 11 A. M.—Pulsation of the radial artery of the right arm to be felt occasionally pretty distinct; cough has become more trouble- some; pulse 100; skin natural and moist. The dressings Avere again removed, and the suppuration is more profuse, apparently DR. MOTT ON ANEURISMS. 317 healthy, though attended Avith considerable foetor; appearance of the Avound every Avay favorable ; small portions of the sloughs are removed at each dressing, and the sides of the Avound look perfect- ly healthy; the same dressings to be continued. 9 P. M.—Complains only of his cough, Avhich troubles him fre- quently ; can move his arm Avith much more facility, and has no pain in it; circulation as before, and the temperature uniform and natural. The Avound was dressed this evening in consequence of the foetor being unpleasant to the patient; continue the dressings. Ninth day, 7 A. M.—Patient Avas found sitting up in bed, sup- ported by a bed-chair, having passed a good night; is in good spirits, and expresses his gratitude for the relief afforded by the operation; says he can move the arm with greater ease, and it gives him no pain; pulse 105, regular and soft; skin natural; every symptom as favourable as could be wished. 10 A. M.—Pulse less frequent, regular and soft; temperature perfectly natural; wound has a more favourable appearance, dis charges less in quantity, and it possesses less foetor; dressed the wound as yesterday ; tumour has diminished two thirds, is soft, and less florid. The apex of the tumour is noAV beloAV the clavicle. 6 P. M.—Patient still in every respect as comfortable as at the last report. 9 P. M.—Pulse 110, regular and soft; the dressings Avere re- moved this evening ; the Avound is much contracted in size, and is perfectly healthy, except a small slough which still remains in the deepest part of the wound; granulations are shooting up rapidly from the sides. When preparing to remove the dressings, an un- expected and unaccountable hemorrhage took place, which sud- denly filled the cavity of the Avound. The rapidity with which the blood flowed, and the size of the stream, gave rise to fearful apprehensions for the man's safety: dry lint was immediately placed in the Avound, and as much pressure made as the patient could conveniently bear, which quickly stopped it. After con- tinuing the pressure for a short time, the lint Avas removed, Avhen no hemorrhage recurring, the usual dressings were repeat- ed : the patient experienced no ill effects from the bleeding, nor did he seem to be much agitated. At 10 o'clock, P. M., has no pain, nor has he as yet had any sleep. Tenth day, 7 A. M.—Has passed a comfortable night, except that he has been frequently disturbed by his cough : tongue clean; skin moist; pulse soft, and has much less strength than before. 11 A. M.—The dressings were again removed, and the wound made clean; its appearance is in every respect favorable; does not appear to have been the least injured by the hemorrhage ; the dress- ings Avere renewed as before : he is directed to take half an ounce of the cold infusion of cinchona every hour, and to drink occasion- ally of ale Avhen thirsty: has had an evacuation from his bowels to-day. 6 P. M.—Symptoms much as before; complains a little of his 318 NEW ELEMENTS OP OPERATIVE SURGERY. elboAV, and a numbness in his hand, to relieve which he is di- rected to have the arm and hand rubbed well, and Avrapped in Avadding. Eleventh day, 6 A. M.—Patient has rested well during the night ■ cough has not been so troublesome ; says he has no pain, and feels perfectly comfortable ; pulse better than yesterday ; other symptoms as before. 11 A. M.—The Avound is dressed daily at this hour ; its appear- ance is still very favorable, although there is still some foetor in the suppuration : the Avound has contracted perhaps one third: the tu- mor is also considerably diminished, and softer than before ; pulsa- tion in the right temporal and radial arteries as before : the same dressings to be continued. 6 P. M.—No change in the patient's general symptoms; pulse soft, and rather more frequent; appetite is as good as usual. 9 P. M.—Appearances have not varied. Twelfth day, 6 A. M.—Our patient was visited as usual -this morning, but there is no evident change in any of his symptoms; says he noAV rests Avell at night. 11 A. M.—To-day, Avhen the dressings were removed, that por- tion of the slough which occupied the bottom of the Avound (ap- parently a portion of the sheath of the vessels) came away: every part of the wound noAV, where its surface can be seen, has a healthy look; the most depending part is obscured by a quantity of pus, which cannot be wholly removed by lint, and it is not thought safe to permit the patient to lie in such a position as Avill allow it to be discharged: with the slough came away the ligature which had been applied to an artery under the lower portion of the sterno- thyroid muscle ; it Avas folioAved by no hemorrhage ; the Avound Avas now dressed with pledgets of lint, spread Avith Ung. Resinae Flavae and adhesive straps. He remains much as yesterday, has drank freely of ale ; pulse rather stronger than yesterday. Thirteenth day, 7 A. M.—No perceptible change in his symp- toms; complains of no pain, and says he feels very comfortable; cough has given him very little trouble for the last two days; he is evidently considerably Aveaker than before the operation, but is not sensible of it himself. 11 A. M.—The Avound was again exposed; it is not as florid as yesterday, and there is a greater secretion of pus; the cavity of the Avound was filled Avith dry lint only; the pus appears well formed, and has very little foetor. The same dressings Avere repeated in the evening ; there is still a quantity of pus at the bottom of the wound, which rises and falls at each inspiration and expiration : it continues to contract above, leaving us uncertain of its extent beneath: during the last three days, the patient has set up for several hours each day. 9 P. M.—Pulse and skin perfectly natural; has had a natural evacuation from his boAvels to-day ; continues the infusion of bark as prescribed before. Wound was again dressed, and is as healthy as usual; suppura- DR. MOTT ON ANEURISMS. 319 tion just sufficient to moisten the lint: the same dressings to be continued. Fourteenth day, 7 A. M.—Patient has slept Avell during the night, and is as Avell as usual; complains of soreness of an ulcer which he has had for some time betAveen his shoulders; it is im- proving in its appearance, and is directed to be dressed as usual with Ung. Resinse Flavse. The erysipelatous blush which sur- rounded it, is not as florid as heretofore ; it is beginning to granu- late, and assume a healthy appearance : in other respects he is per- fectly comfortable: he is noAV able to raise the right arm to his lips, Avhich he has not done since the fourth day after the accident by which his shoulder was injured; says too that he is getting stronger, and that he walked across the floor this morning without any assistance. 11 A. M.—On removing the dressing, the granulations appear perfectly florid and healthy : the bottom of the Avound is not visi- ble, owing to the small quantity of matter Avhich collects there, and from its depth cannot be easily removed, and perhaps not altogether safely; the position of the patient in bed must necessarily make the bottom of the Avound the loAvest: Avhen he coughs or swalloAvs, a small quantity of fluid pus at the bottom of the wound is seen to rise and fall; from the general appearance, hoAvever, of the wound, the man's feelings, and many other circumstances, it is not probable that there is any considerable quantity: the large ligature lying very loose in the Avound, was taken hold of, merely hoAvever to see if it Avas separated; no force Avas used : pulsation of the right ra- dial artery more distinct than heretofore : countenance of our pa- tient is improving ; says he feels more comfortable than before the operation : he can noAV straighten his arm, and raise it to his mouth Avith facility : as yet he has not recovered his strength, but is im- proving daily; has been setting up all day: directed him Avhen lying down, to assume a more recumbent posture; continues the sulphuric acid and infusion of cinchona, as before ; complains of the ale being too strong ; let it be diluted and made pleasant with sugar and nutmeg. 9 P. M.—The large ligature since the operation,has been confined upon the upper part of the sternum by apiece of adhesive plaster, to prevent any accident during the dressings. Upon dressing the Avound this evening, the large ligature as it lay in the wound, appearing to be loose, Avas again taken hold of Avith the forceps, and found float- ing upon the pus, being completely separated from the artery be- Ioav. The ligature Avas draAvn- so firmly upon the artery, that the noose Avas only large enough to admit the rounded end of a com- mon probe. The wound looks healthy, and is contracting rapidly ; it is iioav perhaps not more than one third of its original size. Sup- puration is noAV only sufficient to moisten the lint through. Fifteenth day, 12 o'clock.—The patient is comfortable in every respect ; pulse and skin perfectly natural; is sitting up in bed, and occasionally amusing himself Avith a book ; not the least symptom about him indicating indisposition: wound is healthy, and con- 320 NEW SYSTEM OF OPERATIVE SURGERY. tinues to improve in appearance. The right arm at intervals gives him a sensation of numbness,—not more, however, than can be accounted for from the uniform position in Avhich the arm rests, and no doubt a more languid circulation, as it is readily removed by a little friction and motion of the arm. His appetite improves, and he expresses a desire to walk about the room. The bark and sul- phuric acid to be continued. 9 P. M.—In the afternoon he Avas removed down stairs, from the private room in which he was placed immediately after the opera- tion,to the Avard inAvhich he formerly lay, and appeared highly grati- fied Avith the idea of again seeing his friends, Avhom he had left Avith very little hope of ever returning to. The Avound, upon being dressed, did not appear to have undergone any perceptible change. Sixteenth day, 11 A.M.—Our patient's strength is improving. To-day he made an effort, and Avith success, to visit his friends in Ward No. 7, Avhere he lay previous to his being transferred to the surgical department, and returned, without having any support; pulse as strong as before the operation, and in every respect natural; appetite better than before the operation ; cough a little trouble- some, but less so than for several days previous ; wound dressed with dry lint. 9 P. M.—Dressings removed ; patient as before ; suppuration small in quantity, and appears to be well-formed pus, and is not at- tended with the least foetor. Seventeenth day, 11 o'clock.—The ends of the divided muscles are nearly in contact, and the surfaces of the wound are rapidly granulating, and in every respect look Avell: patient's health con- tinues to improve; he walks about the room Avith perfect ease, and into several wards in the same story; the ability to move the arm increases; pulse and skin natural. The dressings were re- moved at 4 P. M., and also at 10 P. M. Eighteenth day.—The patient's strength continues to improve; every symptom remains highly flattering ; cough less troublesome. The dressings were again removed to-day three times. Nineteenth day.—Continues the same as yesterday; Avound dressed three times. Twentieth day.—To-day he passed doAvn tAvo pair of stairs, and walked several times across the yard, and Avas highly delighted Avith his performance, and felt not the least inconvenience from it; sleeps uniformly well duping the night, and takes more food during the day than he did previous to the operation; continues the infu- sion of cinchona and sulph. acid as before, and directed to use dry lint as the dressing. Twenty-first day.—Dressed the wound three times again to-day; it is nearly closed at the bottom ; the poAver of motion in the right arm continues to increase : he can now move it with as much fa- cility as the left, though not to the same extent: his strength is daily improving, and the operation is considered by all to have been com- pletely successful; size of the tumor continues the same, no dimi- nution of it having been perceived for the last Aveek; the most DR. MOTT ON ANEURISMS. 321 prominent part of the tumor is yet below the clavicle, that above rises to about the height of the clavicle, Avhich gives a little convex- ity to the place between the clavicle and trapezius muscle. Twenty-second day.—Continues to improve in every respect; dressings reneAved as often as yesterday ; OAving to the weather he has not left his Avard to-day; pulse full and strong; temperature of both arms the same. Twenty-third day.—A few minutes before the hour of visiting to-day, a message Avas brought that the patient Avas bleeding from the wound. The dressings were immediately torn off, and dry lint crowded into the wound, and slight pressure applied for a few min- utes, when the hemorrhage ceased. The patient lost at this time, perhaps about 24 ounces of blood, and was very much prostrated. Pulsation ceased in the radial artery of the left arm, and the coun- tenance, gasping, and convulsive throes of the patient, threatened immediate dissolution; all present apprehended the instant death of the patient. The first impression Avas, that the trunk of the ar- teria innominata had given Avay. The conjecture afterAvards was, that the subclavian artery, from the diseased state of it, had not united by adhesion, and that the fluid blood from the tumor had regurgitated through its ulcerated coats. This appeared to be the most probable, both from the suddenness with Avhich the blood ceased floAving, and the cause the patient assigned for the hemorrhage. He says that he felt weary of lying on his left side and back; that he had just turned on the right, Avhich he had not done before since the operation, agreeable to my request. At the instant of turning over, something arrested his attention, which caused him to turn his head to the opposite side suddenly, and he felt the gush of blood from the wound. He Avas directed some Avine and Avater frequently, Avhich soon revived the circulation. The Avound Avas dressed Avith dry lint and a compress. Pulse as frequent as natural, but very small and soft: he appears very languid, and complains of a numbness and painful sensation in his hands ; says also that his back aches. During the last tAventy-four hours he has taken a pint and a half of Madeira Avine : he also took occasionally some egg and Avine, which Avas immediately rejected from the stomach. 9 P. M.—Patient has lost his appetite, and appears considerably depressed; circulation very languid in the right arm; its temperature is a little less than in the left: directed a hot brick to be wrapped in flannel, and placed close to the arm. For a profuse perspiration which he has been in for the last three hours, he Avas ordered to be bathed Avith cold rum. 'Twenty-fourth day, 6 A. M.—Slept the greater part of the night, and feels comfortable ; is still languid, and has no disposition to eat anything ; says he feels sick, and once last evening vomited after drinking some Avine and Avater. Wound looks exceedingly pale, and the discharge is thin and fcctid, for Avhich the carbon and yeast dressings Avere applied. He has vomited several times to-day, and has some considerable dif- 21 322 NEW ELEMENTS OP OPERATIVE SURGERY. ficulty in swalloAving, and complains of a soreness in the wound upon pressure. 9 P. M.—Dressings removed ; wound very pale; right arm of the natural temperature; feels occasionally a little numbness in the hand; has taken very little nourishment during the day, pulse natural as to frequency, but small and feeble ; a few minutes after dressing the wound, information was brought that hemorrhage had ensued, and before it could be commanded, he probably lost four ounces of blood. For his restlessness and pain in the bones he Avas ordered two grains of opium. Twenty-fifth day.—Has rested well during the night, and is per- haps a little better this morning. The repeated hemorrhages have debilitated him exceedingly, and from the irritable state of the stomach, he can take only a very little nourishment. In the morn- ing he Avas directed the effervescing draught to be repeated every tAvo hours; this allayed the irritability of his stomach, and enabled him to take a little breakfast. His countenance has altered since the first bleeding surprisingly, his eyes are noAV heavy, and for the most part fixed ; his cheeks are sunken, and an universal pallor has spread itself over his coun- tenance ; and from every appearance, a short time will terminate his existence. He has not vomited since early in the morning ; is advised to take a little soup, and to drink freely of wine and water; dressings were renewed at 3 o'clock, P. M., shortly after Avhich the patient again bled, but not to exceed, however, an ounce. He was dressed Avith dry lint as usual. IIP. M.—Patient has not as yet had any sound sleep, is rest- less and apparently distressed, although he says he feels no pain; breathing is attended Avith some difficulty; his hands and legs are continually in motion; pulse small and feeble. Twenty-sixth day, 6 A. M.—Patient has not rested Avell; is oc- casionally falling into little slumbers, but is awakened by the least motion: pulse small and feeble; respiration somewhat laboured; appears to be sinking; seems disinclined to take any thing; legs and arms constantly in motion. 11 A. M.—More feeble than before; has been forced to take a little chocolate; is evidently sinking; Avound was dressed, but there was no secretion of pus in it; countenance of the patient foretels his approaching dissolution. 6 P. M.—Is extremely low ; respiration very much laboured; is not able to articulate : for the last three hours there has not been such continued throwing of the legs and arms about the bed: he lies in a state of insensibility; temperature of the two arms the same to the last. My pupil, Abraham I. Duryee, the House Sur- geon, (to whom I am indebted for the correct reports, and the most unAvearied attention to this case, and Avhose ingenious applica- tion of means for the recovery of many of my patients, Avill long be held by them in grateful remembrance,) having for a few minutes left the patient, he Avas sent for immediately, as there Avas another bleeding from the wound, by which he lost probably eight DR. MOTT ON ANEURISMS, 323 ounces of blood : during the Avhole time he did not manifest the least appearance of consciousness, nor Avas the least motion per- ceptible, except that necessary for respiration and circulation : the hemorrhage was stopped with lint, after removing the former dressings; respiration is noAV performed Avith the utmost difficulty, and the patient appears as if every respiration Avould be the last : he expired at half past six in the afternoon: the temperature of the right arm after death, appeared by the touch-to be the same as that of the left; it Avas as natural and uniform as in other parts of the body. EXAMINATION OP THE BODY. About eighteen hours after death, I opened his body ; there Avas considerable emaciation, and the surface of the wound was of a dark-broAvn color, and foetid ; the- Avound Avas perhaps about one- third of its original size ; it had been enlarged by the pressure of lint into it, and other means to arrest from time to time the hemor- rhage : the ulcer behveen his shoulders Avas ill-conditioned. For the purpose of examining the condition of the aorta, where the arteria innominata is given off, as also the origin of the latter ves- sel, as Avell as the state of the pleura at the part about which the ligature had been applied around the artery, the chest Avas opened in the folloAving manner: after removing the integuments and mus- cles from the fore-part of the chest, the sternum Avas carefully sawed through about an inch from its upper extremity, and raised by sawing through the ribs beloAV the junction of the cartilages ; this removed so much of the front part of the chest as to facilitate and expose fully to vieAv the subsequent steps of the dissection ; by thus leaving the clavicles attached, every part connected Avith the ulcer and great vessels could be seen and examined in situ. The arch of the aorta and origin of the innominata being fairly exposed, not a vestige of inflammation or its consequences could be discovered, either upon them, the lungs, or the pleura, at any part. An incision was next made longitudinally into the aorta opposite the origin of the innominata, and upon introducing a probe cau- tiously up the latter vessel, it Avas seen to pass into the cavity of the ulcer ; the innominata Avas then laid open Avith a pair of scis^ sors into the ulcer ; the internal coat of this vessel was smooth and natural about its origin, but for half an inch below where the liga- ture had cut, through ihe artery, it shoAved appearances of inflam- mation, and there was a coagulum adhering with considerable firmness to one of its sides ; showing that nature had made an effort to plug up the extremity of so large a vessel, after the adhesion, Avhichno doubt had been effected by the ligature, Avas swept away by the destructive process of ulceration. The upper extremity of this vessel was considerably diminished in its diameter by the thickened stale of its coats, occasioned by the surrounding inflammation. The innominata ah.nit half an inch from the aorta, and a little to the left side, gave off an anomalous artery larga enough to admit a small sized croAV-quill. 324 NEW ELEMENTS OP OPERATIVE SURGERY, The ulcer at the bottom was more than tAvice the size of the Avound in the neck ; it extended laterally towards the trachea and under the clavicle towards the tumor. The tripod of great vessels consisting of the innominata, subclavian, and carotid arteries, to the extent of nearly an inch, was dissolved and carried away by the ulceration. The extremities of the two latter vessels were found also to open into the cavity of the ulcer. The upper surface of the pleura was very much thickened by the deposit of newly organised matter, for the safety and protection of the cavity of the thorax. Indeed, instead of having increased the danger of penetrating this membrane, the adhesive inflammation which preceded the ulcera- tive, seemed, by the consolidation of cellular membrane, and the ad- dition of new substance, to have more securely and effectually shielded it from harm. The internal surface of the carotid artery was lined with a coagu- lum of blood, more than twice the thickness of its coats, and extend-' ing above the division into the internal and external, so as almost to give them a solid appearance, insomuch that a probe could barely be introduced. The subclavian artery, internally and externally to the disease Avas pervious. The brachial and other arteries of the right arm Avere of their common diameter, and. in every respect na- tural. The external thoracic or mammary arteries^ as they went off from the subclavian, were larger than natural: the right inter- nal mammary was pervious, and of the usual appearance. Upon opening into the tumor, which now gave (from its small size,) no deformity to the shoulder, the clavicle was involved in it, and found carious, and entirely disunited about the middle. Several coagu- la of blood Avere also found in the sac. A number of lymphatic glands under the clavicles, and particularly the left, were consider- ably enlarged, and, Avhen cut into, very soft, and evidently in a state of scrofulous suppuration. No other morbid appearances were observed. Several very important facts are established by this operation —facts which no surgical operation has ever before confirmed. It proves very conclusively, that the heart, the brain, and the right- arm, were not the least injured by it, in any of their functions. To tie'so large a vessel, so near the heart, might very reasonably be .expected to occasion some immediate derangement in the actions of that organ : but it Avas neither increased nor diminished in its contractions, nor did it give rise to the least visible change in the respiration. All this could not have been anticipated. I appre- hend there are no ingenuous surgeons, who Avouldnot have expect- ed quite a contrary result. For my OAvn part, I must confess, that this was to me an anxious moment, when I drew the ligature upon this artery. Indeed, so apprehensive was I that some serious, if not al- most immediately fatal consequences, Avould folloAv, from arresting so large a proportion of the whole mass of blood suddenly, that I drew the ligature very little at first. But when no change took place in the action of the heart, or respiration, I felt a confidence in completely intercepting the whole current of blood through this great vessel. DR. MOTT ON ANEURISMS. 325 The brain in no operation has been deprived of so large a quantity of blood as in this, and yet it suffered no inconvenience : from the effect of experiments however upon animals, I entertained no fear as to the consequences of my operation upon this organ. The right arm, as the reports of the case from day to day will show, was in no want of a sufficient supply of blood for the pur- poses of its economy. That circulation went on to a degree ade- quate to its wants, the natural warmth and function of the skin ful- ly prove; and although at no time could all be satisfied that a pul- sation was perceptible in the radial artery, yet many at times were of the opinion that an occasional undulatory motion was very evi- dent ; every one was confident of the distended and elastic feel of this artery, and could plainly see, from pressing on the distended veins upon the back of the hand, that a free circulation of blood was going on: but independent of these evidences, the natural warmth and free perspiration would alone be sufficient to establish the fact. The route of circulation to the right arm, was somewhat differ- ent at first, from what took place after the ulceration had extended. The inosculation of the epigastric and internal mammary must have thrown a considerable retrograde current of blood through the lat- (Plate I.) Represents the tumor very eorrectly, with its elevation above and below the clavicle, and the extent of it towards the acromion scapulae, and likewise as it encroached upon the tra- chea, rhe form of the external incision with the subsequent steps of the operation as far as can be given «n a drawing, are also shown. ' a, a, a The angles of the integuments as turned over upon the tumor b The sternal and a part of the clavicular portion of the stemo-cleido mastoid muscle raised, and reflected over upon the integuments. ' C The sterno-hyoid muscle laid over upon the trachea. d The sterno-thyroid muscle also raised and reflected inwards over the trachea. 326 NEW ELEMENTS OF OPERATIVE SURGERY. ter vessel into the subclavian directly, and Avhich in all probability passed on into the arm ; after the ulceration had extended, this com- munication Avascut off by the destruction of the subclavian to some distance. It Avas noAV that the principal supply of blood to the arm must have been derived from the free communication of the intercostals Avith the thoracic arteries. From the large size of these, as found in the dissection, I apprehend they must have afforded the principal channels through which the blood was conveyed to the arm after the operation : the anastomoses of the infra-scapular and other arteries of the axilla, more or less with small branches of the intercostals, as also the occipital, with small ascending branches from the subclavian, may have given some trifling assistance. The ulceration Avhich went on so insidiously at the bottom of the wound, Avas the sole cause of the death of my patient. While the upper part of the Avound put on a favorable appearance, and seem- ed healing, mischief Avas extending beloAV. The separation of the ligature on the fourteenth day, spontaneously, Avithout being follow- ed by any hemorrhage for a number of days, and not until ul- ceration had extended, conclusively proves to my mind, that all the purposes of the ligature were completely ansAvered—that adhesion was fully effected. Had it not been for the ulcerative inflammation, no doubt Avill be entertained, I think, by surgeons, but that my patient would have recovered. From occupation his constitution was in- deed very old, and Avith an ill-conditioned habit, every thing favor- ed the process of ulceration. The position of the Avound may be said by some to favor this process, but in a sound healthy habit it would only retard the wound in its recovery, but would never pro- mote ulceration. The practicability and propriety of the operation appear to me (Plate II.) Exhibits 'the morbid appearances which were found upon dissection. a, a, a View of the ulcer as it extended un- der the clavicle, and towards the trachea. b The upper part of the arteria innomina- ta, about which the ligature had been applied, appearing rough and irregular from the erosion of the ulcer. C A coagulum of blood adhering pretty firm- ly to one side of the innominata.' d Contracted and puckered appearance of the upper part of the innominata, and particu- larly of its internal coat. e Arteria innominata cut open from the aorta. / Anomalous branch of the innominata. g, g The aorta. A Left Carotid. i Left subclavian. k The heart collapsed. / Sternum and clavicle turned up. m, m Pleura much thickened. n Probe introduced into the axillary artery, passed through the subclavian, and appearing in the cavity of the ulcer. o A small bougie passed along the common carotid, and its extremity also seen in the ul- cer. DR. MOTT ON ANEURISMS. 327 to be satisfactorily established by this case : and although I feel a regret, that none can realize Avho have not performed surgical ope- rations, in the fatal termination of it,and especially after the high and just expectations of recovery which it exhibited ; yet I am happy in the reflection, as it is the only time it has ever been performed, that it is the bearer of a message to Surgery, containing new and important results. No. II.—Nov. 14, 1818. The Right Carotid tied for the Safe Removal of a Fungous Tumor in the Neck, by Val- entine Mott, M. D., &c. (See the Medical and Surgical Re- gister, consisting chiefly of Cases in the New York Hospital, New York, 1820, part IL, vol. I., p. 381-400, Avith three Plates and Explanations at p. 405-6 of the same work. The same is pub- lished also in The American Journal of the Medical Sciences, with the same plates, Philadelphia, 1831, vol. VIIL, p. 45, &c.) John McGarrigle, born in Ireland, aged forty-nine years, a mason by occupation, Avas admitted into the New York hospital on the 10th of November, 1818, for a carcinomatous fungus. The fungus Avas situated upon the right side of the face and neck, and occupied a considerable portion of each. It extended from the inferior lobe of the ear nearly to the chin, and downward to a hori- zontal line, passing through the inferior edge of the thyroid carti- lage. It projected downward and forward, to the extent of about four inches. At its most prominent part, there was an opening, nearly circu- lar in its form, and about one and a half inches in diameter ; gradu- ally diminishing as it extended through the fungus, and terminating just within the margin of the inferior maxillary bone. The edges Avere everted, and studded round Avith clusters of fun- gous excrescences, varying in size from that of a pea to a marble ; of a pale red colour, and of a granulated appearance ; extremely flabby in their structure, and bleeding upon the slightest touch. From its cavity there was a constant discharge of a thin acrid fluid, amounting to about a pint in twenty-four hours ; extremely offensive, and excoriating the surface with Avhich it happened to come in contact. He seems to have been originally a man of a strong and vigorous constitution, but at the time of his admission, it had suffered much from the disease. His countenance was pale; pulse feeble • he had no appetite, and his Avhole appearance evinced the utmost lan- gour and depression. About eight months previous to the appearance of this tumor, he had been cured of an ulcer situated on his lower lip, that had troubled him more than tAvo years. He says it resembled a wart, that at times it gave him severe pain, and that he had tried various applications Avithout deriving any benefit, until a cancer doctor 328 NEW ELEMENTS OF OPERATIVE SURGERY. gave him a " burning plaster," which brought out the core, and then it soon got well. The patient ascribes the origin of his disease to a severe tooth- ache, Avhich was attended Avith a swelling of that side of his face in April last. When the sAvelling subsided, he discovered a small moveable tumor, very little larger than a pea, immediately under the margin of the lower jaw. It remained nearly stationary for two months, giving him but little pain and no inconvenience. It then began to swell, and became troublesome; the pain was severe, and of that peculiar kind which characterizes carcinoma. He was advised by his physician to apply poultices, Avhich were continued for five or six weeks. The tumor was then punctured with a lancet. A little bloody serum alone flowed from the punc- ture. Shortly after this, the tumor began to increase with more ra- pidity ; tAvo other openings formed spontaneously, which soon com- municated with the first, making the large circular opening before described. In consultation it Avas agreed, that an operation which would lessen the Aoav of blood to the fungus, and permit as much of the tumor to be removed as possible, afforded the only possible means of prolonging the existence of the patient, or of mitigating his suf- ferings. With these views, I accordingly performed the following operation, on the 14th day of November, at 12 o'clock. The right carotid was taken up about an inch beloAV the cricoid cartilage, and secured by two ligatures, but not divided in the in- terspace, in consequence of the depth of the artery, from the SAvell- ing of all the parts around the disease. Such was the enlarged size of the vessels, that it became necessary to take up several arteries and veins before the carotid could be exposed. The tumor was removed by an incision commencing at the ear, opposite the meatus auditorius, and carried obliquely downward and forward, so that it passed over the base of the lower jaw near the chin, passed under the chin, and terminated upon the outer edge of the anterior belly of the left digastric muscle. From thence downAvard to the thyroid cartilage, along the loAver edge of this, across the sterno-mastoid muscle, and terminating about an inch be- hind the mastoid process of the temporal bone, upon the os occipi- tis. Another incision from the termination of this, passed along un- der the ear to meet the commencement of the first. (See dotted line in plate I.) The tumor was noAV dissected from the parts beneath, beginning opposite the thyroid cartilage, so as to detach the lower part first, in order not to have the dissection obscured by the Aoav of blood. In this way, the operation Avas carefully continued until the base of the jaw Avas exposed, then separating the cheek from above dowmvards, the morbid mass was removed. The jaAv-bone was denuded to the extent of about an inch, near the posterior angle, but only slightly carious. In this operation, almost the Avhole of the digastric muscle, anteriorly and posteriorly, all the sub-maxil- DR. MOTT ON ANEURISMS. 329 lary gland, part of the mylo-hyoideus, and stylo-hyoideus muscles, were removed. The venous hemorrhage was very great from the large size of the veins, which returned the blood from the tumor; they Avere visible upon the surface of the tumor. Only three arte- ries were divided; the labial, and two smaller branches; one ap- peared to be a branch of the superior thyroidal, and the other of the occipital. They bled very little. The operations occupied about one hour and fifteen minutes, and the patient lost perhaps nearly thirty ounces of blood, mostly venous. 6 p. M.__The patient is somewhat exhausted by the loss of blood and the exertion he has been obliged to use during the day : complains of a good deal of pain in the wound, and has some diffi- culty in swallowing ; he is also subject to a cough, which now be- comes exceedingly troublesome ; pulse feeble, small, and frequent; skin hot and dry. Is directed to take of Tinct. Opii. gtt. lx. Nov. 15, 9 A. M.—Has rested well during the night, and is com- fortable when not disturbed by the cough; has taken very little nourishment, in consequence of the difficulty of swalloAving; skin is natural; pulse less frequent, and fuller ; tongue does not mani- fest any febrile disposition. 12§ P. M.—The difficulty of sAvallowing food and the cough are the only unpleasant symptoms under Avhich the patient labors. Directed an anodyne draught in the evening. Contrary to direct injunction, the patient left his bed and walked across the floor. Nov. 16, 12 o'clock.—Patient passed a comfortable night, and is considerably better this morning. State of pulse and skin favor- able ; the former rather feeble ; has had an evacuation from his bowels spontaneously ; is directed to take as much nourishment as the state of his throat will permit; is alloAved a bottle of ale. Nov. 17, 12 o'clock.—The inflammation Avhich rendered deglu- tition so difficult, has in a great measure abated ; he is now able to take a sufficient quantity of nourishment, in consequence of Avhich his pulse is better, and his whole appearance has improved; he is noAV alloAved, in addition to the ale, a little Avine. Suppuration had softened the dressings, and they appeared loose, in consequence of Avhich they Avere removed and the Avound dressed. Its appearance is rather more favorable than was anticipated; but the whole of the disease is by no means removed. The extent of the Avound in length is six inches, and three in width. There is a small black slough just where the tumor was first discovered; below that and the chin, there is a cluster of ex- uberant granulations, somewhat resembling those situated on the edges of the opening of the tumor. The wound made for taking up the carotid artery is very florid; there is a slough at the bottom, Avhich is becoming loose ; its edges are highly inflamed by the acrimony of the discharge from the wound above, which is constantly running into it. Nov. 18, 12 o'clock.—The patient is improved, he takes solid food with more facility, and is in every respect more comfortable. 330 NEW ELEMENTS OP OPERATIVE SURGERY. The wound was again dressed; its general appearance is some- what more favorable ; the discharge is very acrid, and excoriates the parts about the lower wound. He is directed to take freely of ale and Avine. Nov. 19, 12 o'clock.—Patient is still improving; the wound Avas again dressed; directed a lotion of 3 ij. of FoAvler's solution of arse- nic, in I viij. of water, to be applied to the exuberant and spongy granulations. Nov. 20.—The wound is improved; patient is also comfortable; appetite is good; boAvels costive ; is directed to take, immediately, Rhei. palmat 3j. and Sup. tart, potass. 3ij.,and to continue the other prescriptions as before. Nov. 21, 12 o'clock.—Discharge is more abundant, and has in- flamed the lower wound considerably, and excoriated the parts about it; his general appearance is better; cough still troublesome, more particularly at night; boAvels free ; no febrile symptoms. Nov. 22, 12 o'clock.—The upper wound is much contracted, the posterior part of it is granulating and cicatrizing rapidly; the lower (Plate 1.) This plate will convey a very good idea of the tumor. The shaded part is intended to represent the disease far beyond the ulcerated, or fungous projections. It was wished to avoid all the morbid hardness in the incision, and as the dotted lines will show, this was very nearly accomplished. The cutaneous veins anterior to the ear, are seen much enlarged, and the arteries and veins on other parts of the tumor, and around it were in a very di»- tended state. DR. MOTT ON ANEURISMS. 331 is still very much inflamed, and rendered extremely sensitive by the discharge of the other; directed to cover the upper Avound Avith flour and lint, and to take the Spermaceti mixture whenever the cough is urgent. Patient is improving, and Avould be very comfortable if not dis- turbed by the cough, Avhich prevents him from resting well. Nov. 23, 9 A.M.— Patient has not rested Avell, cough exceed- ingly troublesome; pulse still feeble ; dressings were again re- moved; the Avound above looks well; the lower-is very much irritated by the discharge, its edges are highly inflamed, and bleed upon a slight touch; his appetite is good, and he takes sufficient quantity of nourishment, with wine and porter ; is directed to take in addition to the other remedies, Tinct. Cinch. I ss. every tAvo hours ; the upper Avound is granulating rapidly ; all the old sloughs are removed; the ligatures have all ccme aAvay; the suppuration has the appearance of healthy pus, but is extremely acrid ; has no factor. Nov. 24.—Patient is in a fair way to do well. The cough re- mains by far the most troublesome symptom he has ; it frequently prevents him from sleeping, and irritates the Avounds by the mo- tion it occasions; his general appearance is hoAvever improving, his appetite is good, and he is subject to no pain. The wound is dressed daily; its appearance is highly flattering; the whole sur- face now is florid, since the sloughs are removed ; the granulations are, hoAvever, spongy on the anterior part, but at the other parts they are perfectly healthy; the loAver Avound is less highly inflam- ed, and the discharge is considerable, but less acrid. Nov. 27.—The patient is perhaps a little better than at the last report; cough is still frequent, and renders him restless at night; it is noAv attended with a copious expectoration ; deglutition is less difficult, and his appetite is reasonably good; he has been con- stantly free from fever, though his pulse is still frequent. The Avounds are dressed daily; the lower edge of the upper wound is contracting rapidly; along the upper edge there is a range of exuberant and morbid granulations, projecting a quarter of an Inch above the skin, partaking soineAvhat of the character of the original fungus. The ligatures on the carotid came away to-day, adhering to the portion of artery included betAveen them, and separating nearly half an inch of artery from the points at which they were applied. Nov. 30.—Patient continues to do Avell; his health generally is much better than before the operation; he is not as strong, but is in every respect more comfortable ; the cough is an accidental thing, and in no way necessarily connected Avith the consequences of the operation ; it gives him more uneasiness at present, than the wounds themselves. He prefers a sitting posture in bed, and is supported in that pos- ture by a bed-chair. All his symptoms continue favorable, but his improvement is very gradual. The Avounds have not altered much in their appearance ; the 332 NEW ELEMENTS OP OPERATIVE SURGERY. acrid discharge from the upper, operates very much against the amendment of the lower, and the granulations have someAvhat the character of the original tumor, bleeding upon the slightest touch, and are exquisitely sensitive. Dec. 7.—Patient has not been as Avell as usual; cough prevents him from sleeping, and the motion produced by it irritates the wounds; expectoration is very considerable ; he seems to be de- pressed and anxious. The discharge from the Avound is less acrid, and has allowed the lower Avound to get into a much better state; it is now completely filled up; the granulations are, however, flabby, and do not appear inclined to cicatrize. The surrounding parts are not so florid and sensitive as they have been. His neck is draAvn considerably to one side, and he is unable to move it; he thinks it partly OAving to its resting constantly in one position on the bed-chair. Is directed to lay in a recumbent pos- ture, and occasionally to leave his bed and sit in an easy chair; appetite not so good as usual. Dec. 15.—The patient has recovered a little from his late indispo- sition ; the stiffness of the neck still remains; appetite good; an anodyne procures him rest at night; the upper Avound not improved much; the morbid granulations are at least half an inch above the skin, and in some places a little higher; he leaves his bed daily, and passes several hours in an easy chair. From this time, his health appeared to be gradually on the de- cline. The lower Avound in a little Avhile healed up; the upper underwent but little alteration from this time fonvard. The cough continued to be very troublesome, the expectoration very copious, and evidently purulent. He became regularly hectic, accompanied with great emaciation, and died on the 3d of March, 1819, having lived three months and nineteen days after the operation. It will be perceived, from the account of this case, that the cough was aggravated by the operation, but not produced by it. In three instances in Avhich we have seen the carotid tied, a very consider- able cough has attended, until suppuration was fully established in the wound, Avhen it has subsided. My patient labored under a cough before the operation, and there was a manifest increase of it for a week or more after its performance, but it by no means Avas the cause of its continuance,as the dissection after death will evince. The hectic symptoms arose from the diseased condition of the mu- cous membrane of the trachea and its bronchial ramifications, rather than the irritation of the ulcer left from the operation. His death may therefore, Avith more propriety, be attributed to the pul- monary, than the fungous disease. Dissection. The carcinomatous granulations had risen a little above the sur- rounding surface ; the size of the ulcer had considerably contracted since the operation; the loAver jaAV Avas exposed to some extent about the posterior angle, but irery little carious. DR. MOTT ON ANEURISMS. 333 On opening the thorax, the lungs appeared externally to be in a healthy state, Avith the exception of several adhesions of one lung to the pleura costalis. Upon dividing the trachea a little above the bronchiae, it Avas found nearly filled with pus ; the lungs, when cut into, exhibited the same appearance at innumerable points, Avith- out the least vestige of ulceration at any part. The mucous mem- brane Avas rough, and thickened in the trachea, and also in the bronchial ramifications. The abdominal viscera were sound, except the kidneys. In the tubular part of each was found a small abscess about the size of a nutmeg, apparently containing a healthy looking pus. As this afforded me an excellent opportunity of examining the arteries on the right side of the head and neck, after the carotid had been tied ; and not knowing that any such case had been recorded, I gladly availed myself of it, and separated the head, neck, and shoulders, in the following manner :— Having saAved through the sternum at the upper part, so as to leave the clavicles attached, the superior extremities were removed from the trunk, and the dorsal vertebra? and ribs divided between the second and third, so as to leave it of a bust-like shape. This preserved the shoulders in such a way that the subclavians and their branches might be injected. The ascending arch, and a por- tion of the descending aorta Avere also included in the preparation. To secure the filling of the arteries of the head and neck, a long pipe Avas passed up the aorta into the left carotid, and a fine wax injection was thrown in with great care, and, as the subsequent ac- count will shoAV, Avith great success. The aorta was next injected to fiil the subclavians and their branches. In the dissection, Avhich was conducted Avith the greatest care and attention, I was assisted by David L. Rodgers and Alexander F. Vache, two of my pupils, ardent in the pursuit, of anatomical and surgical knowledge. The following description of the arteries of the head and neck is taken from the preparation, and they are delineated as far as possible in the annexed engravings. 1st. The arteries that supplied the right side of the head and neck, after the carotid had been tied. See plate II. To give a regular description of these arteries, would be incom- patible with the principle of collateral circulation—inasmuch as they are found to vary in different subjects, for " the inosculation is never carried on by any particular set of vessels, but by all the arteries of the neighboring parts." Upon removing the integuments on the fore-part of the neck, and laying bare the carotid artery from the innominata to the angle of the jaAV, its calibre was fouud completely obliterated from its origin to its bifurcation; leaving a firm, ligamentous cord, which Avas divided into two parts, shoAving the place Avhere the ligatures had been applied. The vein and nerve were perfectly natural. The right subcla- 334 NEW ELEMENTS OF OPERATIVE SURGERY. vian Avas much enlarged, being equal in size to the innominata, from its origin to the scaleni muscles. The left carotid was enlarged to tAvice its natural diameter ; its branches increased in the same ratio, and assumed a tortuous and irregular course. When Ave take into consideration the connexion Avhich the arte- ries of the left have Avith those of the right side of the head, and their free inosculation Avith the subclavian, Ave can have in our imagination the branches that must necessarily supply the place of the right carotid. First, Ave have the branches arising from the subclavian, Avhich are very numerous ; secondly, those arising from the left carotid, which are still more numerous. A minute detail of the numerous vessels Avhich communicate with the carotid, would be tedious and uninteresting, and would perhaps be impracticable, were it deemed expedient. Suffice it to notice the principal branches, and to give a general description of the smaller, but not less beautiful inosculations. We find, then, arising from the right subclavian, first, the arteria thyroidea inferior ; secondly, the cervicalis profunda; thirdly, the cervicalis superfi- cialis ; and, fourthly, the vertebral arteries. The inferior thyroid, as it arises from the subclavian, divides into four branches—two passing downwards and outwards, and the other two passing upAvards; the latter are called the ramus thy- roideus, and the thyroidea ascendens. These require particular at- tention from their large size, and the important supply of blood Avhich they furnish for the support of the arteries of the neck- While the superior arteries Avere enlarged to tAvice their natural diameter, the two inferior ones, viz., the transversalis colli, and the transversalis humeri, although arising from the same trunk, and re- ceiving their currents of blood in the most favorable direction, still retained their natural dimensions. But this phenomenon usually occurs in the circulating system. John Bell observes, " that in whatever Avay the demand of blood upon an artery or set of arte- ries is increased, the effect is an accelerated motion of blood towards that artery." And again, " any demand of blood causes an en- largement of the arteries leading to the part Avhich demands the blood." Guided then by this principle, we need not be surprised that the subclavian is so much enlarged from its origin to the scaleni mus- cles ; for here it affords a supply of blood to new and important parts. The ramus thyroideus passing upwards to the thyroid gland, and anastomosing Avith the superior thyroidal artery, Avas one great source of blood ; its branches were large and tortuous, forming com- munications in every direction, Avith those from above. The thyroidea ascendens is naturally a small and unimportant branch ; it was here three times its usual size, mounting up the neck in a zig-zag direction, lying close to the vertebra?, forming fre- quent communications with the vertebral artery, dividing into many 'small branches at the upper part of the mastoid muscles, forming a beautiful plexus of vessels, Avith the mastoid branch of the occipital DR. MOTT ON ANEURISMS. 335 artery, and sending branches to all the muscles on the upper part of the neck. The cervicalis profunda and superficialis were much enlarged, sending frequent branches upwards to anastomose with the de- scending branches of the occipital artery. By far the most impor- tant and interesting part of the circulation yet remains to be de- scribed. (Plate 2.) In this plate is represented the right carotid artery, obliterated from the innominata to the bifurcation. The success with which the circulation was carried on to the head through the inosculating channels, may also be seen in the enlarged anastomosing branches. Fig 1. Right bronchial tube. Fig. 6. Thyroidea ascendens. 2. Aorta. 7. Scalenus anticus muscle. 3. Arteria Innominata. 8. Subclavian artery, after it has passed 4. Ramusthyroideusarteriae thyroidea?. the scaleni muscles. 6. Sterno-cleido mastoideus. 9. Transversalis humeri of its natsr;>.] ize, a Transver>alis colli. I Cervic-.lis superficialis et profunda. C Portion of the carotid separated by the ligatures. d Obliterated carotid. e Superior thyroidal artery. / Inferior portion of the labial, as divided in the operation. g Mental artery. k Superior portion of the labial, where tied in the operation. t Plexus of arteries formed by inosculations of the ascending thyroid, and a descending branch of the oi cipital." k Descending branch of the occipital. / External carotid filled with injection. 336 NEW ELEMENTS OF OPERATIVE SURGERY. 2dly. The arteries of the left side of the head and neck. See plate III. The left carotid passing up the neck equal in size to the innomi- nata, furnished the'greatest part of the blood for the right side. (Plate 3.) This plate will give some idea of the success which attended the injection of the left side of the head and neck. Most of the more considerable vessels are here delineated, but the beauty of the preparation far surpasses the plate, in the minuteness with which the vessels are filled. All of (Uese are preternaturally enlarged Only a few of the arteries which are most enlarged, wi)l be referred to in the explanation of this plate. There is no variety in the course or distribution of the arteries. Fig. 1. The two portions of the sterno-cleido mastoideus muscle. 2. Left carotid artery, as large as the innominata. 3. Left subclavian artery, external to the scaleni muscles. 4. Superior thyroid artery. 5. Labial artery much enlarged. 6. Mental artery twice its common size. 7. Par vagum raised up, and seen crossing the carotid artery. 8. Arch of the aorta. BkThis beautiful preparation is still in fine preservation in my museum at the Medical College of the University. DR. MOTT ON ANEURISMS. 337 r- In order to determine Avhat particular arteries Avere enlarged it is necessary only to enumerate the branches given off from the ca- rotid, and more particularly those Avhich arise from its forepart Below the jaAV there are four : to wit, the superior thyroid the lin- gual, pharyngeal, and the maxillaris interna, which inosculate Avith open mouths, having the appearance of continuous trunks and sending a plentiful supply of blood to the neck and internal parts of the face. The labial and temporal arteries leaving the axilla under the angle of the jaw, and passing upwards upon the face, send off small branches in a beautiful and fantastic manner. Branches which be- fore were considered unworthy the attention of the anatomist noAv rise into importance. The plexuses and inosculations formed by these branches, excite alike our surprise and admiration, and eluci- date, in the most beautiful manner, the principles of collateral cir- culation. These arteries, in general, are large and tortuous and have frequent communications among themselves. The arteries most enlarged Avere the mental, the inferior labial, the coronary and the angulans. The optic artery Avas likewise much enlarged beautifully anastomosing Avith the angularis. ' So freely did these arteries inosculate with those of the right side that before the operation was finished, it was found necessary to secure the labial artery in a ligature. This Avas clearly illustrated by the retrograde course of the injection, after death, which passed freely from the arteries of the opposite side, filling the superior por- tion of the labial, to the point at which the ligature had been ap- plied The temporal artery was of its natural size, receiving its blood from "all the arteries of the neighboring parts," from the ascending branches of the occipital, the left temporal, the ophthalmic and the transverse facial. This free communication Avas distinctly shoAvn by the injection, Avhich, passing down the temporal, com- pletely filled the external and internal carotids, and several of their branches; particularly the inferior portion of the labial, which is seen emerging from under the jaw, to pass upon the face The labial terminated at that point Avhere the mental is given off The mental itself passed on to its usual destination, and received blood from its folloAv of the opposite side. All of these arteries will be easily seen, and readily recognised by referring to the plates. 8 ' No. III.-March 15, 1S27.—First Successful Case op Liga- ture upon the Primitive Iliac Artery, for Axeurism By Valentine Mott, M. D., Professor of Surgery, N y /gee the American Journal of the Medical Sciences, Philadelnh;* 1827, vol. 1., p. 156-161.) ' luaaeJPni*>. A detailed account of the first operation ever performed upon the arteria iliaca communis, for the cure of aneurism, and ^speciallv of the first attempt to apply the ligature to so'great a vessel wiih 22 ' 338 NEW elements op operative surgert. out dividing the peritoneum, may prove interesting to the profes- sion generally, and must be immediately serviceable to practitioners of surgery. It is therefore as an act of duty, rather than of choice, that the following statement has been prepared, during such few and brief intervals of leisure, as could be obtained amid the daily engagements and solicitudes of business. On the 15th of March, 1827, I Avas requested to visit a patient with Dr. Osborn, (of Westfield, New Jersey, about tAventy-five miles distant from New York,) whom Ave found laboring under a large aneurism of the right external iliac artery. Israel Crane, aged thirty-three years, by occupation a farmer, of temperate and regular habits, having generally enjoyed excellent health, says about the middle of January he felt some pain about the lower part of the belly, which he attributed to a fall received during the winter. He is in the habit of using great efforts in lift- ing heavy logs of wood, as his employment at this season consists in carrying wood to market. It, however, was not until a fortnight since, that he perceived any tumor about the lower part of the ab- domen. Upon examination, the abdomen on the right side Avas considerably enlarged from about the crural arch, as high as the umbilicus. When the hand Avas applied to the parietes of the ab- domen, a pulsation was felt and rendered visible to some distance. To the toueh the tumor beat violently, and appeared to contain only fluid blood. It commenced a little above Poupart's ligament, and reached, judging by the touch, from Avithout, near the navel—in- wards, almost to the linea alba—outwards and backwards filling up all the coneavity of the ilium, and reaching beyond the poste- rior spinous process of that bone. The rapid increase of this aneurismal tumor occasioned, as the countenance of our patient indicated, the most extreme agony. His sufferings at times were so great that his screams could be heard at a distance from the house. He had been bled several times,taken light food, and was kept constantly under the effect of opium. He was now informed of the serious nature of his case, and that without an operation very little chance of his life remained ; with great com- posure, he immediately consented to whatever would give him the best prospect of saving his life. From the extent and situation of the tumor, he was apprised of the uncertain nature of the operation, as Avell as the difficulty of performing it, and indeed that it would require an artery to be tied, which never had been before operated upon for aneurism. With these views of his situation, he cheerfully submitted to be placed upon a table of suitable height, in a room which was Avell lighted. Then, in the presence of Dr. Osborn, Dr. Liddle, and Dr. Cross, the following operation was performed:— The pubes and groin of the right side being shaved, an incision was commenced just above the external abdominal ring, and car- ried in a semicircular direction half an inch above Poupart's liga- ment, until it terminated a little beyond the anterior spinous pro- cess of the ilium, making it in extent about five inches. The in- DR. MOTT ON ANEURISMS. 339 teguments and superficial fascia were now divided, which exposed the tendinous part of the external oblique muscle, upon cutting which, in the whole course of the incision, the muscular fibres of the internal oblique were exposed ; the fibres of which Avere cau- tiously raised with the forceps, and cut from the upper edge of Pou- part's ligament. This exposed the spermatic cord, the cellular covering of which Avas now raised with the forceps, and divided to an extent sufficient to admit the fore-finger of the left hand to pass upon the cord into the internal abdominal ring. The finger serv- ing now as a director, enabled me to> divide the internal oblique and transversalis muscles to the extent ©f the external incision, while it protected the peritoneum. In the division of the last mentioned muscles outwardly, the circumflexa ilii artery Avas cut through, and it yielded for a few minutes a smart bleeding. This, with a smaller artery upon the surface of the internal oblique mus- cle, between the rings, and one in the integuments were all that re- quired ligatures. With the tumor beating furiously underneath, I now attempted to raise the peritoneum from it, Avhich we found difficult and dan- gerous, as it was adherent to it in every direction. By degrees Ave separated it with great caution from the aneurismal tumor, which had now bulged up very much into the incision. But Ave soon found that the external incision did not enable us to arrive to more than half the extent of the tumor upwards. It Avas therefore ex- tended upwards and backwards about half an inch within the ilium, to the distance of three inches, making a wound in all about eight inches in length. The separation of the peritoneum was now continued, until the fingers arrived at the upper part of the tumor, which was found to terminate at the going off of the internal iliac artery. The common iliac was next examined, by passing the fingers upon the promon- tory of the sacrum; and to the touch appearing to be sound, we determined to place our ligature upon it about half way between the aneurism and the aorta, with a view to alloAV length of vessel! enough on each side of it to be united by the adhesive pro- cess. The great current of blood through the aorta made it necessary to> alloAV as much of the primitive iliac to remain between it and the ligature as possible, and the probable disease of the artery higher than the aneurism, required that it should not be too low down. The depth of this wound, the size of the aneurism, and the pres- sure of the intestines downwards by the efforts to bear pain, made it almost impossible to see the vessel we wished to tie. By the aid of curved spatulas, such as I used in my operation upon the in- nominata, together with a thin, smooth piece of board, about three inches wide, prepared at the time, we succeeded in keeping up the peritoneal mass, and getting a distinct view of the arteria iliaca com- munis, on the side of the sacro-vertebral promontory. This re- quired great effort on our part, and could only be continued for » few seconds. The difficulty was greatly augmented by the eleva- 340 NEW ELEMENTS OF OPERATIVE SURGERY. tion of the aneurismal tumor, and the interception it gave to the admission of light. When we elevated the pelvis, the tumor obstructed our sight; when Ave depressed it, the croAvding down of the intestines pre* sented another difficulty. In this part of the operation I was greatly assisted by Dr. Osborn and my enterprising pupil, Adrian A. Kissam. Introducing my right hand now behind the peritoneum, the ar* tery was denuded Avith the nail of the fore-finger, and the needle conveying the ligature was introduced from within outwards, guided by the fore-finger of the left hand in order to avoid injuring the vein. The ligature Avas very readily passed underneath the artery, but considerable difficulty was experienced in hooking the eye of the needle, from the great depth of the wound and the impossibility of seeing it. The distance of the artery from the Avound Avas the Avhole length of my aneurismal needle. After draAving the ligature under the artery, we succeeded, by the aid of our spatulas and board, in getting a fair view of it, and were satisfied that it was fairly under the primitive iliac, a little be- low the bifurcation of the aorta. It Avas now tied—the knots were readily conveyed up to the artery by the fore-fingers—all pulsation in the tumor instantly ceased. The ligature upon the artery Avas very little below a point opposite the umbilicus. The Avound was noAv dressed Avith five interrupted sutures, pass- ing them not only through the integuments, but the fibres of the cut muscles, so as to bring their divided edges together at all parts of the incision, which Avas muscular. Adhesive plaster to assist the stitches, arid lint and straps to retain it, completed the dressing. The operation lasted rather less than one hour.* He was removed from the table and put into bed upon his back, Avith the knee a little elevated upon pilloAVS, to relax the limb as much as possible, and to avoid pressure upon it. It Avas consider- ably cooler than the opposite leg, and flannels Avere applied all over it, and a bottle of Avarm Avater to the foot. From the habit he had been in of taking largely of anodynes, a tea-spoonful of the tinct. opii. Avas administered, with directions to repeat it in an hour if the pain should be severe. In less than one hour from the operation, considerable reaction of the heart and arteries took place ; he felt, as he stated, altogether relieved from the excruciating agony he had suffered since the an- eurism commenced. The Avhole limb had now recovered its natu- ral temperature, * Dr Gibson, then professor of surgery in Baltimore, was near the spot during the riot* In that city, when a man was wounded by a musket ball, " which entered the left 6ideof ihe abdomen, passed through the intestines, opened the iliaca communis artery, and lodged in the sacrum " The doctor states, " thrusting into it (the wound) the forefinger of my left hand, I discovered that a very large artery had been tarn across, and was pouring out blood in considerable quantity." The man died in a few days. " Upon inspecting the vessels of the abdomen," says the doctor, " I found that I had placed two ligatures upen 1he common iliac artery of the left side, one about half an inch below the bifurcation of the aorta, and the other immediately above the division of the artery, into the cxteratl and internal iliacs." See Medical Recorder, Vol. III., p. 185. DR. MOTT ON ANEDRISMS. 341 March 16th.—The day after the operation, pulse eighty—skin moist—limb Avarm as the other—complains of some pain at the ligature—ordered a purgative of neutral salts. 17^/i.—Pulse eighty, and fuller than yesterday—took 1 x. of blood from his arm—skin moist—tongue brown—considerable un- easiness in the limb—no pain at the ligature—leg of natural heat— salts had a good effect. \8th.—Pulse seventy-five—skin moist—tongue, white—pain in the limb considerable—no pain at the ligature or in the Avound— limb Avarm. 19^.—Bled him to-day to ten ounces, the pulse being tense and beating eighty strokes in a minute—repeated the cathartic—suppu- ration appearing to have taken place, the dressings were removed. 20th.—Pulse seventy and soft—skin moist—Avound looks Avell —pain in the limb continues—leg Avarm as the other—cathartic operated Avell. 2lst.—Pulse seventy and soft—Avound looks Avell—repeated the laxative—pain in the leg rather less—continues Avarm. There has been at no time tension of the abdomen, or any particular uneasi- ness in that part. The patient thus far has been altogether more comfortable than could have been imagined. He takes more or less opium daily, from the long habit he has been in of taking anodynes. 26th.—No unpleasant symptoms—wound looks Avell—bled again to 5 xij, as there was a little tumefaction and inflammation about the wound. 30th.—Our patient continues to do Avell—Avound dressed daily. April 3d.—Not being able to leave the city, I requested Dr. Proudfoot, my late pupil, and a most promising young surgeon, to visit the patient. He reports that he Avas free of fever—wound all healed but Avhere the large ligature was passing. The ligature ap- pearing to be detached, the Dr. took hold of it and removed it: this was on the eighteenth day from the time of its application. Limb of the natural temperature—enjoined upon him to keep very quiet and in bed. 8th.—There are no disagreeable appearances Avhatever—he ap- pears to be doing remarkably well—has been bled once since the last report—takes a purgative every other day, and an opiate every night—pulse as in health—no pain—says he is entirely comfort- able— Avound is dressed with dry lint. 16th.—Has improved rapidly since the last report. Two days after the ligature came away, he very imprudently got out of bed, without experiencing any difficulty except weakness. Rode out to-day—wound perfectly healed. April 26th.—He has been using crutches for a feAV days to favor the lame leg, which, as yet, feels rather Aveak. Genera] health greatly improved. 30th.—Is perfectly restored in health—has a little stoop in his walk, which he says is occasioned by the external cicatrix. Leg is not yet of its full size, nor quite so strong as the other. From the period of the operation to the recovery of our patient, he did not 342 NEW ELEMENTS OP OPERATIVE SURGERY. appear to suffer more pain, or have more unpleasant symptoms, than would ordinarily take place in a flesh Avound of equal extent. Much of this, in my opinion, is to be attributed to the prompt and judicious antiphlogistic treatment pursued by Dr. Osborn, to whom I am indebted for the daily reports of the case. May 29th__My patient visited me to-day, having come tAventy- five miles; he was so much improved in health that I did not re- cognize him. Examined the cicatrix, and found it perfectly sound— could not discover any remains of aneurismal tumor—felt the epi- gastric artery much enlarged and beating strongly, and feeble, though distinct pulsation in the femoral artery immediately below the crural arch. The leg has its natural temperature and feeling, and he says it is as strong as the other. Much credit is due the patient for his firmness on the occasion; although apprised of the great danger attending so formidable an experiment, and the uncertainty of its result, yet, with a fortitude unshaken, and a full conviction that it was the only chance of pro- longing his life, he cheerfully and resolutely submitted to the ope- ration. The gratification his visit afforded me is not to be imagined, save by those who have been placed under similar circumstances. The perfect success of so important and novel an operation, with the entire restoration of the patient's health, was a rich reward for the anxiety I experienced in the case, and in a measure compensated for the unexpected failure of my operation on the arteria innomi- nata. This patient very recently paid me a visit, and is up to the pre- sent moment, (December, 1845,) in the enjoyment of excellent health, and pursuing his occupation of carpenter. No. IV.—Septemher 26th, 1829. The Brasdoreal, Distal, or Anti-Cardial operation for Aneurism op the Arteria Innominata, involving the Subclavian and the root op the Carotid, successfully performed by tying the Caro- tid Artery. By Valentine Mott, M.D., &c. (See the Ameri- can Journal of the Medical Sciences, Philadelphia, 1829, Vol. V., p. 297-300.) NotAvithstanding the tone of decided reprobation and ridicule with which Allan Burns* expresses himself concerning Brasdor's proposition to apply the ligature upon the anticardial side of cer- tain aneurismal tumors, and the numerous arguments urged against the revival of his operation by some professional critics of consider- able authority, experience seems to have shown that it is not only safe, but in some cases superior to the Hunterian mode of treat- ment. Some of the cases in which the operation on the anticardial side of the tumor has been lately performed in Europe, are said to » Surgical Anatomy of the Head and Neck. DR. mott on aneurisms. 343 have proved successful ;* and I am gratified to have it in my power to add another instance of its success in perhaps the first case, in which this operation has been performed in America. Moses R. Gardner, aetat. 51, by profession a farmer, of sound constitution and good habits of life, applied to me some time in March for advice. He gave the following relation of his case :—About three years ago, Avhile occupied in removing a building, and compelled to lift heavy weights, he was attacked with pain in the upper and back part of the neck. This lasted until the month of January, when it extended to the right shoulder and arm, and continued until the following May; it then partially subsided, and he observed his voice Avas becoming hoarse, which he attributed to exposure and con- sequent cold. About eighteen months since, Avhile shaving, he dis- covered a small swelling at the upper part of the breast bone, but did not remark any throbbing in it until some time afterwards. He had consulted a physician, but received no positive opinion on the case. Upon examination, I found above the sternum a pulsating tu- mor, about the size of a pigeon's egg, spreading some distance un- der the clavicular and sternal portions of the right sterno-mastoi- deus muscle, in the course of the subclavian artery, and extending as low down upon the pleura as the second rib, compressing more or less the bronchial tubes, and producing on the least coughing or exercise a wheezing, not unlike that of asthma. He shrunk from the least pressure upon it; complaining of impeded respiration, fol- lowed by pain. Its pulsations Avere synchronous with those of the heart, and decidedly aneurismal. After fully explaining to him the nature of his disease, and its probable fatal termination, should it increase and be left to itself, I advised him to return home ; to avoid all exertion ; to be occasion- ally bled, and to confine himself principally to a vegetable diet; but should he observe the least increase, either of the tumor or any of his symptoms, to come again to me, and I Avould decide on the propriety of an operation. After that time, I occasionally saAV him ; he seemed to under- stand his case fully, and was very desirous to take the chance of the operation; but as I could not observe any material change in the disease, I recommended him to pursue the same directions, and wait patiently until it should occur. On the 12th of September he again came to the city. I found the tumor above the sternum had increased to the size of a large Avalnut, and upon a careful application of the stethoscope, it was evidently encroaching more upon the chest. The whizzing sound, (bruit de soufflet,) could be heard ; the thoracic viscera were sound, the respiratory murmur being distinct throughout. His respiration Avas very much impeded by speaking, walking, or coughing, and almost entirely suspended by the least pressure upon the tumor; the action of the right carotid was much more feeble than that of the left; no pulsation could be discovered in its branches; the * See AVardrop on Aneurism. London, 8vo. 1828. 344 NEW ELEMENTS OP OPERATIVE SURGERY. right subclavian, external to the scaleni muscles, Avas natural, Avhile the axillary and brachial arteries could hardly be felt; at the wrist no pulse could be found ; the pulsations of the arteries of the left side Avere natural. His general health Avas good. In reflecting upon this case, and comparing the relative situation of the parts, I Avas persuaded the aneurism Avas of the arteria inno- minata, involving the subclavian and the root of the carotid; hav- ing formed this conclusion, I considered it a proper case for the operation proposed by Brasdor, and recently so ably revived, and first successfully performed by the distinguished Wardrop, Avhose scientific researches and masterly vieAvs of this subject, have since been so fully confirmed by himself and others. I thought further delay unnecessary, and the patient being will- ing to abide by my judgment, after having stated to him the chances of the operation, I resolved on its performance. From the evident interruption in the circulation of the right arm, and the apparent effort of nature to effect a spontaneous cure, I determined upon ty- ing the carotid first, to observe the result, and afterwards to secure the subclavian, should it be required. On the 26th of September I operated. The artery was taken up in the usual manner; no material change Avas observed. 27th.—9 A. M. Slept Avell, and feels refreshed; thinks there is more room, as he expresses it, in breathing ; complains of a little soreness of the tonsils in swalloAving; pulse 58, regular and tran- quil ; skin natural, pulsation and size of the tumor evidently dimin- ished. 9 P. M. Much more restless from mental alarm; pulse 68, tense. In other respects, the same as in the morning; being habituated to laudanum, was permitted to take a tea-spoonful. 28th.—9. A. M. Slept Avell after the opiate; breathes easily, and says he takes "a more satisfactory breath," than he did before the operation ; feels much less of the pulsation in the tumor; pulse 63, not so tense ; skin natural; cough much less. Ordered a dose of calci»ed magnesia and Epsom salts. 9. P. M. Has passed a com- fortable day ; his Avife, Avho arrived from the country since the morning, expressed her surprise at the improvement of his voice and breathing; and the difference in the beating of the tumor. Pulse of the right radial artery very distinct, but intermitting once in every ten to fifteen beats ; in the left arm 80 ; coughs frequently, and expectorates freely ; skin natural; tongue a little white ; salts have not operated. Ordered the dose to be repeated, and if rest- less, after its operation, to take his usual anodyne. 29th.—Saluted me this morning upon entering his room, with a full and fine voice, and said he Avas well enough to call on me; salts operated freely; thinks his cough and expectoration much less. I found hiin lying down, and breathing quietly ; pulse 71, and reg- ular. The radial artery of the right arm beating as last evening, with feAver intermissions, but of longer continuance; skin over the tumor more wrinkled; pulsation appears less, and feels Aveaker. Directed to continue his tea, toast, and gruel. 8 o'clock. As well as in the morning; takes a full breath Avithout the least wheezing; DR. MOTT ON ANEURISMS. 345 pulsation in the right wrist very distinct and regular; in the left 62 to the minute. Continues the opiate. 20th.—Found him lying more recumbent than at any former pe- riod ; pulse 70, and regular ; right radial artery does not beat quite so firm as yesterday; the wound discharging a little, Avas dressed. October 2d.—Says he now feels as if he would get well; cough rather more troublesome ; pulse 57 ; pulsation of the right radial the same ; his boAvels not being free, directed sub. mur. hydr. grs. vhj.—sup. tart, potassae, pulv. jalapae, aa E>j. Mix. Evening. Medi- cine has not operated; directed a dose of sulphate of magnesia. 3d.—Cough and bronchial effusion very much diminished by the operation of the cathartic; pulse 68. 4th.—Feels very well; passed a good night; all his symptoms improved; pulse 74 ; can bear any degree of pressure upon the tumor Avithout the least pain or difficulty of breathing. 10///.—Continues to mend, and is sanguine as to his recovery; pulsation of the tumor hardly perceptible, and to the touch very much diminished; cough less troublesome; left pulse 66; right, very feeble. 16th.—Ligature separated and came aAvay last night; the tumor above the sternum, and pulsation entirely disappeared; cough and breathing better ; voice nearly natural; pulse 66 ; noAV and then a very faint pulsation of the right radial artery ; right hand a little swelled, and feels numb, and the patient complains of the Avant of power to close it. 22d.—Wound just healed ; Aveakness of the arm very consider- able ; fingers very thick and clumsy ; arm SAvelled and pits upon pressure ; no pulse in the right radial artery ; breathing very easy ; cough and expectoration much less; can sleep easy in any position, which he has not been able to do for many months. 26th.—Left tOAvn this morning for his residence in NeAV Jersey. Second Report of Professor Mott's Case of Aneurism, TREATED BY TYING THE ARTERY ULTRA TuMOREM. (lb., Amer. Jour, of the Med. Sciences, Phil., 1830, Vol. VI., p. 532.) After the return of Moses Gardner to the country, he occasion- ally wrote to me: one of his letters stated, " his breathing was much better, and his friends on calling to see him, were surprised at the improvement, particularly at the disappearance of the tu- mor." On the 22d of April, hoAvever, I received information of his death, Avith an invitation to examine the body : all that could be ascertained relating to the case, Avas, that the difficulty of breath- ing had returned and at times threatened immediate suffocation; he had confined himself to the most abstemious living, and gra- dually declined in general health. The dissection was conducted by my demonstrator, Dr. Vache, to Avhom I am indebted for the following particulars :— " Dissection.—On vieAving the body, no tumor appeared exter- nally : the right clavicle Avas rather more elevated than that of the 346 NEW ELEMENTS OP OPERATIVE SURGERY. opposite side, and on removing the integuments, it was found par- tially dislocated from its sternal articulation, the under surface of which has undergone considerable absorption from the pressure of the aneurism. Immediately beneath, and imbedded in the sur- rounding parts, was the tumor ; it extended from the sternal extre- mity of the left clavicle, along the inner and upper surface of the sternum, to which it closely adhered, to about midAvay of the right clavicle, and pressed as low down upon the pleura as the third rib. Laterally it was adherent to the right lung, and posteriorly rested upon the lower cervical and upper dorsal vertebrae. The trachea was greatly displaced; it was closely attached to the left side of the tumor, passing obliquely downward and back- ward, and very much flattened by pressure. On removing the tumor from the body with its connexions, it was about the size of the two fists, and its parietes were found to be firmly consolidated. It emanated from the arteria innominata, in- volving the subclavian and the root of the carotid. Superiorly it was of a globular form, and inferiorly terminated in an apex, which passed down beloAV the division of the trachea, and behind the aorta. The right carotid was obliterated, the right subclavian, beyond the tumor, was pervious and natural in its structure. The heart and lungs were sound." On reviewing briefly the circumstances of this case, no one, I may venture to observe, will attribute its fatal termination to a fail- ure of this form of operation, or of the principles upon Avhich it is founded. The attending symptoms, as well as the dissection, fully prove the cause of death to have been the displacement of the tra- chea, and the consequent pressure of the consolidating tumor upon it and the bronchial tubes. The absence of pulse in the right arm, the oedema and the numbness must also be attributed to the pressure of the tumor. Had the operation been performed at an earlier stage of the disease, there is every reason to expect-it would have terminated successfully. Should I have another opportunity, I Avill operate without any delay, and tie both vessels at the same time, and not leave one for a future performance, to be decided up- on by the effect of the first. It is perhaps a little singular, that a tumor of this magnitude, should not have appeared much larger externally, for it will be recollected that it never exceeded the size of a walnut. I am hap- py to add, that the diagnosis for aneurisms of the vessels of the neck and shoulder as given by Mr. Wardrop, in his very able Avork on this subject, has been fully confirmed in regard to this case. Dr. Vache, in a recent note to Dr. Mott, (dated New York, Nov. 27, 1845,) says in relation to this case :—" To reply to your note of yesterday, I found it necessary to refer to the case of Moses R. Gardner, as published in the American Journal of Medical Sciences, Nos. 10 and 12, Vols. V. and VI., where it is so truly described as to leave nothing to add, from subsequeut reflection, to its history. No person familiar with the surgical anatomy of the neck and shoulder, can read the details of the case, and doubt that he died DR. MOTT ON ANEURISMS. 347 from impeded respiration, consequent on pressure and displacement of the trachea, as well as the lung and contiguous nerves and blood vessels. From the dissection I made at the time, I was fully con- vinced that the operation was perfectly successful; and that he did not die directly of aneurism, the large consolidated tumor, I sup- pose still in your museum, will fully establish at the present day." No. V.—New-York, 1830. Ligature of the Carotid for anas- tomosing Aneurism in a Child three months old. The American Journal of the Medical Sciences, Philadelphia, 1830, Vol. VII., p. 271, says :— In our fifth volume, page 255, we announced Dr. Mott's having performed this operation. The following extract from a letter re- cently received from our friend, Dr. A. F. Vache of NeAV York, gives further particulars of this interesting case:—" You wish to be informed of the termination of the case of the infant whose carotid artery was tied for an aneurism by anastomosis, involving both orbits, the nose, and part of the forehead, and in whom it was intended to tie the other should the first not prove curative. After the operation the tumof evidently diminished, and induced the be- lief that in time it would be removed altogether without taking off the circulation from the opposite side. Since then the little patient was lost sight of until yesterday, (September 10th,) when Dr. Mott heard of the residence of the parents and visited it. He informs me that he found the tumor diminished about one-third, and so much consolidated as to lead to the opinion of the possibility of ex- tirpating it,should it hereafter be thought necessary. In every other respect the child was in perfect health. * No. VI.—Sept. 1830. Amputation of the Thigh, followed by Secondary Hemorrhage. The Femoral Artery tied in several Places. By Valentine Mott, M. D., &c. (See this case in an account of the surgical cases of the NeAV York Hospi- tal for July, August, September and October, 1830, drawn up by Alfred C. Post, M. D., in the New York Medical Journal, New York, 1830. No. 2, Vol. I., p. 271—273.) John Shannon, aged about thirty years, came into the hospital on account of a disease in the knee joint, of several years standing. He had been addicted to intemperate habits. On the 25th of Sep- tember, Dr. Mott amputated the thigh a short distance above the knee, by the double flap operation. Every thing went on favor- ably after the operation. The patient, however, complained of se- vere pain in the stump recurring every afternoon, for which he took anodynes. The stump Avas dressed on the seventh day, and was found to be nearly healed. No untoward circumstance occurred until the morning of the 6th of October, (the 12th day from the * This tumor eventually disappeared entirely, December 1845. V. M, 348 NEW elements op operative surgery. operation,) when the patient suddenly coughed, and sneezed vio- lently at the same time, and a gush of arterial blood, to the amount of three or four ounces, took place from the stump. The tourni- quet was applied, so as to compress the femoral artery, and the hemorrhage was thus arrested for the time. After an hour or two the tourniquet Avas removed, and the hemorrhage did not recur till the night of the 7th, when about the same quantity of blood was lost as before, and the hemorrhage was temporarily arrested in the same way. At midnight, Dr. Mott tied the femoral artery three or four inches below Poupart's ligament. He tied the artery in tAvo places, and divided it in the intervening space. On the morn- ing of the eighth, a new hemorrhage took place to the amount of about eight ounces. It was arrested by pressure in the groin. At 11 A. M., a consultation of surgeons Avas held, when it was deter- mined to tie the femoral artery above the profunda, which Dr. Mott accordingly did. On the morning of the ninth, a hemorrhage again took place from the stump to the amount of above five or six ounces. Pressure on the artery, as high in the groin as it could be felt, appeared to exert no control over the hemorrhage, but it soon ceased spontaneously. Dr. Mott directed, if the hemorrhage should be renewed, that a tourniquet should be applied around the middle of the thigh, with the view of compressing the arterial branches in the posterior part of the limb. Early on the morning of the tenth, a slight hemorrhage occurred, Avhich was not arrested by the tourniquet. Spasms came on in the stump, and the hemor- rhage became more profuse, amounting to about eight ounces. The spasms were frequently repeated. The pulse became small and feeble, the skin cold and moist, the countenance had a haggard ex- pression, and there Avas occasional hiccup. On dressing the stump, the angles of the wound, Avhich had been united, were found to have been pressed asunder by coagula of blood, and had a ragged spongy appearance. The wound Avas dressed with Peruvian oint- ment. Brandy toddy Avas given to the patient in the morning, but his stomach soon revolted against it. A sinapism Avas applied over the epigastrium, but he could not long bear it. Porter and lime water were given in the evening, and a blister applied over the epigastrium. The pulse gradually became fuller and stronger, the irritability of the stomach ceased, and the coldness of the skin di- minished. 11th. Noon. There has been a very slight oozing of blood, but no considerable hemorrhage. The symptoms have all become more favorable. The wound has been dressed this morn- ing with pure balsam of Peru. 22d. No hemorrhage has since oc- curred. The ligatures, which Avere passed around the femoral ar- tery on the night of the 7th, both came aAvay this morning with the dressings. 25th. The ligature Avhich was applied around the ar- tery, in the groin, came away this morning. In the early part of No- vember the patient left the hospital, the wound being nearly healed. The hemorrhagic disposition, in this case Avas very remark- able, and appears to have affected all the arteries of the stump. The hemorrhage which occurred after the inguinal artery was tied, DR. MOTT ON ANEURISMS. 349 probably proceeded from the branches of the gluteal and ischiatic arteries; and, on this supposition, it was Dr. Mott's intention to have secured the primitive iliac artery, if the patient had not been so much prostrated by the last hemorrhage as to have rendered any operation unjustifiable at that time. The recovery of the patient was contrary to the prognosis of all the attending surgeons. No. VII.—August 30, 1830. Case op Axillary Aneurism in which the Subclavian Artery was successfully secured in a Ligature. By Valentine Mott, M. D., 6fC. (See the American Journal of the Medical Sciences, Philadelphia, 1830, Vol. VII., p. 309-311.) William Hines, aged twenty-eight, of Smithville, Virginia, came to New York August 24th, 1830, and became my patient. The account he gave of his case was, " that about seven weeks ago he received a violent strain while carrying a canoe on hand- bars across the arms, which Avas folloAved by an extensive discolora- tion of the skin of the right arm, extending to the chest, and attend- ed Avith considerable pain. It however yielded to the usual reme- dies in such cases. Three weeks subsequent to the accident he ob- served a swelling about the size of a pigeon's egg under the right arm, Avhich had rapidly increased." On examination I found a tumor about the size of a goose egg, and decidedly an aneurism of the axillary artery. His general health being good, I directed him to keep quiet, to be bled, and to take some purgative medicines; and fixed on Monday, the 30th, for tying the subclavian artery. At 11 o'clock, A. M., he was placed upon the table, Avith the shoulders elevated and inclined to the right side. An oblique in- cision was made, two inches in length, through the integuments and platisma myoides muscle, and corresponding to a middle line of the triangular interval formed on the inner side by the scalenus muscle, on the outer by the omo-hyoideus, and below by the clavicle. The cervical fascia Avas next divided to the extent of an inch, and Avith the fore-finger and the handle of a knife, the adipose and cellular tissues were put aside, and the artery readily exposed as it passes from betAveen the scaleni muscles. After denuding the artery a little of the filamentous tissue with a knife rounded at the point and cutting only at the extremity, a ligature was conveyed around it, from beloAV upward, by the American needle, and the artery tied a little Avithout the scaleni muscles. No other ligature Avas required. The patient lost less than two tea-spoonfuls of blood. The operation lasted about fifteen minutes, and Avas performed, with the assistance of Drs. Vache and Hosack, in the presence of Drs. BarroAv, Kissam, Rogers and Wilkes. The Wound was closed by two stitches and adhesive straps; the arm was immediately Avrapped in cotton Avadding; no diminution of temperature took place. 8 P. M. Found the patient comfortable; says he has less pain in 350 NEW elements op operative surgery. the arm than before the operation; heat rather more than natural; a faint pulsation in the right radial artery ; pulse 88. 31st, Morning. Passed a comfortable night after taking fiiteen drops of the sol. sulph. morphine, which was given to allay the pain about the elbow, and which he considered rheumatic, having had more or less of it for some time previous to the operation. This pain was no doubt caused by the pressure of the tumor upon the brachial plexus. Pulse 70; skin natural; says that he feels very comfortable. Evening. Complains of headache ; directed a saline cathartic; pulse 90 ; skin pleasantly moist; pulsation in the right radial artery occasionally very distinct and regular; temperature of the right arm a little higher than that of the left. September 1st. Pain of the arm obliged him to set up most of the night in an easy chair—after the operation of the salts, took again fifteen drops of the morphine, and slept quietly about five hours. Feels at present very comfortable ; pulse 75; not the least evi- dence of febrile disturbance in any of his symptoms. 2d. Feels much more comfortable than yesterday; slept com- posedly all night; little or no pain in the arm ; pulse 80; removed the wadding from the arm, and enveloped it in flannel, Avhich keeps it very comfortable. 3d. Slept well all night after taking his dose of morphine, and feels very well to-day ; pulse 74; pulsation of the right radial more regular and distinct. 4th and 5th. Continues to improve. 6th and 7th. Every way comfortable ; right radial pulsates re- gularly, though more feeble than the left. 9th. Dressed the wound and removed the stitches; mostly healed, except where the ligature from the artery passes out. Pain in the arm for some days past has not been felt; makes no complaint; pulse in the radial artery very distinct and regular with the actions of the heart. 11th. Dressed the Avound, which looks remarkably well; every- thing appears very favorable. 14th. On removing the dressings to-day, the ligature came away; all promises well. 20th. Wound being just closed, permitted him to walk about the room, and to take his usual allowance of food; aneurismal tumor much diminished in size, and very hard. 27th. Left the city to day on his return by water to Virginia. When I reflect on the disease for which this operation was per- formed, and upon the situation, importance and size of the vessel which Avas tied for its removal, it appears to me almost incredible that but twenty-seven days should have been required for its cure. That it should have succeeded is particularly grateful to my feelings, inasmuch as it was first successfully performed by an American surgeon,* and is an additional proof of the triumph of surgery over disease and death. » Dr. Wright Port, of New York. DR. MOTT ON ANEURISM*. 351 No. VIII.—April 25th, 1831. Case of Diffused Femoral Aneurism, for which the External Iliac Artery was tied. By Valentine Mott, M. D., Professor of Surgery in the College of Physicians and Surgeons. (See the American Jour- nal of the Medical Sciences, Philadelphia, 1831, Vol. VIII., p, 393-397.) The external iliac artery has been so repeatedly tied Avith suc- cess, that perhaps, the only interest attached to this case is the ob- scurity Avhich attended its diagnosis. Whilst the leading features of its history, as well as the condition of the tumor, and the absence of some of the most prominent symptoms of aneurism were strongly indicative of the presence of matter, the situation of the wound and the location of the SAvelling, induced me to suspect the existence of the last mentioned disease. Not the least pulsation could be felt, and it was not until visible motion, communicated to the hand by the tumor, and the cessation of it on compressing the artery above, were observed whilst viewing it obliquely, that I could form any opinion upon the nature of the dis- ease. This, together with the situation of the cicatrix and pulsatory thrill communicated through the stethoscope, decided, in my esti- mation, its aneurismal character^ and determined me on tying the vessel. The result of the case will show that opinion to have been correctly founded. Charles Fordham, aged 13, came under my care April 23d, on account of a tumor of his right thigh. The history given of it by the parents of the lad is as follows. On the morning of March 18th, while he was at school, a pen knife slid off the desk at which he was sitting; when clapping his knees suddenly together, to save it from falling, the blade pierced his right thigh, a short distance above the knee. On Avithdrawing the knife, it was found to have penetrated to the depth of an inch. Little or no blood escaped from the Avound. Soon after the occurrence of the accident, he walked home, a distance of about twenty rods, but was so faint as to be obliged to stop twice on the way. In the afternoon the thigh became painful, and Avas uniformly swelled. It continued gradu- ally to enlarge for about a week, at the end of which time a throb- bing sensation Avas felt throughout the thigh, and an obscure pulsa- tion was thought to be occasionally perceived near the wound by one of the attending physicians, who expressed his belief that the femoral artery had been opened. Both the throbbing sensation and the supposed pulsation, however, subsided in an hour or two, and chilliness, followed by fever, supervened. The pain in the thigh was aggravated, and the boy complained also of severe pain in his back. An abscess was now supposed to be forming; accordingly poul- tices were kept constantly applied to the thigh and purgatives occa- sionally administered. Under this treatment the swelling progressively increased until the end of the third week after the accident, when it became softer 352 NEW ELEMENTS OF OPERATIVE SURGERY. and appeared to be subsiding. In the mean time, chilliness and fever at intervals returned, and the pain in his thigh and back con- tinued, to relieve which anodynes Avere freely given. The tumor again increasing, the lad was brought to this city, and placed under my care. « At my first visit, April 23d, I found the patient much emaciated, and complaining chiefly of numbness, alternating Avith a burning sensation in his foot. The thigh Avas enlarged to nearly twice its natural size, being oc- cupied by a tumor Avhich extended from the inside of the knee to the groin. It was most prominent in the middle of the thigh, Avhere it was also softer than at the circumference. The integuments co- vering the tumor Avere nearly of their natural colour, but oedematous. The leg and foot Avere in the same condition. The cicatrix show- ing Avhere the knife had entered, Avas situated directly over the point at which the femoral artery perforates the triceps adductor muscles. Fluctuation could be distinctly felt in almost every part of the tu- mor, but after the most careful examination, not the slightest pul- sation could be detected either in the tumor or in the arteries of the leg. Pressure made upon the artery at the groin had no appa- rent effect upon the size of the swelling. Under these circumstances I had determined to puncture the tu- mor, and in the event of its being aneurismal, to tie the external iliac artery, as the extent of the tumor precluded an operation be- low Poupart's ligament. But on the following day, a very feeble motion Avas perceptible in the hand, when firmly placed upon the tumor and vieAved ob- liquely, Avhich ceased upon compressing the inguinal artery. On visiting the patient the next day, the very visible motion communicated to the hand, especially when placed over the cica- trix, and the evident pulsation in the tumor, conveyed through the stethoscope, decided me in the opinion of its being an aneurism and upon tying the artery. The operation Avas performed at 5 o'clock, P. M., 25th April, with the assistance of Dr. Vache, and in the presence of several of my medical friends, according to the method recommended by Sir Astley Cooper, which has been so frequently executed by myself and others, and the manner of doing it so well known, that to spe- cify the steps of it is unnecessary. The limb Avas enveloped in cotton wadding as is usual, and the patient put to bed. R. Sol. sulp. morph. gtt. xvi. 26th. Passed a better night, his mother thinks, than before the operation. Pulse 128. Says he has less pain. Foot and leg of a natural temperature. For some time before the operation he suf- fered from a burning sensation in the bottom of the foot, Avhich was relieved by wetting it frequently with cold vinegar or applying to it a bottle of cold Avater. This sensation left him soon after the operation, and at present he says there is only a sensation of numbness, or as though the foot was asleep. DR. MOTT ON ANEURISMS. 353 In the evening, being restless and uneasy, took his usual dose of forty drops of laudanum. 27th. Says that he feels better than before the operation—had a comfortable night. BoAvels being confined, took a dose of ol. ricini, which operated three times—pulse 108—skin natural—foot of natu- ral temperature—tumor of the thigh visibly diminished—upon the more prominent part of it the skin appears wrinkled. 28th. Diminished the quantity of anodyne a little—passed a good night—feels no pain—pulse 118—limb naturally warm. 29th. Is very comfortable—took less of the anodyne last night— boAvels open—pulse 112—tumor evidently diminished—limb natu- rally Avarm—upon looking at the foot, discovered a blister on the under part of the ball of the great toe, about the size of a dollar, with a little redness around the margin. Passed a lancet into it and evacuated the Avater. 30th. No more vesications and no spreading of the first. Re- moved the cuticle to the full extent of its detachment, and to my great grief, found it below livid and cold. The foot and toes naturally warm—slept well and feels better than yesterday—pulse 120— boAvels open—directed him some Madeira Avine in his food and drink, and to apply over the livid part frequently in the course of the day, some warm bals. Peru. Eight P. M. Has taken more food and with an appetite—livid spot less in size than in the morning, and evidently has resumed a natural warmth. Directed to continue the same means as in the morning, with the anodyne at bed-time if necessary. May 1st. Passed a good night and feels better than yesterday— pulse 128. The bottom of the foot appears the same as last even- ing. At a small point near the extremity of the great toe, and at the under part, the cuticle is detached about the size of a shilling, but the subjacent integument is of a healthy red colour—foot and leg of a proper degree of Avarmth. To continue the same treat- ment.* 2d. Was somewhat disturbed in the night by a noise in the house Avhich prevented sleep—complains of no pain—pulse 120—bowels open—no change in the foot—same application to be repeated. 3c?. Says he has a more natural feeling in the foot and leg than before the operation—he can noAV feel Avhen the sound foot touches the diseased one, Avhich he could not for some time previous to the operation. His symptoms and pulse the same as yesterday. 4th. Slept very Avell—appetite good—feels and looks better— pulse 110. BoAvels regular—temperature of the foot natural—bot- tom of the foot better—SAvelling of the thigh less. 5th. Line of separation of the slough at the bottom of the foot very evident—feels Avell in every respect—pulse 112—bowels open —urged to take a nourishing diet and to use porter and wine in moderate quantities. * The mother now informed me, that a bottle of very hot water had been applied to the foot, by the attendants, during the night preceding the day on which the first blister had appeared, which greatly diminished my apprehensions of the result. 23 354 NEW ELEMENTS OP OPERATIVE SURGERY. 1th. Very comfortable—separation of the slough in the bottom of the foot progressing, pulse 116; oedema of the foot and leg much diminished. 10th. Fourteenth day from the operation, dressed the Avound— all healed by the first intention, except the openings made by the ligatures. Removed the three sutures and two of the ligatures; pulse more frequent than usual, in consequence of his feelings being much excited by his father leaving tOAvn. In all other respects he is as Avell as before. Slough at the bottom of his foot rapidly sepa- rating, it appears to be no deeper than the corium—directed to con- tinue the balsam to the foot, and take nourishing diet Avith porter and Avine. 15^. Improving very much in general health—slough from the bottom of the foot came aAvay to-day—the granulations look very healthy—Avound entirely healed at every part except Avhere the ligature passes—ligature does not yet appear to be detached from the external iliac—oedema of the foot and leg mostly disappeared. 29th. Ligature from the external iliac came away to-day—aneu- rismal tumor about half removed—ulcer on the great toe healed— that on the bottom of the foot nearly closed—general health much improved. Left the city to-day for his residence in the country. The American Journal of the Medical Sciences, Philadelphia, 1833; vol. XII., p. 274, speaking of this case, says :— Dr. Vache, in a letter Ave have recently received from him, in- forms us that the patient in Avhom Dr Mott tied the external iliac for the cure of diffused femoral aneurism, and an account of which was published in our 8th volume, has done well and enjoys perfect health. No. IX.—September 22d, 1831. Case of Aneurism of the Right Subclavian Artery, in avhich that vessel was tied within the Scaleni Muscles. By Valentine Mott, M.D., &c. (See the American Journal of the Medical Sciences, Philadelphia, 1833, Vol. XII. p. 354-359.) In the early part of September, 1831, I was requested to visit Mrs. B----, a lady, twenty-one years of age, in reference to a tumor situated in the loAver part of the neck. The history of the case was briefly as follows :—A year or tAvo before, she had been thrown from a gig, and received a violent contusion of the right shoulder and left side of the body, from Avhich she had gradually recovered Avith the exception of a fixed pain in the injured shoul- der, and the subsequent appearance of a small throbbing tumor above the collar-bone. Her physicians had informed her of its character, and the object of her visit to NeAV-York Avas to place herself under my care and abide by my judgment. On examina- tion, I found a tumour as large as a hen's egg on the outer edge DR. MOTT ON ANEURISMS. 355 of the scaleni muscles, and immediately over the subclavian artery. Its pulsations Avere unequivocally aneurismal, and left no hesita- tion as to the correctness of the opinion already given on the nature of the disease. Her general health was considerably impaired, and the tumor was rapidly increasing in size. With no other precedent than Dr. Colles' case* and aware of the uncertainty that must ever attend the result, of putting a liga- ture amidst large collateral branches upon a great vessel so near the heart, I deemed it a duty to explain to my patient, her hus- band, and her friends, the critical situation in which she Avas placed, and leave it for them to decide on the course to be pursued. In a few days I was informed of her resolution to take the chances of the operation, and fixed on the 22d of September for its perform- ance. At 12 o'clock on that day, she was placed upon a table, having taken an hour previously sol. sulph. morph. gtt. xx. The shoul- ders Avere elevated on pillows, Avith the head throAvn backAvard, and the face and body inclined to the left side. An incision Avas begun at the lower part of the outer edge of the sternal portion of the mastoid muscle, and carried upwards about two inches, and another from the commencement of the first along the upper surface of the clavicle of the same extent. The triangular flap, and a cor- responding portion of the platysma myoides Avith its investments, Avere separately dissected from their connexions and turned aside. The clavicular portion of the mastoid muscle was next severed im- mediately above its insertion, and reflected upon the neck. This laid bare the deep-seated fascia, Avhich Avas raised Avith the forceps and divided a little below the course of the omo-hyoid muscle and outside of the deep jugular vein. Upon enlarging this opening an inch doAvnward, the adipose and cellular tissues Avere readily pushed aside, and the scalenus anticus exposed to vieAV. Desirous of tying the artery, if admissible, on the acromial side of this muscle, I passed a finger carefully doAvn upon its outer edge, but found from the vicinity of the tumor, that it would be best to secure it on the tracheal side, and avoid all disturbance of the parts in that situa- tion. Accordingly, the cellular substance was separated with the fingers and handle of the knife, and the subclavian exposed just within the thyroid axis, the branches of Avhich could be plainly seen. The filamentous tissue Avas raised from the artery Avith the forceps, and cautiously divided Avith a small scalpel, and the liga- ture conveyed under the vessel from beloAV upAvard by the Ameri- can needle. In accomplishing this part of the operation, curved spatulas Avere used to separate the Avound, and a blunt hook to draAV the deep jugular tOAvards the trachea. The knots Avere rea- dily made Avith the fore-fingers. Pulsation in the aneurism and vessels of the arm immediately ceased. The detached parts Avere restored, and the integuments retained by the interrupted suture and adhesive straps. Three small arte- *The patient died on the eighth day after the operation. See the particulars in ihe Edinb. Mcd. and Surg Journ. for January, 1815. 356 NEW ELEMENTS OP OPERATIVE SURGERY. ries were tied—no vein Avas cut that required a ligature—about four table-spoonfuls of blood were lost. Dr. Vache assisted me in the operation, and it was performed in the presence of Drs. Parkin and Howard, and a number of my pupils. The patient sustained it remarkably well, and did not evince any particular sensation, or effect when the artery was tied. Evening. Has vomited several times, which she attributes to the morphine taken in the morning ; right hand and arm warmer than natural; has a little reaction of the heart and arteries; complains of pain in the right arm and side of the neck ; radial artery feels full, but has not any pulsation in it. 23rd, morning. Passed a comfortable night; the vomiting Avas allayed by mint tea; arm warmer than natural, and feeble pulsation in the radial artery; pulse «8, soft; still feels pain in the arm and neck. Evening. Complains of head-ache ; pulse the same ; skin moist and not heated ; temperature of both arms alike, counted eighteen feeble pulsations in the right radial artery. The pulsation of the carotids being unpleasant, recommended the head and shoulders to be elevated on pillows. 24^. Pain in the neck and arm less than yesterday ; head-ache continues ; skin natural; tongue a little furred ; temperature of the limb natural; pulse the same; counted nine or ten pulsations in the radial artery in a minute, but more feeble than yesterday. Di- rected a Seidlitz poAvder to be taken at intervals until the bowels are moved. Evening. The aperient has operated but once; pulse 70; only a slight tremulous motion to be felt in the radial artery; has had se- veral turns during the day of cool hands and feet, folloAved by flushes of heat, and attended with some feeling of weight about the chest; violent pain in the head, Avith a flushed countenance; pain in the arm less, and in both arms alike. Took eight ounces of blood from the left arm, which relieved her unpleasant feelings im- mediately. 25th, morning. Has slept but little during the night, notwith- standing the relief afforded by the bleeding. Complains of pain through the upper part of the right shoulder and base of the sca- pula, and occasional sensation of a tingling or creeping motion in the arm to a painful degree ; pulse 80; skin natural; no distinct pulsation in the right radial artery, but tremulous as yesterday. Seidlitz powders to be repeated. Evening. The medicine has operated freely ; has had some sleep ; head-ache much less; pulse 80; skin moist and natural. Complains of great pain in the upper part of the right arm, also deep in the neck and extending to the spine, between the scapulae; says she has pain in swallowing and in taking a full inspiration. Advised her to take seven drops Sol. acet. morph. 26^, morning. Has slept well, and feels much better; breathing good ; head, back, shoulders, and arm free from pain; pulse 80; skin natural and moist; tongue white. Pulsation in the radial ar- tery more distinct; counted forty-one beats in a minute. DR. MOTT ON ANEURISMS. 357 Evening. Says she has passed a very comfortable day. No al- teration since the morning. Directed ten drops of the Sol. acet. morph. at bed-time. 27th, morning. Did not pass as good a night as. the preceding; pulse 74 ; arm and body of natural temperature ; pulsations of the radial artery fifty in a minute. Evening. About the same as in the* morning ; bowels have been moved by some ripe fruit eaten during the day. Ordered thirteen drops of the morphine at bed-time. 28^, morning. Feels much better ; very little pain in the shoul- der, and none in the arm ; pulse 79 ; pulsation in the radial artery more distinct, and beats sixty-one in a minute. Evening. Only complains of a trifling pain in the shoulder, such as lying in one position occasions ; pulse 75 ; in the right arm 71 distinct beats in a minute. The wound discharging a little sanious fluid unpleasant to the patient, removed the bloody lint and part of the plasters, and re-dressed the wound ; it looks very Avell. 29th, morning. Omitted the morphine last night and slept well; in all respects better; pulse 72 ; in the right arm 69. Evening. The same as in the morning; number of pulsations in both arms alike, but much more feeble in the right. 30^, morning. On being carefully raised up in the bed in order to take nourishment, after a little irritation from the absence of the nurse at the moment Avhen Avanted, she suddenly called out to a re- lation in the room and said that she was bleeding. About two ta- ble-spoonfuls of dark-colored blood were sloAvly discharged. It ceased on a little pressure ; pulse 76 in both arms; removed the lint, and dressed the lower part of the wound, Avhich looks well; gave eight drops of Sol. acet. morph. Evening. At eight o'clock, four table-spoonfuls, as near as could be judged, Avere again discharged from the Avound, and at 12 per- haps a tea-spoonful more. It was of a dark color, and was readily checked by pressure. October 1st.—Feeling sick at the stomach this morning, some Cologne Avas poured over the epigastric region, which immedi- ately occasioned a chill that lasted half an hour. During it she vomited several times. Considerable increase of heat and other attendants of the hot stage continued during the day. Pulse 100 in both arms. Evening. Febrile disturbance still continues; pulse the same; no further discharge of blood from the wound. 2d, morning. Complains of soreness of the throat; febrile ex- citement still continues ; pulse 110, rather tense; directed Epsom salt in Seidlitz powders. Evening. Salts have operated twice, and she feels better; has had several rigors during the day, and vomited several times ; pulse 104, somewhat tense ; took I xviii. blood from the left arm with manifest abatement of the symptoms ; the blood upon standing exhibited strong evidences of inflammatory action; it Avas very buffy and much cupped. 358 NEW ELEMENTS OP OPERATIVE SURGERY. 3d, morning. About 10 o'clock last night, had a trifling oozing of blood from the wound, after a hard turn of hawking ; Avas com- fortable afterAvards, but did not sleep much ; complains of headache ; for tAvo hours past, has been in a free and easy perspiration ; pulse 100, soft; says her throat is very painful in deglutition; the left tonsil is swelled ; directed a dose sulph. magnesia. Evening. Has had a severe ague Avhich lasted about fifteen mi- nutes, during Avhich she vomited; heat that folio Aved very con- siderable ; perspiration very copious for several hours; Avound has discharged a small quantity of blood tAvice since morning ; medi- cine has operated on the boAvels; pulse 108; febrile heat much less. Whilst sitting by the bed-side and preparing to dress the wound, four table-spoonfuls at least of florid arterial blood were suddenly discharged; on removing the plasters and lint it as sud- denly ceased. 4th. BetAveen the hours of four and five A. M., had an ague, Avhich continued half an hour, accompanied Avith vomiting, heated skin, and profuse perspiration. Delirium commenced Avith the chill, and continued more or less until ten o'clock. Directed to take on the subsidence of these symptoms, one tea-spoonful of the folloAving medicine every hour until another chill supervened:— R. Sulph. quiniae, . . . grs. xxiv. Acid, sulph. arom. . . . 3 ij. Sirup, simplicis, . . . I iij. M. In the afternoon between four and five o'clock, a slight chill came on, attended with vomiting; the fever Avhich supervened was mild, and early in the evening the quinine Avas resumed. At 10 P. M., the wound Avas dressed ; looks very well; no bleeding since last night; pulse 100. 5th. Had a slight chill about midnight, and is noAV, 10 A. M., la- boring under a similar one; pulse 110. The bitterness of the preparation of quinine being very offensive to her, ordered instead of it one grain of the sulphate in pill every hour; as soon as per- spiration came on. Dressed the wound; two tea-spoonfuls of blood appeared to have been discharged; says her throat is much better, and a cough which Avas quite harassing yesterday has left her. Evening. Has had her clothes changed, and been removed into a clean bed ; perspiration left her in a great measure about noon, and she has had a refreshing sleep. 6th, morning. Passed an excellent night; tOAvards morning had slight sensation of the chill and much less fever; pulse 108 ; direct- ed more nourishment to be given and the quinine continued. Evening. Has had still less chill and fever in the early part of the afternoon ; dressed the Avound ; compress stained Avith perhaps a table-spoonful of blood. 7th. Had a very comfortable night; feels but little pain in the shoulder this morning ; tongue beginning to clean off; has not had any ague since yesterday; feels some appetite; pulse 100. Qui- nine continued. DR. MOTT ON ANEURISMS. 359 8th. In all respects better; had a slight sensation of coldness this morning; fur upon the tongue much cleaned off; appetite greatly improved; no bleeding since the evening of the sixth ; wound looks well; all of it healed except a small part above the clavicle through Avhich the ligature passes ; pulse 104 ; continues the qui- nine. 9th. In the early part of last evening, after a quiet day, she Avas attacked Avith hemorrhage. The discharge was sudden and to the amount of a pint; it stopped spontaneously. The effect was great and alarming; she Avas pale, cold, almost pulseless, Avhen I reached her. In about an hour she rallied, but was restless and disturbed; any form of anodyne was declined. About midnight, three or four table-spoonfuls more of blood Avere lost. At six o'clock this morning, a profuse gush took place, accom- panied Avith a jet and Avhizzing noise ; I thought it the moment of dissolution; she again revived. Her mind is calm, and she is re- signed to the event; no more hemorrhage occurred. She lived un- til the afternoon of the tenth, and died Avithout a struggle. No. X.—December 29th, 1834. Aneurism of either the Ischia- tic or Gluteal Artery, in Avhich the Right Internal Iliac Ar- tery was successfully tied. By Valentine Mott, M.D. (See the American Journal of the Medical Sciences, Philadelphia, 1837, vol. XX., p. 14—15, reported by Dr. W. C. Roberts, of N. Y.) Richard Charlton, the patient, is a colored man, born in this city, and about 38 years of age. He has Avorked in a grocery store. He first felt the symptoms of his disease in the summer season of 1832 ;—during the cholera then prevalent he had a diarrhoea, and* Avhile making frequent straining at stool, perceived a SAvelling and pulsation in the right buttock, which has gradually increased until this time. It is noAV about the size of a goose egg, and contains only fluid blood. On the 29th of December, 1834, at noon, I proceeded to tie the right internal iliac artery, in the presence of Drs. J. Kearney Rod- gers and A. E. Hosack, and assisted by Drs. Vache and Wilkes. The incision Avhich was fully five inches long, extended from a spot on a line Avith the umbilicus, about midAvay betAveen the linea alba and the anterior superior spinous process of the ilium, to within half an inch of Poupart's ligament, and then curved for- Avard an inch over the course of the spermatic chord. The opera- tion lasted about forty-five minutes, owing to the almost unre- strainable intractability and frantic restlessness of the patient. His great straining and jactitation caused me to make a small opening in the peritoneum, whilst separating it from the iliacus internus muscle. The peritoneum and intestines being draAvn up and sup- ported by a large curved spatula, the internal iliac artery Avas readily seen, crossed by the ureter, Avhich Avas easily pushed aside. The filamentous tissue Avas quickly separated by the fingers from about the vessel, and the ligature conveyed under it by the Am- 360 NEW ELEMENTS op operative surgery. erican needle. At the moment of tightening the knot the hand was applied to the tumor, in which all pulsation immediately ceased, and Avhich itself almost entirely disappeared directly after. The patient, being put to bed, took tAventy drops of a solution of morphine, and in the evening was easy. December 30. Had a good night's rest, and Avas comfortable in the morning. Some excitement coming on early in the afternoon, he was bled from the arm to about 1 xviij., and took a solution of sulph. magnes. in divided doses. Evening—Much easier; salts had not operated. Directed an enema, and applied a strip of blis- ter plaster around the wound. 31st. Has had a good night; is doing well; is free from pain, and the pulse is tranquil; enema operated several times, and the plaster dreAv well. In the evening he was still better than in the morning. January 1st, 1835. Feels much more easy than he did yester- day, and can move better—the abdomen is less tumid. Pulse not more frequent, but rather quicker than it was yesterday. Since the enema Avas administered has had frequent teazing stools. Ordered enema opii c. amylo. Cold Avater and barley tea for drink. 2nd. Anodyne enema quieted the bowels. Pulse, though still frequent, soft and compressible ; tension and tenderness of abdo- men gone. 3rd. Freedom from tenderness continues ; pulse nearly natural. Re-applied the blister and allowed panada and arrow-root. 4th. Much depressed by the intense cold of to-day, (10° below zero of Fahr.) 6th. Pulse natural; tongue nearly clean; is cheerful and hungry. 1th. No unpleasant symptom whatever. 9th. Removed the sutures from the wound, which is very much closed. Is free from pain; pulse natural and bowels regular. The report of the case terminates here ; and owing to the ab- sence of Dr. A. E. Hosack, upon Avhom the case of the patient devolved, Ave are only enabled further to state that the ligature came aAvay on the 42d day.* No. XI.—April 11,1844. Case of Ligature of the Subclavian Artery above the Clavicle, for enormous Diffused False Aneurism of the avhole upper extremity from the Acro- mion to the Fingers, from a gun-shot Wound, followed by a complete cure. By Valentine Mott, M. D., Professor of Sur- gery in the University of New-York. (See New-York Journal of Medicine, Langleys, Publishers, Vol. IV., No. 10, p. 16—19, Jan., 1845. C R. M., aged thirty-five years, by trade a machinist, of Kings- ton, Ulster county, NeAV York, of a bilious temperament and sober habits, whilst on a hunting excursion Avith a friend, had occasion to pass through a thicket, and, in the act of stooping to clear aAvay * I have seen this patient within the past year in excellent health. Dec, 1845. V. M. DR. MOTT ON ANEURISMS. 361 some bushes which impeded his progress, the gun of his friend ac- cidently went off, lodging its contents (buck-shot) about the inferior angle of his scapula. Two of the balls passing obliquely through the axilla, were extracted from the anterior portion of the arm; twelve had been previously removed by means of poultices, from about the place of entrance ; two were still to be felt under the in- teguments, below and about the middle of the clavicle. At the time of the accident the patient was not stunned, nor did he experience a sensation of numbness in any part of the arm. In the course of a feAV hours, however, a tumor began to appear in the axilla, and continued to increase until the third day, when, for the first time, pulsation was detected. It was not until the sixth day, when, after a paroxysm of pain, extending through the whole arm, and so excruciating as almost to render him frantic, that he experienced a sensation of numbness through the entire limb. The paroxysm lasted about one hour, during which time he was obliged to take over one hundred drops of laudanum. This was followed by an cedematous swelling of the arm, oblig- ing him to sleep seated in a chair, with his arm placed on a pillow before him. The paroxysms of pain returned for two successive days at about the same hour, with the same violence, and lasting about the same length of time. This was followed by a violent burning sensation in the palm of his hand, which continued until some time after the operation was performed. This was the only sensation that remained in the whole limb. . He was now brought to the city and placed under my care, being the tAventy-second day from the time of his receiving the injury. On my first visit, I found the cedema to extend from the shoulder to the extremities of the fingers. So great was the extravasation in the axilla, that the circumference of the upper part of the arm was found to be about tAventy-eight inches. On the day of the operation (11th of April, 1844,) the condition of the arm was such as clearly shoAved that no time Avas to be lost. The cuticle was detached to a considerable extent on the most prominent part of the tumor in the axilla; the skin was cracked, and from it there oozed a thin sanious fluid. In short, it presented the appearance of a slough, produced by the application of caustic. Operation.—The patient being seated in a chair, with his arm and shoulder depressed as much as the condition of the parts would admit of, an incision of about three inches in length was made through the skin, extending from the anterior border of the sterno- cleido-mastoid muscle one inch and a half above the clavicle, in a direction doAvnwards and outwards towards the acromion process of the scapula. The superficial fascia and platisma myoides being successively exposed and divided, a mass of extravasated blood was brought into view, Avhich entirely obscured the subjacent parts. On the patient making attempts to SAvalloAV, a prominent line, ex- tending in a direction upwards and inwards, Avas observed in this confused mass, Avhich, after a little dissection, proved to be the omo- 362 NEW ELEMENTS OP OPERATIVE SURGERY. hyoid muscle, but of a much darker color than natural. The deep cervical fascia being iioav cut through, the subclavian artery, ac- companied on its external and superior side by one of the cords of the axillary plexus, appeared just Avhere it emerges from behind the scalenus anticus muscle. An aneurismal needle, armed with a strong silk ligature, was noAV passed round the vessel, the point of the instrument being directed outAvards and backAvards, so as to avoid the subclaA'ian vein. The artery being then tied, the edges of the Avound Avere brought together by two interrupted sutures and adhesive plasters. In the course of this operation, tAvo or three small vessels, branches of the transversalis humeri and transversalis colli arteries, had to be taken up. The external jugular vein Avas divided, and tied on each side of the wound. Progress of the Case. April 12.—Patient says he has felt much more comfortable since the artery Avas tied; the tension and weight of the arm having greatly diminished. On taking a view of the upper part of the arm and shoulder, the attention Avas at once ar- rested by the general reduction in its size ; the skin was softer and more natural. About the elbow it has also subsided, but the oede- ma of the fore-arm and hand are about the same. Temperature of the arm has remained about natural since the. operation, but at present the heat is a little augmented. By accurate measurement, taken before the artery Avas tied, and again to-day, there is about three-quarters of an inch abatement in the size of the aneurismal tumor in the axilla and under the pectoralis major muscle; livid- ness of the axillary part of the tumor much less than yesterday. Pulse 117 ; tongue and skin natural. Owing to the frequency and irritability of his pulse, I directed him, since he came to the city, to take a good nourishing diet. This he is requested to continue. Also, to keep the arm wrapped up in cotton Avadding. April 13.—General expression of his countenance much im- proved — says he feels much better; temperature of the arm and hand about natural; more cedema of the hand ; diminution of the tumor a quarter of an inch, by actual measurement, since yester- day. Pulse 101. General irritability of the system lessened. Di- rected him to continue the same diet. April 14.—Pulse 100. OZdema of arm gradually subsiding, that of the hand remaining nearly the same ; temperature of the limb nearly natural: the size of the tumor has diminished half an inch since yesterday : feet being cedematous, I put on a bandage, and directed him to keep his legs in a horizontal position. April 15.—Patient expresses himself, this morning, as being more comfortable, and says that he has passed the best night since the operation, having remained in his easy chair in a reclining po- sition. Temperature of the arm natural; dimensions of the tu- mor and shoulder the same as yesterday. Pulse 94; appetite good. On the under part of the fore-arm, near the elboAV, some threat- DR. MOTT ON ANEURISMS. 363 ening of ulceration was visible before the operation. This arose from the pressure and Aveight of the limb. As some redness ex- tended from it over and about the olecranon, he Avas directed to cover over the Avhole Avith an emollient poultice. The most projecting part of the tumor is at the axilla, Avhich Avas quite livid before the operation, continues iioav to have the cuticle cracked, and is oozing a Avatery, and somewhat purulent fluid; it is quite soft and fluctuating to the touch. The lint over the strips of plaster covering the Avound, being someAvhat saturated with matter, Avas removed, together Avith the adhesive straps Avhich retained the edges in contact. Most of the wound, except at the outer extremity, is united by the adhesive process. April 16.—Better than since he received the injury ; is a little excited by a visit from several of his friends from the country. Pulse 100 ; appetite good; slept very Avell during the night; tumor in the axilla discharges from the cracks a sanious fluid. April 17.—In all respects as comfortable as yesterday ; more of his friends visited him to-day ; pulse eight or ten beats, more fre- quent than yesterday ; directed him to be kept more quiet; dressed the wound ; it looks Avell. April 18.—Does not look so Avell; says he did not haAre a good night's rest; was not in any pain, but could not get into the right position ; is sleeping from time to time during the day ; pulse 120 : arm of the natural temperature ; circumference of the tumor the same as yesterday ; a small quantity of dark grumons blood is be- ing discharged from the most prominent point of the aneurismal SAvelling in the axilla. Sense of feeling begins to return in the arm from the shoulder to the elboAV ; it is accompanied Avith a painful sensation Avhen the finger is passed over it. Directed him to continue his nourishing diet, take porter, and if his restlessness requires, to take his tea- spoonful of laudanum. April 19.—Found him this morning in a recumbent position on his couch. At my urgent request, he, yesterday afternoon, Avent to bed, previous to Avhich he Avas someAvhat incoherent, and now says that he hardly kneAV Avhat occurred yesterday. Passed a much better night, looks and expresses himself as much better than yesterday ; cedema of the fore-arm, hand and feet, much diminished. Aneurismal tumour discharged dark-colored blood in small quantities; size, the so m? as yesterday; pulse, 103, soft, and free from the irritability it had yesterday, and for sometime before the operation. This more tranquil condition of his vascular system is to be ascribed to the exclusion of his friends since yester- day. April 20.—Passed but an indifferent night, not being able to re- lieve himself by any change of position ; feels better, hoAvever, to- day than for several days past. Dressed the Avound, Avhich is gra- nulating very Avell; removed the second suture and two of the liga- tures ; circumference of the aneurism diminished one quarter of an 364 NEW ELEMENTS OP OPERATIVE SURGERY. inch since yesterday: it continues to discharge from the most pro- minent part of the tumor; cedema of the. hand and fore-arm much diminished. Indeed, the Avhole extremity begins to assume a much more natural appearance; tongue clean; appetite better than for two days ; pulse 94. April 21.—Passed a better night; the tumor has not undergone any perceptible change since yesterday ; oadema of fore-arm and hand is gradually diminishing; pulse, 84; temperature of hand nearly natural. April 22.—Tumor in the axilla has discharged more freely since yesterday: all his symptoms are ameliorated ; dressed the wound; looks well; another ligature came aAvay ; pulse 86. Sense of feeling in the arm increases gradually; it has now ex- tended to the elboAV. In the fore-arm and hand sensation and mo- tion are entirely abolished. April 24.—Is sitting up, and says he is in all respects much bet- ter ; dressed the Avound; it is granulating beautifully; removed the other ligature from the external jugular vein; pulse ninety-six; appetite good; sleeps Avell, Avithout his accustomed tea-spoonful of laudanum. April 26.—Says he feels constantly improving; dressed the wound; much filled up since the last dressing; ligature from the subclavian came away, having separated spontaneously; pulse ninety-four; more grumous blood discharged from the tumor; scab upon the apex of the aneurism about the size of a dollar. April 28.— In all respects improving; wound looks very well; but for the Aveight of his arm, he Avould feel perfectly Avell. May 2.—Wound nearly healed ; Avalks about the room; in all respects improved. May 16.—Greatly improved in appearance ; feels in all respects very Avell; eschar from the tumor in the axilla came away spon- taneously yesterday, leaving a fresh surface of coagulated blood. There was an increased Aoav of grumous blood when it came off; it was about the circumference of a dollar, and nearly half an inch thick; it had remained on about tAventy-eight days; it Avas com- posed of black grumous blood, very hard, dry externally, and cracked. June. — Has continued to improve regularly ; is permitted to re- turn home. After the first slough of integuments took place, it was curious to watch the steps of nature to prevent hemorrhage. As one eschar would come aAvay, another would very quickly form, to plug up the opening ; it would be many days in separating, and had the ap- pearance of a regular slough from the application of caustic; it was, however, a thick layer of the grumous and lamellated blood of the sac. In this way, plug after plug of hard coagulated blood would form and be cast off, and then there Avould be a pretty free dis- charge of this grumous blood, with some coagulated portions. The sac Avas gradually evacuated in this way until all its contents were DR. MOTT ON ANEURISMS. 365 removed, and a fresh granulating surface Avas left, which readily healed up. November.—Came to the city to see me ; appearance of the whole arm very natural; sensation and motion considerably restored hi the fore-arm and fingers. Those interested in the advancement of surgery in our country, may, perhaps, be gratified to learn that this is the fourth time that I have put a ligature around the subclavian artery above the clavi- cle, on the acromial side of the scaleni muscles. All the operations have been attended Avith success. Appendix to Chapter of V. Mott.—First Successful Ap- plication of the Ligature to the Left Subclavian within the Scaleni Muscles. Since the foregoing chapter was prepared for this work, a case oc- curred in the New York Hospital, in Avhich Dr. Jno. K. Rodgers, one of the surgeons of this institution, determined to undertake this im- portant operation, never hitherto performed by any person. The patient was a German of middle age, Avith an aneurismal tumor, apparently about the situation where the left subclavian passes under the scalenus anticus muscle. At a full consultation of all the surgeons and consulting surgeons of the hospital, (myself included among the latter,) it was con- cluded after a free expression of opinion, to leave the case to the discretion and judgment of the surgeon, (Dr. Rodgers,) under whose care the patient came. I may observe, hoAvever, that at the consultation mentioned, I gave it as my opinion, that although the artery in question, could undoubtedly be tied by a careful and well informed surgeon, I nevertheless, considered that it was improper so to do. I founded my opinion in this case: 1st, upon the relative anatomy of the left subclavian artery in the Avhole of its course Avithin the scaleni muscles, and its intimate association with the internal jugular vein and the thoracic duct; 2nd, upon the result of all the operations which had been performed upon the right subclavian within the scaleni muscles ; this latter operation having been performed four times, and all the cases having terminated fatally by secondary hemorrhage. A fortiori, it was my opinion that the ligature on the left subcla- vian" from the anatomical relations stated, Avould make this opera- tion still more hazardous. Insomuch that I remarked then, and still reiterate the assertion as my belief, that I do not think it a justi- fiable operation, and would not perform it myself. This case of Dr. Rodgers, the only one in which a ligature has ever been applied to the left subclavian Avithin the scaleni, termi- nated fatally by secondary hemorrhage ; the ligature having been applied, as Ave understand, just beloAV the origin of the vertebral artery. The case with the post mortem appearances will, Ave learn, be given by Dr. Rodgers himself. 366 NEW elements of operative surgery. Dr. Rodgers of New York, has then, the satisfaction of knoAving that he has been theirs* to apply a ligature to this great artery. I may add that I regret for the honor of American surgery, that this first attempt of a ligature on the left subclavian Avithin the scaleni, has not been croAvned Avith success. V. M. Supplemental Note on Aneurisms. Dr. J. Kearney Rodgers, of New-York, informs me that he has tied the internal iliac Avith perfect success in a case of complicated aneurisms, Avhich he has not yet published, but of Avhich he pro- mises the particulars in time before this volume is issued from the press. The external iliac and the femoral were also both tied in this patient! We also hope to receive in time for this ATolume the same sur- geon's account of a ligature upon the left subclavian, above noted in Dr. Mott's chapter. Dr. Rodgers says the ulceration which caused the secondary hemorrhage in that case Avas, as has been ob- served by Sir A. Cooper, Mr. Vincent and others, (see Cooper's Surg. Diet., Reese's Amer. edit., 1842, art. Aneurism, in Appendix,) after all operations for aneurisms, on the distal side of the ligature, and involved also the vertebral artery in this instance, from the ligature having been placed Arery near its origin. The classification of aneurisms of Mr. Luke, (see a note supra,) is, in some parts, not neAV. The sacculated form, Avith pouches with greatly attenuated coats, (of Avhich a specimen exists in the Hunterian Museum,—the sac ulcerating into the pulmonary artery,) is noticed by Mr. Guthrie, (Diseases of Arteries.) Breschet (Differentes Especes d'Aneurismes,) adopts this variety, and makes also three others, viz., the fusiform or spindle-shaped, the most usual; the cylindroid, where the artery is sometimes di- lated uniformly through a track of one or tAvo feet, observed by him in the arteries of the limbs, brain and splanchnic cavities; in which cylindroid aneurisms he includes the aneurism by anastomo- sis of Jno. Bell, and erectile tumors of Dupuytren. Another variety of Breschet is the true vari.r-like aneurism, where the artery is tor- tuous and also studded with small sacculated tumors. Both the primitive carotids have been tied also in the same pa- tient, Avith an interval only of twenty-seven days, by Professor Kuhl of Leipzig, (See Crosse in Prov. Med. Chir. Trans., vol. V.,) for a pulsating tumor, involving nearly the Avhole scalp, from a Avound in the occiput. The case was perfectly successful. The heaviness and throbbing in the head, produced by such operations, as Avas found to be the result in this case, required copious venesection. Dr. Mussey of Cincinnati, (State of Ohio,) has also tied both pri- mitive carotids, after an interval of only twelve days, for an enor- mous naevus on the vertex, (American Journal of Medical Sciences, Philadelphia, 1S3S,) Avhich, however, had but little effect on the tumor, the radical cure of Avhich was not accomplished until the naevus Avas excised, an operation which required forty ligatures ! This makes five cases in all of ligature of both carotids. dr. mott on aneurisms. 367 Dr. T. S. Kirkbride (American Jour, of Medical Sciences, 1839,) has met Avith eminent success in curing Avounds of arteries by direct compression, having succeeded in this manner in five cases, where the brachial, radial or femoral were implicated. The internal iliac, according to the London Gazette, has been also tied by Dr. Thomson of Barbadoes, but the case ended fatally. Dr. Gross, in his Western Journal of Medicine and Surgery, for June, 1841, states that he hastied the right subclavian artery for axillary aneurism, and that the ligature came aAvay, and the pa- tient did well, until the contents of the sac made their Avay by ul- ceration into the thoracic cavity, and caused death. He enumerates in all twenty-six cases, in which this artery has been tied, seventeen of which Avere attended with a successful result. T.] THE LIGATURE ON THE PRIMITIVE ILIAC The common or primitive iliac, as will appear by the folloAving summary, has been tied up to the present year, (1845,) no less than twelve times. Thus :— 1. If the case of Professor Gibson, now of the University of Penn- sylvania, at Philadelphia, (see account Avhich folloAvs,) is not exclud- ed by its imperfect details, it Avas the first on record, the operation being performed at Baltimore on the 27th of July, 1812, Professor Gilson being then a resident of that city. The patient died on the 13th day from peritoneal inflammation, perforation of the intes- tines, &c. Dr. Gibson states (Amer. Med. Recorder, Vol. III., 1820, p. 185, &c.) that Avhile at Baltimore during the political riots there, and himself in the midst or near by the belligerent parties, he Avas sud- denly, July 27th, 1812, called to a laboring man close by, aged 38, who had just the moment before received a musket-ball in the left side of the abdomen, causing profuse hemorrhage. He placed his finger in the Avound, and succeeded in arresting the hemorrhage partially, and thus kept his finger as Avell as he could in the same position, and Avalked by the side of the man while he Avas being carried home. Though this occupied but a feAV minutes, the he- morrhage could not be stopped, and Avas profuse and exhausting. Nevertheless, the surgeon still holding his finger in situ, (probably the left index,) he operated instanter, Avith the other hand, in pre- sence of Col. Mitchell, U. S. Army, Drs. OAven, Hall, &c, dilating the Avound rapidly up and doAvn, and finally, by great efforts, suc- ceeded by means of an eyed bent probe, in applying two ligatures on the vessel. The circulation Avas soon restored to the left limb ; but the peritoneum having been Avounded, and the intestines per- forated, and also requiring ligatures, the inflammation proceeded to such extent from these causes, and from the quantities of blood effused, that Avith the almost incessant hemorrhages, followed by an enormous distension of the abdomen, death Avas inevitable ; though to the surprise of all, he lived 15 days. The surgeon found the upper ligature, Avhich he had believed to have put on about half 368 NEW ELEMENTS OP OPERATIVE SURGERY. an inchbeloAV the bifurcation of the aorta, had now at least slipped off, leaving the gaping, unclotted, ununited orifice of this vessel in the midst of masses of effused coagulated blood in the cavity of the pelvis and abdomen. The other ligature was on firm in the same trunk, immediately above the bifurcation into the external and in- ternal iliacs. A jury's inquest, in the then tumultuous times, in- terrupted any further examinations. So this case is left in too much obscurity to serve any more than as a point for suggestion, not a landmark to be depended upon. The bullet was found imbedded in the upper and left side of the sacrum. There was no adhesion of the sides of the artery under the ligature which was found on it. Dr. Gibson justly supposes that there can be no reasonable hope of success in Avounds of the primitive iliac, even though the sur- geon be on the spot; but he suggests the fact of the circulation being restored in this case, and the patient living so long, as valu- able data to serve as ground-Avork for the prospect of success in the deliberate application of the ligature in aneurisms of the exter- nal and internal iliac. The continuance of life, after the interruption of a column of blood so large as that of the primitive iliac, Avas not, however, an event to be unanticipated, and need not have occasioned any sur- prise in the mind of Dr. Gibson after the full knowledge he had of the fair prospect of cure that followed, for weeks, the ligature upon a much larger trunk, and one so near the heart, (the innominata,) which Dr. Mott had tied in 1818. Dr. Gibson considers his opera- tion the fitst ever performed on the primitive iliac. 2. Dr. Mott's case, 1827. [Vid. his account of the same, in his chapter on Aneurisms, &cc, supra. Also article Aneurism, by Mr. Wardrop in the Cyclopaedia of Practical Surgery.] The ligature came away on the 18th day, and the patient recovered. 3. Sir Philip Crampton, of Dublin, for aneurism of the external iliac, 1828. Death on the 4th day, from hemorrhage. It is to be regretted, says Mr. Richard Hey, (Medico-Chirurg. Transactions, London, 1844, Vol. XXVII., p. 326,) that the common silk ligature was not used in this case, as a different result probably would have ensued, (sec also lb., Medico-Chirurg. Trans., London, Vol. XVI.) 4. Mr. Liston, of London, 1829, for secondary hemorrhage after amputation. The patient, a boy aged eight years, died very soon after. (Ib., Medico-Chir. Trans., London, Vol. XXVII., p. 326.) 5. Mr. Guthrie, of London, for supposed aneurism of the gluteal. The patient recovered, but died eight months afterAvards from an- other cause, as it Avas found no aneurism existed, (Ib. ib.,) but a medullary tumor, (Philadelphia Medical Examiner, Vol. I., 1842, p. 645-647.) 6. M. Salomon, of St. Petersburg, IS37, cured. 7. Mr. Syme, of Edinburgh, 1838. Death on the 4th day. 8. M. Deguise at the Hospital of Charenton, near Paris, 1840. Cured. 9. This operation was a second time performed successfully in Ame- rica, at the Pennsylvania Hospital, Philadelphia, by Dr. Edwd. Peace dr. mott on aneurisms. 369 of Philadelphia, for a case of right inguinal aneurism, Aug. 29, 1842, in a laboring man named Israel Jones, who about five months be- fore had strained his groin while lifting a heavy stone. A few days after, appeared a hard tumor of the size of a pea, which in a month increased to the size of a Avalnut, and in four to five months acquired its maximum growth, two inches in height, and five and a half inches both in its transverse and its vertical diameters, the tu- mor being of an irregular hemispherical form, involving nearly all the right external iliac, and tAvo inches of the right femoral, causing latterly such constant and distressing pain night and day as to de- prive him of sleep, and oblige him to sit up Avith his leg flexed on the thigh, and this latter on the pelvis. The patient was an excel- lent subject, in the prime of life, robust, temperate, and uniformly healthy. Dr. Peace commenced with a semi-eliptical incision, seven inches long, and extending from over the anterior superior spinous pro- cess of the ilium obliquely downwards, to within half an inch of the external abdominal ring, and nearly parallel to Poupart's liga- ment. The integument, the fascia of the external oblique, the ex- ternal oblique, and the fascia of the internal oblique, were divided with the bistoury. The transversalis and internal oblique muscles were noAV exposed, and with the aponeurosis Avere divided on a di- rector. The peritoneum was then separated Avith some difficulty, and the vessel brought into view. The vessel, says the account published by M. C, (See the Phila- delphia Medical Examiner,Vol. I., 1842, Philadelphia, p. 645, 646, 647,) was taken up about half an inch above the bifurcation, the ligature being passed around it very readily by means of Gib- son's needle. Pulsation and pain in the tumor cased immediately ; followed as quickly by numbness of the limb and foot, and insensi- bility, particularly of the toes. The numbness continued occasion- ally for the first two Aveeks. Sensibility of the parts, however, Avas entirely restored after the 3d day, evendown to the toes. The limb below the knee became sensibly cold an hour after the opera- tion, but by an envelop of carded wool, recovered its natural tem- perature doAvn to the ankle, in the first tAvelve hours, and to the foot in twenty-four—the toes only remaining beloAV the proper stand- ard of heat. The heat, then augmented in the limb to excess; so that for the first two weeks it was warmer than the sound one, ex- cept in the toes, which did not reacquire a proper temperature until after the sixth day. About the middle of the second Aveek, the pa- tient complained of severe pains darting from the toes up into the tumor, which, however, Avas relieved by lint wet with laudanum.. The tumor, soft until now, became much more dense and decid- edly smaller. Some tumefaction of the limb on the fifteenth day soon subsided. The wound Avas dressed on the fourth day, and daily afterAvards. The discharge Avas healthy and moderate, appetite excellent, and general health improved. One half the wound was united by the first intention, and the Avhole Avound, except the sinus- occupied by the ligature, had cicatrized within the first two weeks*. 24 370 NEW ELEMENTS OP OPERATIVE SURGERY. The ligature came away, Sept. 27th, the thirty-fifth day. Friction Avith soap liniment gave great relief to the numbness and pain. There appears to be a discrepancy in the above account as to the simultaneous existence of numbness and sensibility in the limb. 10. The tenth case Avas performed by Mr. Richard Hey, surgeon to the York County Hospital, (see his account in Medico-Chi- rurgical Transactions, London, 1844, Vol. IX., second series, p. 325—332,) Dec. 2d, 1S43, at Acomb, near York, with the sanction of his brother, Mr. W. Hey, of Leeds. The aneurism had sudden- ly appeared in the beginning of November, and had increased in the course of two or three days from what seemed to be a cluster of enlarged hard glands, to such considerable size as to give great pain along the crural nerve, and in about three Aveeks from its first ap- pearance, had acquired the size of a large pulsating tumor above Poupart's ligament, leaving no doubt of its being an aneurism of the external iliac. This was the situation of the patient, a Mr. Taylor, on the day of the operation, which latter Avas decided upon immediately, from the evidently imminent danger of the tumor bursting. The tumor occupied the Avhole of the left iliac fossa from below Poupart's ligament, to within little more than an inch from the umbilicus; the vertical diameter was six inches, the transverse six and a half, and the swelling projected at least three inches from the plane of the abdomen. The tumor had all the usual characters of aneurism. Mr. Hey commenced Avith an incision from two inches and three quarters above the umbilicus to the base of the tumor, being about six inches in length, and moderately curved; this Avas afterAvards extended, by an angular continuation, an inch and a half in length; it was also exactly three inches to the left of the median line. The fibres of the external and internal oblique and transversalis mus- cles were successively divided; and the transversalis fascia having been readily raised Avith a director, Avas carefully opened, to an ex- tent equal with that of the external incision. The peritoneum, Avhich now protruded,being depressed and drawn towards the oppo- site side, the surgeon slowly insinuated his fingers behind it so as to separate it from its cellular attachment to the adjacent parts. " The common iliac," says Mr. Hey, " Avas easily reached, and its com- pression with the finger instantly stopped the pulsation in the tumor. A little time was occupied in scratching through the sheath of the artery; a common silver aneurism needle Avas noAV passed under the artery, armed Avith a double ligature of stay-maker's silk Avaxed. By holding aside the peritoneum and viscera, a moment- ary view of the artery was now obtained, and its complete isolation ascertained. The ligature was then tightened with the fingers -close doAvn upon the artery, Avhen the pulsation entirely and finally -ceased. The situation of the ligature was, I believe, an inch bejow the bifurcation of the aorta, or very little more." The Avound was closed with sutures and strips of adhesive plaster, and over the Avhole Avas placed a coating of lint dipped in strong mucilage. The •operation Avas performed in twenty-five minutes. Though little DR. MOTT ON ANEURISMS. 371 or no blood was lost, and no vessel had to be tied, much exhaustion ensued. The Avound, upon the whole, healed favorably, and the ligature came aAvay the 28th day after the operation. The limb at first Avas three degrees lower in temperature, but on the third day tAvo degrees Avarmer than the other. On the fourth day both limbs Avere of equal temperature, and so continued. One source of anxiety Avas a constant sense of distension of the bowels, accompanied with violent spasm, especially when the bowels were. moved, and Avhich was but partially relieved by the use of aperients and anodyne injections. " On the 4th of January, (33 days after the operation,) these symptoms assumed," says Mr. Hey, " a very serious aspect. No action of the boAvels could be obtained, the at- tacks of spasm were most distressing, the abdomen was tympani- tic, and the patient became quite exhausted, slight coma denoting his dangerous condition." On attempting to empty the bladder with the catheter, so much obstruction Avas found, that the rectum was explored and found to be distended Avith an enormous mass of faeces, resembling to the feel the presentation of a child's head in labor. This mass was perfectly dry and hard, and with difficulty broken down; after being removed, the alarming symptoms subsided immediately, shoAVing how imperiously obligatory is the medical treatment of surgical cases. Mr. Hey thinks the pressure of the an- eurismal sac on the colon prevented the contents of that, viscus from descending into the rectum, thereby causing a gradual and formid- able accumulation, and which was at length suffered to descend by the progressive absorption of the fluid in the sac. On Jan. 20th, the patient Avas restored to his usual health, and enabled to take daily walking exercise. The above highly interesting and remarkable case, and which Avas communicated to the Royal Medical and Chirurgical Society, by Sir Benj. Brodie, Bart., April 9th, 1844, becomes still more so from being " the first case (according to Mr. Hey) which has oc- curred in that country, (England,) in Avhich aneurism of its branches has been cured by tying the common iliac artery." [The first successful operation of a ligature upon the primitive iliac having been performed by Dr. Mott. See supra.] Mr. Hey calls attention to the extraordinarily rapid groAVth of the tumor, which in the short space of three weeks had acquired the dimensions above described. He seems to incline to Sir Philip Crampton's mode of making the incision, arid says he sees no rea- son to doubt the practicability of successfully tying the aorta itself; the more so from the number of instances in Avhich that vessel is found obliterated after death. 11. Of the eleventh case of ligature on the primitive iliac a brief account only has been given at one ot the sittings of the Royal Medical and Chirurgical Society of London, March 11th, 1845, (London Medical Gazette, March, 1S45, p. S05, 806, 807, 808,) at which sitting Mr. EdAvard Stanley, surgeon of St. Bartholomew's Hospital, states that he tied the primitive iliac on a patient of th. t hospital, aged 42, for a pulsatory tumor of bone on the ilium. This 372 NEW ELEMENTS OP OPERATIVE SURGERY. is a species of tumor of bone, Avhere the internal structure appears, according to this surgeon, to be converted into blood-cells and blood- vessels, continuous with some neighboring artery of large volume; the pulsations being rendered in such tumors more distinct from their dense elastic structure. In other tumors of bone, the vicinity of a large arterial trunk alone gives the pulsation. Mr. Stanley alludes in the case in question to the little value to be attached to the bellows-sound in the diagnosis betAveen aneurism and the pulsa- ting tumor of bone. The tumor in the case under consideration had its chief attach- ment to the left ilium and projected from both surfaces of the bone. It reached, says Mr. Stanley, downAvards to Poupart's ligament and to the extent of about three inches into the abdomen. It felt moderately firm, and a little below the crista, near the anterior su- perior spine, a small moveable piece of bone was discovered appa- rently involved in the tumor. EveryAvhere within reach of the fin- gers the tumor pulsated, not with a thrill or vibration, but with the deep, heavy beat of aneurism. By the ear resting against the ab- dominal parietes, a belloAvs-sound was plainly recognised. Mr. Stanley shows the impotency in England, as here and every- where, of auscultation : here Avith a tumor Avithin the grasp of all, the opinions of the surgeons predominated in favor of its being an aneurism; but Avhether of the external or internal iliac no one could say. At all events the primitive Avas the trunk to be tied, Avhich operation without giving any of the details, he states that he per- formed Jan. 27, 1845. The case proceeded favorably to the mid- dle of the second day Avhen peritonitis came on, and the patient died on the morning following that of the third day from the opera- tion. The effects of peritonitis were observed in the deeper parts and left side of the abdomen. A small medullary tumor of the size of a filbert Avas found in the wall of the left ventricle of the heart. The pelvic tumor was composed of spongy tissue Avith cells and convoluted vessels distributed through it. There Avas also a tumor on the inner side of the right upper arm of the size of a small orange, Avhich was loose and free of pain or pulsation. It had exist- ed ten years, and had ceased to groAV. It Avas found identical in structure however with that in the pelvis. Some medullary mat- ter was found in the bronchial glands and lungs. There was clearly, too deep-seated a vitiation in the constitution and fluids of this man to warrant, as we think, a ligature on the com- mon iliac, the apology for which in this case is the fatal delusion created by the fallacies of auscultatology ; for the vaunted bellows- sound, a sound which charlatanerie in this country has blown to some profitable results to its OAvn cupidity, led to the diagnosis of an aneurism. The surgeon, from the peritonitis which ensued, thinks the safest method of reaching the vessel would be through the posterior abdominal parietes. 12. Mr. Fergusson, at the same sitting, showed similar disastrous results Avhile he was at Edinburgh, from depending on the pre- tended disclosures to be obtained from murmurs, bruits, cooings, DR. MOTT ON ANEURISMS. 373 raspings, &c, whereby pulsatory pelvic tumors near large trunks are mistaken for aneurisms; Mr. Syme himself having been thus de- ceived in a case Avhich he supposed an aneurism of the external iliac. After he made the incision to tie the common iliac or external iliac, he found his mistake and removed the tumor, but the patient died. Mr. Fergusson spoke of a case in Avhich during similar doubts as to a tumor in the course of the external iliac, at Edinburgh, the com- mon iliac was tied and the tumor did in reality prove an aneurism, but the patient died—no date is given. This must hoAvever make a twelfth case. So for the total we have twelve cases, six cures and six deaths; but by no means a criterion for pure aneurismal cases. Case of Aneurism op the Basilar Artery. One of the most clearly defined and interesting cases of this rare affection, is by an American surgeon. We are indebted to Dr. Ruschenberger, surgeon of the U. S. Navy, and now surgeon of the United States Naval Hospital, East Brooklyn, (King's County, Long Island, State of New York,) for the details of a remarkable case of basilar aneurism, recently observ- ed by him in his extensive practice in our naval service. This case may be considered the only one of an aneurism of the basilar artery on record, Avhich has been unequivocally established; the others we have alluded to, [in the text supra,] or Avhich have been spoken of by various authors, being altogether too imperfect or confused in the descriptions to allow of our giving that credence to their state- ments which it would be desirable Ave should be enabled to do, in regard to an abnormal deviation so remarkable and important as that of the arterial circulation of the encephalon. Christian Wahlman, marine, admitted May 25, 1845, for " para- lysis," from the U. S. S. Lexington. Left side paralysed; ptosis of left eye; no control of sphincters : urine required to be drawn off; tongue turned to the left side; un- able to sit up Avithout support; difficulty of deglutition; intellect clear but slow. When sitting up there was an antero-posterior vibration of head and body, and at all times when awake, the right leg, foot and arm were in constant motion, so that the right side seemed to be suffering from chorea, while the left was para- lysed. Thus Avhile the power of the motive nerves on the left side appeared to have undergone a sensible diminution in their energy, that of the motive nerves as Avell as the sentient of the right side seemed to have acquired a morbid intensity. [This case will be reported in the American Journ. of Medical Sciences for 1846, by W. S. W. Ruschenberger, M. D., U. S. N.] Autopsy fourteen hours after death.—Dr. Ruschenberger con- tinues :— " Limbs flexible; great development of the sub-cutaneous cellular tissue ; countenance of nearly a natural color. Brain found in a 374 NEW ELEMENTS OP OPERATIVE SURGERY. somewhat softened condition, and an effusion, amounting to perhaps a pint, completely inundating the organ and filling up the ventri- cles. When the anterior part of the corpus callosum Avas torn, there Avas a jet-d'eau of perfectly limpid serum of three inches in height, from contraction of the cavities containing the fluid; over the pons varolii an aneurismal enlargement of the basilar artery the size of a pigeon's egg Avas revealed. The sac contained a very hard dry clot of blood, but notwithstanding this the communication Avith the artery Avas easily traced ; an extravasation of blood from rupture of the sac had taken place into the substance of the pons which was considerably softened and of a black color. The viscera of the abdomen were healthy: thorax was not ex- amined. The day was excessively hot; thermometer 92, and the sick list large, which prevented the thorax from being inspected. Dr. Ruschenberger, informed me, in a recent conversation with him, that the aneurismal tumor was situated in a position as nearly central as could be imagined upon the basilar process of the occipi- tal bone, just before the junction of the two vertebral arteries which form the basilar trunk. The tumor which was, as has been men- tioned, of the size of a pigeon's egg, the long axis of which Avas in a vertical position, of course pressed upwards upon the pons varolii, and rose to a level with the posterior clinoid process (sella turcica,) of the sphenoid bone. It must of course have made pressure in all directions, more especially upon the middle lobes at the base of the brain, and consequently upon those portions of the cerebrum which give origin to numerous important nerves. The jet-d'eau of limpid serum came probably from the lateral ventricles, Avhich latter consequently must have been greatly dis- tended. The pressure of the aneurismal tumor had probably caused this effusion, and the pressure of the distended lateral ventricles on the surrounding parts of the brain, and the origin of nerves, is to be taken into the account, as an important element in the production of the symptoms described. Some reflections naturally arise from this most important case of aneurism communicated by my friend Dr. Ruschenberger: If the great pathological principle, that pressure upon the origin of the nerves of the encephalon on the right hemisphere, causes paralysis and other abnormal results on the opposite side of the trunk and limbs, and vice versa, (which pathological axiom I have no reason to call in doubt) then the aneurismal tumor in this case, central as its position appeared to be, must have produced more lesion on the right side of the portions of the cerebrum; which is furthermore confirmed by the existence of an augmented muscular activity on the right side, as is evinced by the co-existent symptoms of chorea. I had occasion some feAV years since to examine at the Hospital of the Poor of this city atBellevue, (Avhile Dr. Vache was physician of that establishment,) a remarkable case of chorea, which in contra- distinction to that above described by Dr. Ruschenberger, may be denominated rotatory chorea. The patient would for hours or even DR. MOTT ON ANEURISMS. 375 days, as Dr. Vache said, continue to make rotatory movements of the head from side to side, incessantly, and from one side to the other, or vice versa, according as the first movement was communi- cated by the surgeon either to the right or left. I do not know Avhether this patient is still alive, or if dead, whe- ther any autopsy has been made ; but Dr. Ruschenberger's valua- ble case, allows us to infer, that there may have been in this patient of Dr. Vache an aneurism of the basilar artery Practitioners therefore should direct their attention to these facts ; and in all cases of chorea and paralysis, search in their post mortem examinations for aneurismal or other tumors at the base of the brain. The retraction of the tongue to the left side, is an important point to be noted in the case of Dr. Ruschenberger. In our note on frac- tures of the base of the brain, and especially of the petrous portion of the temporal bone, (infra,) it will be seen that much important light has been throAvn upon that subject; and that in such lesions, it is noAv contended, that the retraction of the uvula and velum to one side or the other, may serve as an important diagnostic mark to denote injury to the opposite side of the encephalon at the base of the brain. For it has been found, it will be seen, (if the state- ments are correct) that the motive functions of the uvula and velum are derived from the portio dura pair of nerves; and that conse- quently Avhen one of this pair is injured, the parts mentioned (velum and uvula) will by the integrity of the nerve on the opposite side.be drawn to the opposite side of the lesion, the antagonism of the mus- cles on that side no longer having any force to counterbalance its action. In the case in question, the tongue, it appears, Avas draAvn to the left side ; which was the side of the body affected Avith hemi- plegia. It is consequently another argument in support of the idea we have throAvn out, that the greatest degree of lesion, so far as pressure on the nervous centres of sensibility at the base of the brain, Avere concerned, must have been on the right side. THE IMPORTANCE OF THE PERUVIAN ASTRINGENT PLANT, MATICO, IN ARRESTING HEMORRHAGE. Dr. Ruschenberger, of the U. S. Na\-y, has also kindly communi- cated to me the folloAving important observations in respect to the value of this new American remedy. The case Avas.one of conse- cutive bubo in each groin, in a patient aged about 35, who had been cured of chancre. The buboes on each side had been evacuated freely, and had been for some time burroAving under the skin and fasciae of the groin; each having an external opening Avith the usual characteristic ragged, leadish-blue-colored shelving edges, so pecu- liar to and diagnostic of these cases. In dilating them, Avhich is Dr. R.'s constant practice, and the only true and sound treatment, as our own experience testifies, he divided in both, as it so happened, the arteria ad cutem abdominis, which on both sides, singular as it may appear, had taken the same sub-cutaneous course in the groin over 376 NEW ELEMENTS OF OPERATIVE SURGERY. the sinuous passages of each bubo, and having become much enlarg- ed, bled freely, and per saltern. The assistant of the hospital, after some hours, finding it difficult to suppress this hemorrhage, Dr. Rus- chenberger directed the application to the dilated Avounds and cut ends of the arteries, of the celebrated Peruvian astringent plant, ma- tico, (the Piper angustifolium of Ruiz and Pavon.) This was first attempted by the dried leaf entire moistened; but Avithout effect. The surgeon then himself broke up a portion of it into poAvder between his fingers, and having moistened it with water, applied this paste into the wound. The bleeding in both arteries ceased instantly and did not return. It may be well to remark that Dr. Ruschenberger was the first who brought this valuable styptic from Peru to this country, viz., in 1834. He has used it, he informs me, beneficially in gonorrhoea, leucorrhoea, and chronic diarrhoea; and in ophthalmia, where astrin- gents are required. He has given it in doses internally of 5 grains to half a drachm, three times in 24 hours. In a case of hematemosis, where every thing had foiled, this astringent, in five grain doses, (meaning ahvays the powdered dried leaf) three times a day, effected a perfect »eure. The story told of its discovery is this : that in 1824, at the battle of Ayacucho (Bolivia, in South America,) a soldier having had his leg shot off, gathered up the Matico that grew around the spot where he lay and applied it to the bleeding stump ; by which means the hemorrhage was immediately arrested, and a cure effected. Hence its name of yerba del soldado. Dr. Ruschenberger last summer, (1845,) derived most satisfactory results from the external application of the matico in a case at the U. S. Naval Hospital, of a marine who had received a gunshot Avound in the neck about an inch below the right commissure, about 14 months before, at Montevideo (South America). The ball had knocked out all the molar teeth of the lower jaw on the right side, and lodged near the root of the tongue, lying there very superfi- cially. It was extracted Avithout difficulty. There was a hard fis- tulous opening, hoAvever, an inch beloAV the angle of the loAver jaw, communicating with the base or root of the tongue. Ascertaining with the probe the presence of a foreign substance there, he dilated the Avound and extracted to his surprise a molar tooth ! But in doing this the surgeon must have divided, as he thinks, the internal maxillary artery, as the bleeding was profuse and for some time uncontrollable, owing to the difficulty of getting hold of the cut end of the bleeding vessel, from the indurated state of the parts. It then occurred to him that he would use the matico directly to the wound, which he promptly did in the manner above described It acted like a charm, and arrested the hemorrhage immediately. Some remarks touching the value of this hemostatic remedy, as communicated by Dr. Ruschenberger, may be read with advantage in the Journal of Pharmacy of Philadelphia, year 1844, the details thereof being drawn up by Professor Carson of the College of Phar- macy of that city. DR. MOTT ON ANEURISMS. 377 Dr. Ruschenberger, in his communication to me, suggests that it would be important to ascertain Avhether the matico might not be of great value in cases of secondary hemorrhage, Avhich are always so embarrassing and frequently so fatal after surgical operations. CURE OF ANEURISM BY COMPRESSION. Since the publication of the valuable Memoir of Dr. Bellingham of Dublin, (see our note above,) another triumphant case, making the thirteenth, has been added to the list; and what makes the case more important is, that the treatment was simplified down to the purest principles of the admirable plan established by the surgeons of Dublin, as Ave have already described it in the note just alluded to. The case Avas communicated by Mr. W. NeAVCombe to the Surgical Society of Ireland, (See Dublin Journal of Medical Sci- ence, March, 1845, p. 157,) and was one of popliteal aneurism. Two clamps only were used, one on Scarpa's space and the other higher up the limb, and tightened alternately with the first Avhen that produced uneasiness. No bandage Avas applied to the limb or over the tumor. Dr. Bellingham has well remarked in a former essay on com- pression as a cure for aneurism, (Dublin Journal of Medical Science, 1843,) that when it Avas considered absolutely necessary for the success of compression, that such an amount of pressure should be applied as Avas almost certain to produce sloughing of the part, and very certain to occasion intense pain and suffering to the patient; and when in addition, this was to be prolonged through five succes- sive nights and days; Ave can readily understand Avhy patients re- fused to submit to it, and we can easily account for the disrepute into Avhich the practice fell, and for the unwillingness of surgeons to adopt this treatment, in preference to the simple operation of placing a ligature on the femoral artery. But even Dr. Bellingham, as recent as that date, (1843, July,) Avas yet disabused of the ancient and noAV proved erroneous treat- ment of Valsalva by bleeding, low diet, &c, Avhich he conceived to be still absolutely essential as accessories to compression. Dr. Bel- lingham even believed that bleeding Avould aid in the coagulation of the blood. We have no doubt he now sees the evils of such practice, and is convinced that the modern doctrine now so rapidly gaining ground is the true one, to wit, that Avithout pretending to advocate a stimulating course, the reverse of the exhausting treatment of Val- salva, that is, a nutritive generous diet is the one that must now be adopted, as the only means in fact of promoting the formation of plastic lymph or fibrine in the blood. SUCCESSFUL LIGATURE UPON BOTH CAROTIDS AT AN INTERVAL OP POUR AND A HALF DAYS. The only successful case on record in this country that we are aware of up to the present time, of a ligature on both carotids after a 378 NEW ELEMENTS OP OPERATIVE SURGERY. short interval of time, is that of Dr. Mott, (See his chapter, p. 288 supra,) in which both carotids Avere tied in an interval of 12 months. In another attempt of this kind by the same surgeon, in Avhich there was an interval of only fifteen minutes, the case ended fatally. We have now the pleasure of recording another triumph for American surgery, in the successful application of a ligature to both carotids after an interval of four days and a half, in a case of gun- shot Avound attended with secondary hemorrhage. This operation Avas performed in October, 1844, by John Ellis, M. D., a young surgeon of Grand Rapids, State of Michigan, and affords a gratify- ing evidence of the progress of surgical science in the neAV, and until Avithin a feAV years, uninhabited regions of the vast fertile prairie country of this empire beyond the Alleghanies. The case as recorded by Dr. Ellis (in Dr. Lee's New York Jour- nal of Medicine and the Collateral Sciences, number for September, 1845 ; Langleys, proprietors and publishers; Vol. V., No. XIV., p. 187, et seq.) states that the patient, Peltish Hill, aged 21, Avhile hunting near Grand Rapids, received, Oct. 21, 1S44, the contents of a rifle in his back. The ball striking near the centre and imme- diately above the spine of the scapula of the left side, and after making a flesh Avound of about tAvo inches and a half towards the neck, passed out, and after about the same space entered his neck over the centre and posterior edge of the sterno-cleido-mastoid mus- cle. It then passed up through the centre of his tongue, and out of it to the right of the median line, striking the lateral incisor, cuspi- datus and bicuspidatus of the right side, which teeth it knocked out together with the alveolar process external to them. It then passed through the upper lip, leaving a ragged opening through it. Dr. Ellis saAV the patient a few hours after the accident, and found he had lost but little blood. The surgeon drew the edges of the wound on the lip together with adhesive plaster and tAvo or three sutures, and dressed the other Avounds Avith cold applications. The patient suffered but little pain, but Avas entirely unable to swalloAV even liquids, owing, as Dr. Ellis thinks, to the swelling of the tongue. As secondary hemorrhage was apprehended, directions Avere given that the patient should be carefully Avatched night and day by two intelligent assistants, who were directed to compress the carotids and the orifice of the Avound in case of need. Very little inflam- mation followed, owing doubtless, as the surgeon says, to the pa- tient being unable to take any food for three days, at the end of which time some water and nourishment Avere injected into the oesophagus through a flexible catheter. The next day he sAval- lowed some liquids Avith difficulty, and soon after recovered his poAvers of deglutition. On the seventh day Dr. Ellis Avas sent for during the night to visit his patient. A hemorrhage had taken place from the Avound of the tongue, but was readily suppressed by compressing the carotid of the left side and the orifices of the wound ; and on removing the pressure no bleeding returned. The hemorrhage, however, returned in considerable quantities a few hours after, and Avas restrained with difficulty by compression. DR. MOTT ON ANEURISMS. 379 The surgeon again sent for and arriving in the evening, applied with the assistance of Dr. Piatt a ligature on the left carotid, below the omo-hyoideus muscle; Avhich operation Avas attended Avith much difficulty, OAving to the swollen condition of the parts, the necessity of maintaining pressure, the unfavorable position of the parts for the operation from the necessity of keeping the mouth in a certain position to avoid strangulation from the blood, and also from the inconvenience of being compelled to perform the opera- tion by candle light. Arriving at the common sheath, the descen- dens noni, which AAras found in its usual place, Avas pushed aside, but on opening the sheath, the operator came in contact Avith a large nerve directly in front of the artery which seemed to him of un- usual size for the par vagum. It was pushed aside, and on sepa- rating the artery and vein a little he saw no appearance of the par vagum in its usual place. A slight coldness of the face on the side operated upon, and an occasional throbbing beneath the sternum, Avere the only unpleasant symptoms that folloAved the tightening of the ligature. The patient did well until the eleventh day, when there was a return of the hemorrhage, which Avas easily controlled hoAvever by pressure on the right carotid and on the Iavo orifices of the wound. A slight pulsation was noAV for the first time felt in the left temporal artery. The hemorrhage returned several times in the night and during the next forenoon; and as the patient could not endure pressure on the carotid, it Avas confined to the two ori- fices of the Avound, producing there hoAvever a good deal of pain in the direction of the ninth pair of nerves. In this dilemma Dr. Ellis, in consultation with Drs. Piatt and Shepherd, being uncertain whether the hemorrhage Avas from the right lingual or from the unligatured end of the left carotid, and finding also, a good deal of tumefaction under the angle of the jaw, which rendered it difficult to identify the cornu of the os hyoides, determined to take up the right carotid; Avhich was performed without difficulty. The internal jugular vein overlapped the artery to some extent, and the descendens noni and par vagum were found in their place. The patient being in the sitting posture, tAvo ligatures Avere passed under the artery, and one of them tied over a cork applied to the vessel A slight paleness ensued, together with cessation of the hemorrhage, and also of pulsation in both temporals In an hour the pulse rose from 95 to 104, but soon came doAvn to 110 ; there Avas no difficulty in breathing. The first ligature Avas cut over the cork and removed, the other tied and the wound closed Avith sutures and adhesive plaster. A hacking cough and difficulty of breathing came on at the end of 24 hours, Avith pain in the chest and heaviness, the pulse being 120 and rather full for his reduced state. Twelve ounces of blood Avere now taken from the arm and some by cupping, affording, hoAvever, little or no present relief. Some tincture of belladonna Avas given for the cough. Four or five hours after, there Avas more distress, pain, and difficulty of breathing, the pulse remaining about the same. A drop of the tincture of aconite Avas added to a glass of Avater, and 380 NEW ELEMENTS OP OPERATIVE SURGERY. a tea-spoonful administered o( this mixture. In four hours after he felt better and breathed easier; pulse 110 and less full. The aconite and belladonna Avere noAV given whenever the cough and dyspnoea required, while all other fluids were abstained from. The symptoms of difficult breathing subsided under this treatment, and the pulse came down in a few days to 80. Neither of the wounds healed by first intention, but commenced discharging a healthy pus. The ligature of the right carotid came aAvay the 14th day, that of the left on the 17th. The wound on the left side continued to dis- charge for several weeks, Avhen the portion of the artery between the wound and the ligature sloughed, and came aAvay in three pieces at different times, the last portion being about one inch in length. The young man at the date of the communication, (June 18th, 1845,) was enjoying comfortable health and attending to business. No perceptible pulsation could be felt in either temporal. Dr. Ellis, in conclusion, remarks:— " There are several reasons which make the above case very interesting. It shows the comparative safety with which both carotids can be ligatured, so far as the brain is concerned, [a fact already established by Dr. Mott's successful case,] and the danger of pulmonary congestion, [even after all the privation of blood, hemorrhage and venesection.] It shows also, with what rapidity anastomosing branches of the opposite vessel, supply blood enough to give rise to pulsation in the temporal artery, and of course the danger of hemorrhage from the unligatured end of the artery, [a point to which the attention of surgeons is so strongly directed by our author, M. Velpeau,] where it is not possible to ligature both ends of the wounded vessel." We have thus on record five instances of a ligature on both caro- tids :— 1. Two by Dr Mott. 2. One by Dr. Mussey of Cincinnati (Ohio.) 3. One by Professor Kuhl of Leipzig. 4. One by Dr. Ellis. VENOUS SYSTEM. 381 SECTION VI. VENOUS SYSTEM. The same operations are practised upon the veins as upon the arteries; this class of vessels in fact, like the arterial system, is liable to Avounds, fungous degenerations, and hypertrophy. Wounds.—The wounds of the venous system, however, unless they should be situated upon trunks of the first order, the vena cava, internal jugular veins, subclavians, axillaries, iliacs, femorals, or popliteals, rarely give rise to dangerous hemorrhages, and if they are formidable they are rendered much more so by the inflam- mation they cause, than by the loss of blood that proceeds from them. Wounds of veins differ also essentially from Avounds of arteries in cicatrizing with facility, without necessarily involving the ob- literation of the Avounded vessel. It results from this, that if a large vein is divided upon its side, and that compression is not sufficient to put an end to the hemorrhage, the ligature Avill not have to embrace its entire calibre. The most convenient and secure process in such cases, consists in seizing the tAvo lips of the opening with the tenaculum, and in then passing a thread around the wound on the side of the vein, Avhich thus cicatrizes without difficulty and Avithout interposing any obstacle to the circulation. When a vein is divided transversely, Avhether Ave compress it or apply a ligature to it, it rarely happens that it becomes necessary to act upon any other portion of it than the inferior extremity. However, it might be necessary to obliterate the other end also, if the wound was situated in the neck, in the upper part of the arm, or even in the fold of the groin. I have often seen the popliteal vein pour out blood copiously by an actual reflux movement. When veins are found in the Avounds of an amputation, it is generally useless to apply a ligature to them. Nevertheless, if they keep up a hemorrhage, I think Ave should do Avrong not to tie them. The dangers of this ligature, upon which so many sur- geons have insisted for half a century, are shoAvn to be farthest from the truth, (vid. Process for tying the Carotid,) and I should not be surprscd to find that it would prove more advantageous to sur- round them immediately with a ligature, than to leave them free at the bottom of the wound. As for the rest, almost all the operations that have been prac- tised on veins, seem to have been devised for cases of varices. This article, therefore, will be devoted to the treatment of these affec- tions. 382 NEAV ELEMENTS OP OPERATIVE SURGERY. CHAPTER I. OPERATIONS REQUIRED FOR VARICES. Though varices do not constitute a disease essentially dangerous, they may often so far incommode those avIio are affected by them, as to make it proper that surgical aid should be had recourse to for their treatment. The trouble, deformity, and ulcers that they cause or keep up,and the hemorrhages Avhich sometimes take place from them, sufficiently explain the solicitude Avhich they have occasioned at every epoch of the science. Article I.—Varices in General. The ancients, who employed topical applications, astringents, de- siccatives, and resolvents for varices, used also the compressing bandage, applied to the whole extent of the limb, and professed to aid their action by means of internal remedies. Then, as at the present day, those different modes of treatment were nothing more than simple palliatives. To obtain a radical cure, they had re- course to operations properly so called. § I.—Ancient Methods. • A. Acupuncture___Sometimes it Avas thought sufficient, in con- formity Avith the recommendations of Hippocrates, and as Avas also advised by Pare and Dionis, to puncture the varices, (Hipp. Traite" des Ulceres, a la fin,) and incise them lengthwise, but more freely than in phlebotomy, in order to empty them of their blood and clots. " Practitioners of the present day," says De Gouey, (La Veritable Chirurgie, p. 236,) make use of a needle of gold or silver, with which they puncture these tumors to empty them of their blood; but this operation is but a feeble resource." B. Cauterization.—According to Avicenna, the vein should be seized with hooks at tAvo points, distant three fingers' width apart, then tied Avith a good silk thread, and divided transversely upon the space betAveen the ligatures; after which, the ligature upon the lower end is to be removed, in order to bring the blood from below upAvards, and to force out as much of it as is possible with the hand ; then to cauterize the upper end of the vessel, and even the Avhole extent of the Avound, Avith a hot iron or arsenic. Avi- cenna appears to have been the first, in the treatment of varices, who actually applied methodical compression from the foot to the knee. Others tore out the varices, after having cut into them ; this, at least, is Avhat Ali-Abbas appears to recommend. Celsus (De Re Med., lib. 7, cap. 31, Ou Ninnin, t. II., p. 371) speaks of cauteriza- tion and extirpation, and all the Avorld know, from Plutarch, (Hommes Illust, t. IV., p. 380, Trad, de Dacier,) that the stoic Ma- OPERATIONS REQUIRED FOR VARICES. 383 rius—Avho, remarking that the remedy was Avorse than the disease, declined presenting his other leg, covered with varices, to the sur- geon, Avho had removed them from the first—had undergone this last named operation. Dionis (Operat., p. 766, 9e Demonstr.) is as- tonished that the ancients did not advise the hot iron to traverse (barrer) the varicose veins, as is done Avith horses, and that they should have been satisfied Avith the potential cautery. An .enor- mous varix Avas cauterized and cured by Bidloo, (Coll. de Villars, Cours de Chirurgie, t. I., p. 434-439.) Bayrus (Louis, Diet, de Chirur., t. I., p. 561) speaks of a varix that resembled gutta rosa, and Avhich he cured by cauterization of the frontal vein. We are not surprised to see M. A. Severin (Med. Ejf., p. 368, ch. 98, Exo- pirie) cauterize Avith the red-hot iron. Dionis admitted, however, that the roller bandage, in form of a buskin, (bottine,) Avas prefer- able to all other means. This was also the recommendation of the greater number of the surgeons of our epoch, Avhen an attempt was made, some years since, to simplify the operations of the Greeks and Arabs. C. Excision, either simple, or as Celsus describes it, or as it must have been performed upon the leg of Marius, or combined Avith the ligature as in the process of Galen, or that preferred by Paul of Egina, (Vid. Vidius, Comment sur Gal, lib. 6, cap. 83,) is but rarely necessary, and cannot be required, as Boyer remarks, but for those large tumors or varicose bunches (pelotons) Avhich are sometimes met Avith in the legs; it is also uncertain if it might not even then be superseded with advantage by processes more simple. We may learn, from J. L. Petit, (OEuvr. Chir., p. 266, 267, 279, 280,) the kind of hemorrhage to Avhich patients may be exposed from the incomplete extirpation of varicose veins. D. The Ligature, Avhich Avas distinctly recommended by the an- cients after excision, and Avhich Dionis describes Avith much mi- nuteness, (Oper. Cit., p. 765,) Avas frequently employed by Ev. Home, in England, and by Beclard in France. We take up, says M. Briquet, (These No. 193, Paris, 1824,) who relates the results obtained by Beclard, a longitudinal fold of the skin on the point Avhere the vein is alone and most superficial, and divide the fold doAvn to its base; Ave then pass under the vein an eyed probe furnished Avith a ligature, and after having tied the same, divide the vessel immediately above it." We may also cut the skin and the vein at a single stroke, and then tie the lower end of the venous canal by seizing it with the forceps. Strips of adhesive plaster serve to hold together the lips of this little Avound, and the patient is to be kept at rest. MM. Smith, Travers, and Oulknow, have followed the method of Home ; but not with as constant success. Physic, hoAvever, says, he has great reason to be satisfied with it, "and M. Dorsey, (F/ements of Surgery, Vol. II., p. 404,) Avho frequently made trial of it, affirms it, that it was never, in his practice, attended Avith any serious accidents. According to Briquet, at no time during the service of Beclard at La Pitie, did this method ever produce an 384 NEW ELEMENTS OF OPERATIVE SURGERY. unpleasant symptom, except in tAvo cases, out of an aggregate of sixty persons operated upon. It is difficult, in fact, to understand how this ligature, if properly applied, could be attended Avith much pain, or be followed by tetanus, as has been pretended, or Avhy inflammation of the vein, on the cardial side of the disease, should be more frequently caused by this than by any operative process, Avhich causes the obliteration of the vessel. The process of M. Gagneles, referred to by Marechal, (These de Concours,) and Avhich consists in passing a ligature around the vein through a simple puncture in the skin, Avould have no other effect than to render the operation more difficult Avithout diminish- ing its inconveniences. " Nevertheless," says Chaumette, (Enchi- ridion de Chirurg., liv. 1, cap. 58, p. 278,) " I am in the habit of introducing with less trouble and pain, and by means of a sharp, curved (crochue) needle, a ligature under the vein, then tying it and leaving the thread there until it comes away of itself." Does Lombard, (Clinique des Plaies Recentes, an VIII., p. 248,) where he relates that some recommend incising to the right and the left upon the side of the vein to avoid the inflammation which must ensue from puncture with the needle and insertion of the ligature; and that others call this inflammation in question, wish us to infer that they knotted the ligature upon the skin? De Gouey, (Op. Cit, p. 237,J who tied the vein beloAV the varix, and then divided it above, followed this practice with much success. Lombard, (Op. Cit., p. 248,) who had recourse but once to the ligature, applied it at 6 or 7 millimeters below the tumor, inserting under the vein a needle of the shortest possible curvature, and laying a small compress of four double along the course of the vessel, in order to support the knot of the ligature, and render the whole secure. Afterwards opening the tumor, he dressed with a pledget of lint dipped in alcohol. M. Cantoni, (Observateur des Sc. Med. de Marseille, Juillet, 1825, trad. par Gerard,) who relates twenty cases, four of which are taken from his own practice, and others from that of Vacca, Mori, and Orlandi, says, that after having made trial of the ligature, recision and excision, this last offers the most favorable prospect of success: but Vacca Berlinghieri, (Valentin, Voyage en Italic, Ire edit., 1825, p. 94, et trad, par Gerard, 2e edit., 1826,) who, in 1820, had already in six cases effected the cure of varices by the ligature according to the method of Home, has seen the disease reproduced, and some time after, having seen a man upon whom a surgeon had per- formed incision of the vein above the knee Avith success, he wrote to Valentin, that seeing that the dangers surpassed the advantages that had been hoped for by different processes, he had abandoned all of them, and no longer practised the operation for varices. E. Incision. Not Avishing to confine himself to the simple liga- ture, M. Richerand supposed that by incising in a direction parallel to the limb, and to a great extent the tortuous bunches or varicose pelotons, he would be more sure to succeed. I have many times seen him at the hospital of San Louis employ this practice Avith en- tire success, and I have myself used it with advantage upon a num- OPERATIONS REQUIRED FOR VARICES. 385 ber of patients ; but the only one upon whom I performed it at the hospital of La Pitie died on the ninth day. We select the part on the limb Avhere there are the greatest number of varices collected together, then with a convex and very sharp bistoury, Ave cut deeply and to the extent of four, five, six, and even eight inches. After having emptied the veins of the clots by pressure, the wound is filled with lint covered with cerate, and applied either directly or upon a piece of fine perforated linen ; the first dressing after this is not made until at the end of three or four days. Then the venous orifices are found closed, and the Avound may be dressed flat like any other simple solution of continuity. Beclard proceeded in the same manner in several cases, and was not less fortunate than M. Richerand. Those long gashes, however, have something frightful in them to the patient, and in reflecting seriously upon them, we cannot see what great utility they can have. In conclusion, Ave must not confound this method with the simple long incision recom- mended by Avicenna, (Huguier, These de Concours, 1825, p. 12.) F. The section, upon a single point selected, or on different branches when we do not wish to act upon the principal trunk of the vein, would be evidently preferable to the preceding operation. I have performed it fifty-tAvo times at the Hospital of San Antoine and at La Pitie,in the space of six years. One of the patients, it is true, died on the twelfth day, but with ataxic symptoms of a very unusual character, which could only be accounted for from the state of fear or unaccountable morbid apprehension under which he labored before the operation. We met with no traces of phlebitis above the wound, and that which existed beloAV it was found to be wholly disproportionate to the severity of the symp- toms. Another died from the effects of a true phlebitis. In three other cases, the phlebitis, after having given occasion to unpleasant symptoms, terminated in abscesses about the Avounded vein. The cure was afterwards accomplished without difficulty. M. Warren, who has frequently practised this method, told me that he had al- ways found it to answer well. Nothing is more simple than an operation of this kind ; the vein is first raised up in a fold of the skin ; a narrow and keen-edged bistoury then passed through the base of this fold, effects the division of it Avith a single stroke ; we thus successively practise the incision upon all the veins that are somewhat considerable in size, and that appear to come from the varicose bunches (pelotons de varices.) The blood immediately escapes in large quantity ; and we allow it to Aoav for a greater or less length of time, according to the strength of the patient, after which the wound is filled with small balls (boulettes) of lint, before covering it with a plumasseau of the same material spread with cerate, and then Avith soft compresses ; the whole should afterwards be supported Avith a roller bandage moderately tightened; if we attempted primitive coaptatation, the continuity of the vein might be re-established, and thus defeat the object of the operation. G. M. Brodie, with the view more effectually to guard against phlebitis, (S. Cooper, Surgical Dictionary, t. II., p. 594,) confines 25 386 NEW ELEMENTS OP OPERATIVE SJRGERY. himself to dividing the veins transversely by making only a simple puncture in the skin. For that purpose he makes use of a bistoury with a narroAV blade and a little concave upon its cutting edge. The point of the instrument is first passed through the integuments upon one of the sides of the vessel; it is then made to glide flatwise between the vein and the dermis; when it has reached the oppo- site side, its cutting edge is turned backwards, and the Avrist at the same time raised in such manner as to divide the venous cord per- fectly Avhile withdrawing the bistoury. M. Carmichael and other practitioners have greatly extolled this process; a patient upon Avhom M. Bougon performed it in my presence, also did remark- ably Avell under it; but Beclard, who made trial of it at La Pitie, affirms that it gives us no better security against phlebitis and phlegmonous erysipelas than the ordinary incision, and moreover, that it sometimes fails in producing the obliteration of the vein. I agree entirely in opinion with Beclard, and can add, that without securing us against any danger, this process is the most difficult and the least certain of all. H. Exsection (resection) which had already been practised from the time of Celsus, Paul of Egina, Avicenna and Albucasis, has found some partisans among surgeons of the present day. The two ends of the vein, by retracting under the lips of the Avound, cease to be exposed to the influence of the external air, an action which, according to M. Brodie, is a powerful cause of phlebitis. This last argument is entirely hypothetical, and not deserving of the importance that a surgeon of Paris (Rev. Med., 1836,1.1., p. 29,) has given to it while claiming it as his own property. To say that if an inch of each end of the vein under the skin is not removed, the air may bring on a phlebitis capable of causing death in twenty-four hours, is an absurdity Avhich I have no need of making any remark upon. I. Appreciation.—In conclusion, the avowed and unquestionable purpose of the operator is to obliterate the veins that have become varicose ; but it cannot be denied that the ligature, without or with the section, or whether that section be transverse or longitudinal, open or under the skin, and that extirpation itself as well as cau- terization Avith potash or the red-hot iron, may all bring about this result, and that this constitutes the whole amount of relief they are capable of affording to the patient. It is desirable, therefore, to knoAV which of all these means is that which produces the least pain, may be performed with the most ease, and exposes to the least danger. The transverse section of the vein, including the skin with it, possesses the different advantages of the other me- thods, combined with all the simplicity that could be desired. [Whoever may be the author of the germ of the idea, it is one that undoubtedly belongs to sub-cutaneous surgery, though this is obvi- ously one of those cases where the principle or leading feature of this method (occlusion) seems not only not applicable, but injurious, by confining the immense sub-cutaneous extravasation and danger- ous infiltration of venous blood that must ensue. T.] OPERATIONS REQUIRED FOR VARICES. 387 It is finished in an instant; and the youngest pupil can perform it Avith ease; the pain is almost nothing, and the whole operation differs but little from an ordinary bleeding. What is to be obtained by the ligature so much extolled by Home and Beclard, except to make the operation considerably longer and more dangerous ? Why run the risk, in imitating M. Brodie, of an incomplete division of the vein, and of seeing the blood effused into the sub-cutaneous tissue, and forming there a nucleus and centre for phlegmon or abscess? Is it the division of the skin that should ever disturb us after such an operation ? And who does not now know that the action of the air upon the veins is incapable of producing any of those formidable accidents which have been so gratuitously im- puted to it? As to the long and deep incisions recommended by M. Richerand, and formerly by J. L. Petit; and to excision ac- cording to the method of Celsus, and as Boyer has practised it, they never should be countenanced except for those cases Avhere the varices form painful masses, or have given place, by their de- generation, to tumors that can only be removed by extirpation. J. But above all other considerations, is it not allowable to have recourse to the mildest of these operations ? For has not humanity a right to recoil from the danger of phlegmons, erysipelas, purulent abscesses, phlebitis, and all other accidents Avhich have more than once folloAved in the train of the operation? Why should Ave not confine ourselves to a laced stocking or to a roller bandage, which securely supports the parts Avithout making the patient in- cur any risk ? These objections are more specious than solid. It is incorrect to say that varices left to themselves involve no dan- ger. M. Girod, (Journ. Gen. de Med., t. XIX., p. 65,) in 1824, satisfactorily established this, and Petit (Mercure de France, Nov., 1743, p. 2418,) had already shoAAm the danger of rupture of varices. Two patients of Avhom Lombard (Plaies Recentes, &c, 229) speaks, died from the effects of it. Chaussier has related an in- stance of the rupture of a varicose vein in a pregnant Avoman, which speedily caused death. Murat has given the case of a washerAVoman, in whom death took place from the same accident. In 1827, a statement was made at the Academy of Medicine, of a man in whom it had a similar fatal termination. In 1819, I saAV a countryman perish from the loss of blood tAventy-four hours after rupturing a varix. The death of Copernicus is attributed to this cause. MM. Reis, Lacroix and Lebrun, (Nouv. Bibliot. Med., t. II., p. 275,) have each made knoAvn a similar fact. A pregnant woman to whom M. Forestier was called, also ran the greatest degree of danger. Those bandages or gaiters that are recommended to every one require care and precaution; they incommode more than is gene- rally thought, give rise to excoriations and exudations, (suinte- ments) on different parts of the limb and are not, therefore, so per- fectly free of inconvenience. Madame Boivin cites a case of a young Avoman who could produce a miscarriage at pleasure, by applying a bandage to her varicose legs. Those eczemas 'too 388 NEW ELEMENTS OF OPERATIVE SURGERY. in fine, and those eruptions (dartres) and ulcerations so difficult of cure, which are almost always produced as soon as the patient takes any exercise, and which inspire terror to the surgeon as well as to the persons who are afflicted with them, can it be said they have never caused death in a single instance, nor never given origin to any dangerous disease, nor made it necessary to ampu- tate the limb ? On the other hand, if it be admitted that after incision of the veins, there sometimes supervene phlegmonous inflammations, and engorgements of various kinds, and that phlebitis also may be produced, it is not the less true that all those accidents are rare, that for the most part they are easily subdued, and that moreover, we may almost always prevent them, if after the simple incision such as I have described it, we take the precaution while inflam- mation is to be apprehended, to keep the limb enveloped in a com- pressing bandage from its extremity to its root; the presence in fact, of the varices themselves, endangers the liability to such acci- dents as much perhaps as the operation does. § II.—New Methods. We possess, after all, at the present time, processes more simple than the preceding, to effect the obliteration of superficial veins. The experiments upon the acupuncture and ligature of vessels, which I described in this work in 1830 and 1832, brought about re- sults which have since been adopted in practice. M. Davat and M. Fricke have proved, as I also have done, that a needle or a thread passing through each varix, and left for some days, is suffi- cient to effect its occlusion. I have myself devised a plan Avhich is yet more simple. In place of perforating the vessel with the needle, I seize it, and raise it up in a fold of the integuments, with two fingers, in order to pass a pin below it, and form a kind of tAvisted suture, or one of circular construction. The vein is thus strangulated between the body of the pin, Avhich should be strong, and the skin which the thread tends to divide backwards. We may thus place from ten to twenty pins in the same sitting, or at intervals of a few days, upon the principal varicose branches. No dressing is afterAvards necessary. If we cut off the points of the pins, or apply a piece of linen or a containing bandage, it is only to prevent the possibility of the patient wounding himself while turning in bed. I remove the pins on the sixth, eighth, or even tAvelfth day, according as the vein appears more or less com- pletely obliterated. The puncture closes soon, and in a few days after, the patient may recommence walking. When the portion of the skin included between the pin and the thread forms an eschar, we must Avait for its separation, and treat the wound afterwards as for a burn of the fourth degree. Nevertheless, Ave mnst not count on the efficacy of these opera- tions, which can be performed only upon patients whose deep- seated veins have preserved their natural condition, and where the OPERATIONS REQUIRED FOR VARICES. 389 patients themselves desire the operation, and that the varices have produced effects that are calculated to interfere Avith the functions of the diseased part, or to compromise the general health. The cure at best, is rarely complete. The anastomoses soon reproduce the varices, and at most, prudence suggests that we should confine our- selves to the obliteration of the branches which are in the neigh- borhood of the ulcer or the eruption Avhich alone have caused the patient to ask for relief. I have already performed on one hundred and fifty persons the operation which I have described ; and up to the present time, no accident of a grave nature has occurred. A very small circumscribed phlegmon is the most serious one I have noticed. More circumstantial details, however, will be given upon this subject in the following article. Article II.—Varices in particular. Although varices of the loAver limbs have almost exclusively attracted attention, all the other regions of the body are not less liable to be affected Avith this kind of disease. Wedel, (Col- lection Academique; partie etrangere, t. VII., p. 450,) speaks of varices of the upper extremities which gave place to dangerous hemorrhages by their spontaneous rupture. I have tAvice seen the arms, fore-arms and hands covered with varicose enlargements (bosselures.) A young man admitted into the hospital of La Charite in 1838, had from his infancy a varicose tumor (un peloton de varices) as large as the fist, between the angle of the jaw and clavicle on the right side of the neck. M. Champion informs me that he has seen a young lady Avho had a varix of the size of a small egg, under the tongue. I have met with a young person who had one of the size of the thumb under the superciliary ridge. I have in fact seen one in a man of about thirty years of age, situated upon the course of the sagittal suture, and which appeared to be connected with the longitudinal sinus in the falx of the brain. Baillie, Alibert and M. Huguier (These de Concours, p. 19) have given instances of them upon the cranium or jugular vein. Vari- cosities upon the nose, eyelids, and the entire face are far from being unusual. The chest also is frequently the seat of them. But the hypogastrium, the external genital organs, and the lower ex- tremities are nevertheless their favorite localities. If it is true that in the hypogastric region the sub-cutaneous or deep-seated veins may acquire a volume so considerable, and in- tertwine (enlacer) and fold themselves in such manner as to resem- ble numerous leeches gorged with blood, as I have seen in three instances, it is also true that such varices scarcely ever create any solicitude either in the patient or the surgeon. In treating of hernia I shall speak of the danger which results from such varices Avhen they spread in the neighborhood of the groin, or are prolonged in the form of cylinders or tumors as high up as the umbilicus. We find in Theden (Neue Bemerkungen, etc., t. II., chap. 5, p. 75) an instance of aneurismal dilatation of the veins of the belly, 390 NEW ELEMENTS OF OPERATIVE SURGERY. which appeared to have no influence upon the health of the patient. Theden also speaks of a vena cava whose dilatation might have given rise to the belief of a hernia of the heart. If operations are not practised upon the veins of which I have been speaking, it is not because the obliteration of these vessels, however enlarged they may be, are in reality dangerous. I have elsewhere given an in- stance of a vena cava descendens (superieure) obliterated by a tumor at the apex of the chest. Dance (Nouv. Bibliot. Med., 1828, t. I., p. 451) speaks of a similar obliteration, Avhich was accompa- nied by that of the subclavian veins and the azygos, without there having been any oedema or infiltration above. In the patient men- tioned by Wilson, (Exper., t. II., p. 336,) this obliteration had caused only a slight oedema in the face. The external iliac veins were obliterated in a patient who had never been attacked Avith dropsy, which case has been published by M. Manec (Nouv. Bibliot. Med., 1827-28, t. I., p. 451.) Descot (Affect. Loc. des Nerfs, p. 124) mentions a case of the same kind from Beclard. We are indebted for another to Baillie (Anat. Pat/ml, p. 20-22). In the case of M. H. Berard (These No. 23, Paris, 1826) it was the vena cava ascendens (inferieure) which was closed; so that there is scarcely perhaps a vein in the animal economy whose obliteration, and that without endangering life, has not been noticed. In some regions, where they are found exter- nally, the varices might in truth be reached by the operations which have been described above; but in reality Ave occupy ourselves only with those of the legs and the external genital organs. It fol- lows, therefore, that in treating of particular kinds of varices I shall confine myself to those of the abdominal extremities and the scro- tum. § I.—Varices of the Lower Limbs. All that I have said of varices in general, applies particularly to those of the pelvic extremities; I have only now therefore to point out what there may be of a special nature in the manipulation of the operation on these organs. [Before which we take occasion to speak in this place of tAvo ex- traordinary cases of varicose enlargement, or hypertrophy of the veins of the lower extremities, Avhich have been observed in this country, and Avhich are both noAV living, one an adnlt of about 60 as observed by Dr. Mott, the other a young man of about 21 which recently occurred in my OAvn practice. There are perhaps not on record two more remarkable cases. Dr. Mott states that in his pa- tient, Avho is a person of unusually tall and erect stature, and of stout frame and othenvise perfect health, but from habit and his profession much accustomed to walk or to be in the erect position, the entire mass of venous trunks and anastomoses in the sub-cuta- neous tissues are so enormously distended, that they seem to con- stitute in each leg from the toes to the hips one general diffused encasement of venous blood and aneurismal dilatation. Were it OPERATIONS REQUIRED FOR VARICES. 391 not for firm containing "bandages in which both limbs are kept con- stantly enveloped throughout their whole extent, death would in- evitably ensue from the continual danger of exhausting hemorrhage by the spontaneous rupture which the gravitation of the blood above would doubtless cause. When the bandages are momenta- rily removed, the veins fill up to such degree as to enlarge each leg and thigh almost to the dimensions of the body of an ordinary sized man. When the bandages are on, the poAver of walking slowly, though even that is much impeded, is not destroyed. This patient is of a highly sanguineous temperament and of very florid fair skin, though very temperate and regular in his habits, and tall, robust, remarkably straight and well made in his frame, and of unusually symmetrical proportions, though near 6 feet 6 inches high. In the case of the youth, in my own practice, and Avho on the other hand is of unusually pale complexion and of delicate make and dark hair and eyes, indicative of that order of scrofulous tem- peraments, the disease is congenital, similar in some respects to the remarkable case only described by Breschet, but infinitely more ex- traordinary. The superficial veins of one leg only appear to be affected. The dorsum of the foot and the entire outer part of the lower leg are covered with their convolutions so thickly and to such extent as to resemble large worms intertAvined in every possible tortuous and serpentine shape—making a perfect net-work. But about the ankles they form large reservoirs of several inches in length and near three-quarters of an inch in calibre. One of these also crosses the patella obliquely, where it maybe seen and felt through woollen pantaloons, as large as the thumb and slightly pulsatory. It then proceeds obliquely upwards and backAvards upon the outer part of the thigh. Here on the outer part of the thigh it forms a tortuous reservoir of near an inch in diameter. When lying doAvn they all nearly disappear for the moment. The disease seems hereditary. The general health is unaffected. T.] A. Ancient Processes.—I. Compression.—When varices of the legs are treated by compression we generally envelop the Avhole of the limb in a roller bandage or a laced stocking, in order that the entire mass of veins may be supported in a uniform manner. M. Colles, however, a distinguished surgeon of Dublin, informs me that he has limited himself to making strong compression upon the internal saphena vein in the fold of the groin by a kind of circular pelote, and that he has by this means effected cures. This method appears to me so contrary to Avhat we knoAV of the progress of va- rices, that up to the present time I have not ventured to make trial of it. As hoAvever I have particularly remarked, "that the garters though tied someAvhat tight, did not ahvays increase the size of the varices, and that compression made at the lower part of the leg only occasionally causes temporary engorgement of the veins of the foot, and as M. Colles is a gentleman entitled to confidence, I shall take an opportunity to make trial of his method upon some cases that may offer. II. Excision, (l'excision.) exsection (la resection) and incisions. 392 NEW ELEMENTS OF OPERATIVE SURGERY. by the method of the ancients, or J. L. Petit, could be practised upon the legs as well as in any other region. The same remark applies to the ligature and exsection. Vesicatories employed, it is said, (Chir. des Hopitaux, t. II., p. 392. Huguier, These de Cone.,) in St. George's Hospital, London, Avould require no special direc- tions in these cases. III. Transverse section.—In order to divide the veins of the lower limb by the most simple process, it would be necessary that the leg and thigh should be in a state of relaxation. The surgeon then seizes the vein in a fold of the skin above its swollen portions; holding this fold by one of its extremities with the thumb and fore- finger of one hand, while an assistant raises the other extremity in the same manner, it is divided transversely by inserting the point of a straight bistoury near its base and under the vein, and in such manner that the back of the instrument should be turned towards the limb. Performed in this way, the operation is prompt and but lit- tle painful. To arrest the bleeding a considerable degree of pres- sure is required upon the lower end of the cut vein. Balls of lint should be applied directly, or upon linen spread with cerate at the bottom of the wound; without that the continuity of the vein might be re-established and the object of the operation defeated. There are no points upon the leg where this section cannot be performed. If the varices belong to the system of the external saphena, we are to look for the trunk of this last in the neighbor- hood of the ham. It is well to remark (Huguier, These,]). 35) upon this subject that the external saphena is often composed of two principal branches : one, ascending, Avhich belongs to the leg; the other, descending, Avhich comes to it from the posterior region of the thigh, which branches unite to form a common trunk in the popliteal space (creux.) When, on the contrary, the varices depend upon the internal saphena, it is below the knee and opposite to the pes anserinus and above the inner condyle of the femur that its section is to be made. For greater security, also, it would be advisable to divide each dilated vessel upon different portions of the leg. Without that there would be reason to fear that the innumerable anastomoses of the veins of the whole limb Avould ultimately reproduce the varices. B. New Processes.—All the neAV processes applied to varices of the legs may be referred to acupuncture, the ligature, or local com- pression. I. Acupuncture.—The researches which I made in 1829, (Read to the Institute, the 27th of December, 1830,) having proved that it required only tckeep a foreign body lying transversely through a vessel for some days to effect its obliteration, it Avas very natural that acupuncture should be soon applied to the treatment of va- rices. This method Avhich M. Fricke and M. Grossheim (Jour, des Conn. Med.-Chir., t. II., p. 221, 1834) were the first to put in prac- tice upon the living human subject, in cases of varicocele, is divided at the present time into two processes, that of M. Fricke and that •of M. Davat. OPERATIONS REQUIRED FOR VARICES. 393 a. Process of M. Fricke.—M. Fricke has not confined himself to pure and simple puncture ; if he perforates the vein Avith a needle it is in order to insert into it a thread in the manner of a seton. For that purpose the vessel is grasped in a fold of the integuments, as if it Avere with the vieAV of performing the transverse section, or we hold it firm by placing the fore-finger and thumb upon its sides. Then with a needle armed Avith a simple thread we transfix it from one side to the other. In order to be more sure of obtaining inflam- mation we may pass in this manner two or three setons through the same vein at intervals of a few inches. The operation is repeated in this manner on each of the venous trunks that we wish to oblite- rate. If we attack the trunk of the saphena vein at two different points below the knee, and at two other points on the thigh, it will generally be rendered unnecessary to transfix the other veins of the leg, unless the system of the external saphena should also be impli- cated. Each seton should then be tied separately and moved in the vein morning and evening until inflammation has supervened. We are generally enabled to remove them from the second to the fourth day. A deposit of plastic lymph is noAV effused in the neighbor- hood, the walls of the vein inflame, and it soon becomes impossible for the blood to flow there. If the inflammation is developed too rapidly, or becomes too intense, we first remove the threads and then reduce it by the ordinary means, but only in moderation so long as it continues to be local. M. Fricke has written to me (13th of November, 1835) that the treatment of varices by threads or setons has always succeeded with him, and that in his hands it has never caused serious accidents. I have myself made trial of it on twelve patients : the veins became inflamed in all. Eight of them had local symptoms only, and left the hospital apparently cured ; three others were seized Avith inflamma- tion which extended along the veins from the foot to the upper part of the thigh, and which taking on the character of a phlegmonous ery- sipelas, terminated in large purulent collections: numerous incisions in the leg, ham and thigh became necessary, and these cases caused me much alarm. I will add that one of them came back to me eighteen months afterwards, and that his varices had re-appeared. Moreover the internal saphena which had been perforated by the threads was itself again dilated. The twelfth was still more unfor- tunate ; he Avas a butcher's boy of extreme timidity, but also in excellent health. Symptoms of internal and external phlebitis, and angioleucitis soon supervened, ending in death at the expiration of eight or ten days. Since this accident I have no longer indulged the thought of re- peating the essays of M. Fricke Avho, hoAvever, in his lettter, spoke only of varicocele. Two reasons combine to induce us to reject this process: 1. It is impossible that the inflammation which is thus designedly created should not sometimes become diffused and purulent; and then all the dangers of internal phlebitis and puru- lent infection present themselves before the eyes of the practitioner; 394 NEW ELEMENTS OF OPERATIVE SURGERY. 2, on the supposition that the operation occasions no serious acci- dent, and that it effects the obliteration of the vein, it is next to cer- tain that the circulation will frequently ultimately re-establish it- self in the vessel and defeat the result of the operation. It is a process, in fact, which has nothing to recommend it but the promp- titude and facility of its manipulation. b. Process of M. Davat.—M. Davat, from researches of which he published a summary in 1833 and 1834, (These No. 93, Paris, 1833.—Arch. Gen. de Med., 2e ser., t. II., p. 5,) was led to the con- clusion that to cure varices with certainty, it was necessary to adopt the following mode:—A pin is first passed under the vein and through the skin from one side to the other. Raising up the vein by embracing this pin by its two extremities, the surgeon, provided with a second needle, transfixes the vessel itself, from the skin to- wards the deep-seated parts, penetrating thus underneath the first pin, in order to pierce again through the same vein from the deep- seated parts towards the skin, in such manner that the two metallic stems cross each other at right angles. A thread then passed un- der their extremities serves to retain the Avhole in its place. This process, which was not put in practice on the living subject until after 1835, and Avhich M. Norris, (Philadelphia Med. Examiner, April 1838, Exp., t. II.,p. 112,) says he has made trial of with suc- cess in America, is invariably successful, according to the author, and never produces serious accidents. In the memoir of M. Davat, however, there are facts Avhich disclose the danger of this method, and in the case of a man upon whom it was performed at the Hotel Dieu, in 1837, death Avas the consequence, (Landouzi, Journ. des Connaiss. Med.-Chir., 1838, p. 97.) We cannot indeed understand how a pin left through a vein, would not produce phlebitis as soon as the presence of a thread, and every one knows that phle- bitis is the principal danger in all the operations performed for va- rices. If this process, hoAvever, is a little more difficult and embarrassing than that of M. Fricke, it ought also to be more certain in its result. The tAvo pins, crossed, necessarily cause the ligature which passes under them to give a curve to the vein and to have a tendency to interrupt its continuity. There is, therefore, less chance of re- lapse by this method than with a simple seton. II. Compression.—Process of M. Sanson.—Taking his idea from a process used for varicocele, and of which I will speak further on, M. Sanson (Brioux, These No. 282, Paris, 1836,) has proposed a sort of clasp or forceps, by means of Avhich he has attempted to ob- literate the varicose veins of the legs. This forceps which the au- thor (Boinet, Gaz. Med. de Paris, 1836, p. 84,) appears to have of- ten used with success, is not to bear on the vein itself. To apply it, we endeavor to draw the vein into a fold of the integuments and place the bite of the instrument immediately below it. It results from this, that the vein is compressed by the skin which permits itself to be drawn and pulled backwards by the pressure of the for- OPERATIONS REQUIRED FOR VARICES. 395 ceps. What I have said of the return of the disease, after the use of the seton or pin, sufficiently shoAvs that this kind of compression, though simple and attended Avith but little danger, cannot have much efficacy. For which reason I have not thought it necessary to make trial of it. b. Process of the Author. The ligature upon varicose veins is, as I have said, one of the most ancient methods. But if we adopt what Paul of Egina, and those who have described it formerly, say of it, we ought first to incise the teguments in order to lay bare or isolate the vessel. In this manner,the operation is as painful and as serious, as by the different processes of excision or incision. At the present time, we have in use other kinds of ligature. Having devised my process in 1830,1 first tried it upon animals, and confined myself in the first edition of this treatise to make only casual mention of it. I employed it for the first time in 1833, at the hospital of La Pitie for varices of the legs; since that time I have performed it on more than a hundred patients. M. Franc, (These de Montpellier,Mars, 1835,) Avho on his part thought that he Avas the author of it, also extols its simplicity. 1. First Stage. This process is performed Avith a pin for each vessel. It is advisable that this pin should be strong though well sharpened, and Avith a large but smooth head. A strong and well- waxed thread is also necessary. After having seized and raised up the varicose vein in a fold of the skin, we cause an assistant to hold one of the extremities of this fold, while we stretch the other ourselves. 2. Second Stage. The parts being thus arranged, and the vein completely pushed above the fingers, which should try to'touch be- hind it, the surgeon transfixes the whole cutaneous fold with the pin, in passing it under the nails of his tAvo fingers. The vein is then situated astride the pin, which it crosses at a right angle, with- out having entered its interior. We thus proceed upon two or three points of the saphena above the knee, and upon all the veins which are found dilated along the leg or on the foot. It may be necessary to use eight, ten, or even fifteen pins, successively on the same limb, though the insertion of two or three is often found quite sufficient. 3. Third Stage. In order to complete the operation, a noose of thread must be passed upon each of the pins, in order to strangulate upon them as firmly as possible the veins to be obliterated. At first, I crossed this thread in the manner of a twisted suture, as in hare- lip ; but having found how difficult it was to obliterate the vein, so as to prevent a return, I thought it advisable to adopt another mode. At the present time, then, and since the year 1837, I place the ligature circularly under the extremities of the pin, Avhich an assistant is charged Avith raising up, while I strangulate the tissues forcibly behind it. I thus obtain three constrictions Avhich bear on three points of the vein, one Avhich the pin effects from behind for- wards, and the two others which are produced by the superior and inferior border of the circle represented by the thread, and which act from the skin tOAvards the deep-seated tissues. For greater cer- 396 NEW ELEMENTS OP OPERATIVE SURGERY. tainty still, I wait until the constriction has mortified its way through the small pacquet of tissues included in the thread; Avhich happens in the space of from six to twelve or fifteen days. If, about this pe- riod, the eschar does not come away of itself, I remove the pin and also the ligature, being well assured that at that time the vein is certain to have closed. 4. Fourth Stage. It is not the insertion of the pins which is painful in this operation ; but it is the application of the ligature which seems to produce in some patients an acute degree of suffer- ing. Nothing can be more simple than the phenomena which fol- low ; often they are limited to the mere mortification of the pelo- ton of strangulated integuments, and unaccompanied with any marked inflammation. Livid-colored phlyctenae supervene, and the skin takes on a darkish or muddy tint. An inflamed line Avhich afterwards becomes purulent and ulcerated forms under the ligature. The eschar is then isolated and separates as in a burn or contusion, and leaves exposed a sanious wound, which is cleansed and cica- trized afterwards in the manner of ulcers or ordinary wounds. Of- ten also a red, painful kernel, (noyau) having the appearance of phlegmon, is developed about each pin, at the same time that the strangulated vein becomes sAvollen and hardened and is transformed into a solid cord above and below. It sometimes happens that the inflammation proceeds on to suppuration, and gives rise to true abscesses. 5. Fifth Stage. The pins having been once placed, the operation requires no dressing, and so long as there is no acute inflammation we may allow the patient to get up and take some exercise. At a later period it may be required to use leeches or topical applications, emollients, or resolvents; and so also when the pins are removed, each region that they occupied must be treated as a small abscess or burn. It is unnecessary to add that immediately after the ope- ration the point of each pin should be snipped off by means of a cut- ting nippers, or a pair of stout scissors, and that to prevent our wounding the fingers in applying them, it is advisable to make use of a thimble or a piece of thick linen. These precautions would be unnecessary, if we had pins with the heads Avell rounded, and of a metallic quality sufficiently solid to alloAV of their being well- sharpened and reduced to a small size. (See on this subject: Hou- el, Bulletin de Therapeut, t. XIII., p.145; Dupresse, Journ. Heb- domad., 1836, t. I., p. 257 ; Bulletin de Therapeut, t. II., p. 59-62, t. XIII., p. 108, Septembre, 1837 ; Journ. des Conn. Med.-Chir., t. III.,p. 20; also May or June, by M. Helot; France Med., t. —, p. 56 ; Brioux, These No. 282, Paris, 1836.) 6. Whenever the veins are rolling and moveable under the skin, the operation which I have described presents no difficulty; but it not unfrequently happens that we find them too closely adherent against the inner side of the tibia, the dorsum of the foot, and the neighborhood of the malleoli, to allow of our raising them in a fold of the skin. In that case, we must insert the pin almost perpen- dicularly upon one of the sides of the vein, then incline it so as to OPERATIONS REQUIRED FOR VARICES. 397 slip its point underneath, and make it come out from within out- wards, upon the other side. The pin in such case should possess considerable strength ; otherwise, Ave should soon find its tAvo ex- tremities bend or raise up under the pressure of the ligature, espe- cially Avhen using the circular constriction in preference to the twisted suture. 7. A precaution also to be attended to, in all the processes to be employed for the cure of varices, is that which relates to the posi- tion in which the patient should be placed at the time of the ope- ration. In order that the veins may attain their full size and be rendered prominent, it is advisable that the limb should be held in a pendant position. If the teguments are pliant, and the sub-cuta- neous tissue but sparingly supplied with fat, this position will not interfere with our obtaining a grasp upon the veins, or in any way incommode us in the application of the pins. In individuals, how- ever, who are fat, and in whom the skin is tense, the case is very different. The veins in such persons lie close against the aponeu- rosis and the bone, and it may be impossible to grasp them in a fold of the integuments. In such cases, Ave select with care the points Avhere the pins are to be placed, while the patient is in the vertical position. We then place him in a recumbent posture, and while the limb is in a state of semi-flexion, pinch up, beWeen the thumb and fore-finger, the vein, which is recognizable under the skin by its form, resembling that of a cord, as if it Avere a woody substance. I should remark, moreover, that it is best to begin by strangling the vein around the upper pin, as the nervous filaments, Avhich might possibly be included in this upper ligature, would render the pain of the others less acute. 8. The application of a ligature to the veins, by entwining it around a pin, is an exceedingly simple operation—one that pro- duces no more pain than any of the others, that all patients bear Avithout any inquietude, and one which any person has it in his power to perform. As it is one also which mortifies and destroys a portion of the vein, it ought to be as effectual and complete as any of those that have been made trial of up to the present time. The object of all surgeons, in this matter, is to obliterate the vein operated upon; but the process of the pin accomplishes this result with as much certainty as excision, and in a more perfect manner than acupuncture or local compression. With respect to dangers, I have as yet made trial of no method which is attended with fewer than this. Out of more than one hundred patients, upon whom I have employed it, not one has died. I may add, also, that not one of them Avas exposed to any real danger. The worst that did happen, was an external phlebitis and a phlegmonous kernel. The only objections that might be made to it, are, that of incur- ring the risk of passing the pin between the integuments and the vein, and thus completely frustrating the object in view; also that of alioaving in some cases the vein, at a later period, to reacquire its permeability, where the strangulation has not been applied at a suf- ficient distance. But these inconveniences belong, in a still greater 308 NEAV ELEMENTS OF OPERATIVE SURGERY. degree, to acupuncture by the process of M. Fricke, and also to the method of M. Davat. The different modes of incision, also are not free from these objections. ' c. Process of M. Reynaud.—A surgeon of Toulon, M. Rey. naud, (Gaz. Med., 1837,) after modifying the process by the liga- ture Avhich I have described above, adopted, in some of his cases the folloAving method: Passing a needle, with a thread properly waxed, under the vein and through the skin, he proceeds to tie the tAvo ends, and to fasten them by a boAV-knot upon a roll of diachy- lon plaster, or a small graduated compress. This appears to be the indirect (mediate) ligature Avhich Chaumete (Exchirid. de Chir., p. 278) and Lombard, (Plaies Recentes, etc., p. 249,) employed, and of which these authors had already given an imperfect description. As the thread may be untied at pleasure, it alloAvs of being again tightened every day or other day until the vein is divided. There is no doubt that we may succeed by operating in this manner • but the obliteration of the veins by this mode of division is so diffi- cult, that there is always danger of their continuity and circulation being re-established. The process by the pins, which is at least as simple and as easy, and which also allows of increasing the con- striction at pleasure, appears to me to be still preferable. C. I must not, hoAvever, terminate this article, without adding, that such processes are still too new to enable us to judge of their comparative value, with a full knowledge of the causes. On the other hand, practitioners should bear in mind that varices of the legs are far from ahvays yielding to these modes of cure. Thus, though one of the dilated veins may be obliterated, three or four others will soon reappear. Owing to the branches of the ex- ternal saphena communicating with those of the internal saphena, and the superficial veins anastomosing with those that are deep seated, the venous system of the abdominal extremity represents a vast net-work, Avhose circulation it is next to impossible to inter- rupt, and which, whatever we may do, will always render the complete success of these various operations exceedingly problem- atical. [Varicose Veins.—The mediate or indirect application of the ligature to varicose veins, the saphena and spermatic for example, as lately much commended by Dr. Pagani, (Gazetta Medica de Mi- lano, November, 1844; see also Cormack's Lond. & Edinb. Month. Journ. of Med. Sc, Feb., 1845, p. 140,) and which consists, after passing the ligature by a curved needle under the raised vein and fold of the skin as above described, in tying the knot on a small rouleau of linen, placed on the skin, is a very ancient practice revived, so far as relates to this indirect pressure on an artery, (See this present vol., also vol. I.) In varicose veins, the pressure thus sought for externally is equally well, if not more completely and effectually obtained by the sub-cutaneous, and, as it may be called, the sub-venous methods, combined, as practised by M. Velpeau. Through means of the direct linear pressure, sub-cutaneously ex- ercised by the pin from within and outwards, and the correspond- OPERATIONS REQUIRED FOR VARICES. 399 ing pressure from the circular threads externally, embracing the head of the pin, our purpose of the gradual division and cicatriza- tion of the vein is much better fulfilled. Varicose Veins in the Pudenda.—Death by Hemorrhage.—The pudenda themselves are not free from a varicose enlargement of their veins, which in one case, related by Dr. Hesse, (Medicinische Zeitungvon Preuss., Verein No.48, Nov. 30,1842 ; also, Cormack's Journal, Feb. 1843, p. 158-159,) proved fatal by sudden and ex- cessive hemorrhage, near the termination of a fifteenth pregnancy. The Cesarean operation was performed a feAV moments after the death of the mother, but the child was also dead. The uterus ap- peared to be ensanguined, and in the left labium, which was large and flabby, there was an opening of about half an inch in length, from Avhich black tar-like blood was readily expressed. This opening led to numerous venous canals, both laterally and inwards, deep into the perinaeum. The husband informed Dr. Hesse that his wife had long labored under a great enlargement or swelling of the left labium, which, as it appears, was nothing more than an enormous varix. T.] § II.—Varicocele. The word varicocele, employed, like that of kirsocele or cirsocele, to designate the dilatation of the veins of the scrotum, though ap- plicable to every tumor formed by veins, is, however, exclusively confined, at the present time, to the dilatation of the veins of the spermatic cord. Varicocele, though a very common disease, and noticed principally betAveen the age of fifteen and that of forty, that is, during that period of life when the genital organs possess all their activity, is almost always confined to the left side. It is rare, however, that serious consequences result from it. The swell- ing, inflammation, suppuration, and atrophy of the testicle, which some authors have attributed to it, do not happen in one in a hun- dred, perhaps in not one in a thousand cases ; and I can scarcely comprehend hoAV modern surgeons should have so far misconceived this subject, as to consider a disease dangerous which, in 99 cases out of 100, constitutes but a slight infirmity. The usual incon- veniences are only a slight uneasiness, a draAving-down pain in the loins and in the groin or scrotum, together with a slight numb- ness of the testicle. To which I may add, that an immense ma- jority of persons who are affected with it, may have it all their lives Avithout being aAvare of it. These preliminaries being established, we shall be enabled to understand to what extent varicocele may be subjected to surgical operations. A. Ancient Methods.—All the old processes which I have point- ed out under the article of varices in general were applied formerly to varicocele itself. Cauterization with slender-pointed rods of iron and Avith chemical caustics Avere made use of at the time of Celsus, (De Re Med., lib. VII., cap. 32.) The ligature, excision, incision, 400 NEW ELEMENTS OF OPERATIVE SURGERY. and extirpation, Avhich also had their partisans, are likewise men- tioned by Celsus. Pare (Liv. VIII., chap. 18) proposes that af- ter having passed a double ligature underneath, we should fix one of the threads at the upper and the other at the loAver part of the varix, in order to incise the veins between the tAvo ligatures and afterwards to dress the entire wound as in the case of an ordi- nary varix. Pare (Liv. XIII., chap. 30) expresses himself to the same effect about varices of the legs. Cumano (Mouton, Diet, des Scien.-Med., t. V., p. 261) had recourse to extirpation as well as ligature upon the varicocele. After having made a long incision through the integuments and penetrated to the cord, this surgeon isolated the tumor which he tied above and below before excising a large portion of the scrotum. The upper ligature came away on the twentieth, and the lower on the thirty-fifth day; but the wound was not completely cicatrized before the fiftieth day. I. Like Celsus and Paul of Egina, Delpech, (Lancette Francaise, t. III., p. 24,) laid open the scrotum, exposed the cord, isolated it, and tied or incised its veins. By this method he cured, it is said, six cases out of seven ; but abscesses and sometimes death were the consequence. It is also known that Delpech, (Gaspard, Theses de Montpellier, 1832,) Avho sometimes confined himself to introduc- ing and securing a piece of sponge under the dilated veins with strips of adhesive plaster, was assassinated by a patient upon whom he had thus operated. II. M. Warren Avrites to me that he has often excised or tied va- ricocele with success, and M. Moulinie (Bulletin Med. de Bordeaux, 1833, p. 57,) who has no apprehension of incising the tissues even from the inguinal ring to the loAver part of the scrotum in order to tie the dilated veins of the cord, and to divide them above, main- tains, as does also M. Rima, (Gaz. Med., 1737, p. 234,) that this mode is still preferable to all others. In fact it seems very clear to me, that the accidents which have been imputed to all these me- thods have been singularly exaggerated ; that inflammation and ab- scesses of the scrotum are, with some rare exceptions, all the re- sults that they can in any case produce. If, therefore, Dionis, and in our own time, Boyer, (Malad. Chir., t. X., p. 233,) and all dis- creet surgeons have rejected them, it is less on account of their real danger, than because of their insufficiency, or the benign character of the disease. III. As to the proposition to lay bare the cord, in order to tie the spermatic artery, which M. Bell approves of, and some surgeons (Arch. Gen. de Med., t. XIX., p. 461, 462, 614,) have practised, which M. Maunoir has performed for sarcocele or to excise a portion of the vas deferens, as has also been done by MM. Morgan, (The Lancet, 1828, Vol. I., p. 251,) Lambert and Key, (Ibid., Vol. II., p. 476 ;) it is an operation the propriety of which we have no need of discussing at present while treating of vari- cocele. IV. Castration, which is an operation that Celsus reserved for cases where the testicle itself was the seat of varices, and which OPERATIONS REQUIRED FOR VARICES. 401 Boyer (Malad. Chir., t. X.,p. 234) also sanctions where varicocele becomes in reality a serious disease, cannot in the present day be indicated in any presumable case, except that of complication. V. In fact, if surgery were to confine itself to the ancient pro- cesses, it were better to abandon varicocele to itself, and to mode- rate its development and inconveniences by means of topical as- tringents and good suspensories. The exceedingly rare cases in which it manifestly has a tendency to produce disorganization in the testicle, would be the only ones Avhich would justify the con- scientious surgeon in having recourse to such operations. B. JSew Processes. In devising the new processes of which I have already previously spoken, surgeons at the present time had vari- cocele chiefly in view. These processes, now six in number, are those of MM. Davat, Fricke, Breschet, Sanson, and Reynaud, and that of my OAvn. Based upon my researches, on the acupuncture of veins, they have come into practice in the following order:— My experiments made in 1829, were published in 1830, (Gaz. Me"d. de Paris, Janv., 1831 ; Lancette Francaise, Janvier, 1831 ; Journ. Hebd. Univ., t. I. et II.) M. Davat made his known in 1833, (These citee, 1833,) and it appears to have been in the be- ginning of the year 1834 that M. Fricke introduced his mode into practice. M. Breschet (Gaz. Med. de Paris, 1834, p. 33,) commu- nicated his to the Academy of Sciences in January, 1834. Mine had already been applied to the human subject about the close of the year 1S33. It Avas not until 1835 or 1836 that M. Sanson (Boinet, Gaz. Med., loc. cit.,) proposed his forceps. Finally, in the year 1S37, we have the process of M. Reynaud, (Gaz. Med. de Paris, December, 1837.) These processes, though originating from a common source, differ so much from each other, that there is no necessity of discuss- ing their priority. I. Process of M. Fricke.—In order to perform the operation pro- posed by M. Fricke, the patient is placed on his back, unless it should be advisable that he should be kept in the erect posture or upon his knees for the purpose of increasing the dilatation of the veins. The surgeon then proceeds immediately to search for the principal varices of the cord. Having seized them with the thumb and forefinger of the left hand, he inserts through them an ordi- nary needle, or as M. Fricke advises, a needle made expressly for this purpose, and armed with a single thread. If the vein is long we pass the needle through it a second time an inch higher up or loAver down, and we do the same Avith each of the other veins whose size appears to be enlarged. The threads remain there in the form of setons for one, tAvo or three days. We then remove them in order to prevent too active an inflammation. During the time the patient remains in bed the scrotum is supported upon a small cushion and kept covered with resolvent or emollient appli- cations, according as the inflammation should appear to be more or less active. This process, which M. Fricke had already employed success fully upon 38 patients when he Avrote me in 1835, appears to be 402 NEW ELEMENTS OP OPERATIVE SURGERY. liable to a number of objections. In inflaming the interior of the veins which penetrate directly into the abdomen, it incurs the risk of producing a phlebitis which it might not be possible to control and Avhich might speedily prove mortal. Moreover varicocele is never constituted of a single vein, and the tissues of the scrotum are too moveable and too supple to enable us to be perfectly assured Avhen we have placed setons in the veins, that Ave have perforated all of them and that none have escaped. In fact the circulation might evidently be re-established in some of the veins themselves that have actually been transfixed, and thus alloAV the varicocele to be reproduced. So also the needle may miss the veins we Avish to hit, the per- meability of those it has traversed may be afterwards re-established, and if phlebitis should supervene it is of course exceedingly dan- gerous. This then is a process which should be rejected. II. Process of M. Davat.—M. Davat, like the surgeon of Ham- burg, first seizes the veins of the cord with the forefinger and thumb of the left hand. He then inserts under them a first pin transversely, then a second through the vein in such manner as to make it pass under the first pin before its point emerges on the op- posite side, so that we form in this manner a cross, one of whose branches twice transfixes the vessel. If some of the veins at first have escaped they are treated in the same manner. Nothing re- mains but to introduce a sort of ligature under the pins so as to strangulate the vessels. It does not, hoAvever, appear that M. Davat has yet applied his process to the treatment of varicocele. He has hitherto employed it only for the veins of the leg; but it is liable to the same objections as that of M. Fricke. Nor should we have more certainty of transfixing all the varicose veins of the cord Avith the pin than with a needle or seton, and it is evident that one of these bodies exposes as much to internal phlebitis as the other. The only advantage in the process of M. Davat might be in thus associating a sort of external constriction Avith acupuncture, the possible chance of strangulating the veins Avhich have not been pierced, and perhaps, also, of thereby restraining the progress of the phlebitis. It is, hoAvever, singular that M. Davat Avho had used my process alone in the year 1831, as the first stage of his own, (Petit, Journal de Med. et de Chir. Prat, (fee, 1831,) has since persisted in rejecting it as insufficient. (These citee, p. 24.) III. Process of M. Breschet. M. Breschet employs*neither setons nor pins (Gaz. Med., 1834, p. 33) for the cure of varicocele. The method of this surgeon consists in strangulating all the dilated veins together Avith the envelopes of the scrotum, by the branches of a species of forceps. This forceps designed after the manner of that which Dupuytren contrived to remove the salient angle (eperon) of the intestine in artificial anus, has undergone a modification by M. Landouzy, (Jour, des Conn. Medico-Chir., Mars, 1838,) which renders it at the present day exceedingly simple. To apply it we commence by isolating the veins in the cord as completely as possible from the vas deferens and spermatic artery. Placing the OPERATIONS REQUIRED FOR VARICES. 403 extremity of the branches (des plaques) of the instrument betAveen these two orders of bodies, Ave immediately approximate them to- gether by means of a screw or ring so as to compress and embrace the varicose bundle only. The whole is thus left in place and the patient kept at rest. The compression is afterwards increased each day, until it is no longer possible for vitality to be maintained in the portion of tissues which has been strangulated. The forceps is not to be removed except with the eschar. The loss of substance which results from this, and which in the first process of M. Bres- chet sometimes exceeded tAvo inches in length, leaves a Avound which gradually diminishes and cicatrizes after the lapse of six weeks or two months. With any kind of forceps whatever applied upon these princi- ples we necessarily interrupt the continuity of the veins, and as they are all strangulated, we have thereby a fair prospect of effecting a radical cure of the varicocele. M. Landouzy (Journ. des Conn. Medico-Chir., 1838, p. 88) avers that more than 100 patients have been cured in this manner. The forceps of M. Breschet hoAvever is annoying to the patient; an eschar so extensive endangers ery- sipelas, phlegmon, and abscesses in the scrotum, Avhile there results from it an enormous ulcer of great length and difficult to heal. Nor can Ave perceive why phlebitis might not occasionally be produced by it, or why the testicle and the generative function have less to apprehend from this operative method than from the others. It is certain that some of the patients who have submitted to it and have come to consult me, make great complaints against it. Moreover this process with all its apparent simplicity has much analogy in fact to that of Cumano; and if it is to be regarded as one of the most efficacious, there is room at least to hope that Ave may dis- cover others that are more simple. IV. Process of M. Sanson.—Being desirous, above all things, of avoiding the danger of phlebitis, M. Sanson proposes to obliterate the vein by the concretion of the blood, much rather than by an actual inflammation. The forceps he uses is so constructed that the extremity of its points exercises a compression stronger than the rest of its branches. It results from this that the varicose bundle (rouleau) is found to be confined by it in a fold (bourrelet) of the integuments, and compressed only to the degree required to prevent the blood from passing through it. This fluid having ceased to cir- culate, solidifies, contracts adhesions, and ultimately blocks up com- pletely the strangulated veins. As, by this method, Ave have nei- ther eschar nor wound, the process of M. Sanson would be infinitely superior to that of M. Breschet if it was equally effectual; but I am convinced that it Avould not enable us to procure a permanent obliteration of the veins. So long as the vein has neither been divided nor inflamed in its interior, the blood Avhich closes it has a tendency to be re-dissolved; gradually it becomes fluid, and in a short'time Ave find that the channel of the vessel is reopened. Some- thing, in fact, more effectual is required to obtain a radical cure of varicocele. I have seen but one patient who had been treated by 404 NEW ELEMENTS OP OPERATIVE SURGERY. this kind of forceps: he was a student of medicine, and the varico- cele, at the end of tAvo months, had resumed its former size. V. Process of M. Reynaud.—When we wish to adopt the method of M. Reynaud, Ave gathef together, as in the processes above described, all the varicose veins in a fold of the integument in order that we may introduce behind them a strong ligature by means of an ordinary curved needle, which pierces the skin twice. For greater security it. Avould be advisable to pass in this manner two ligatures at about an inch apart. We then tie them firmly upon a small graduated compress, a piece of linen, a rouleau of diachylon or a dossil of lint; and in order to be able to relax or tighten them at pleasure, we fasten each of the ligatures by a sim- ple bow-knot. It happens necessarily that the ligature, by the con- striction Avhich it produces, divides the strangulated veins from be- hind forwards. After that takes place, it is to be removed, and this completes the operation. There is nothing more to do than simply to dress the wound which results from it, and to await the cicatrization. The process of M. Reynaud has more simplicity and despatch, and less danger than that of M. Breschet; and I have no doubt that it may, and will often, succeed. Nevertheless, the section of the veins by a single ligature, is too nearly analogous to their divi- sion by the bistoury, not to incur the danger of the re-establishment of their continuity, and the reproduction of the varicocele. By means, also, of the intervention of the small cushion recommended by M. Reynaud, the section, and likewise the obliteration of the veins, must necessarily be much retarded and difficult to effect. Nevertheless, this process is one of the best that has been devised. VI. Process of the Author.—Struck, like most other practition- ers, with the uncertainty or the dangers presented by the ancient modes of treating varicocele, I asked myself the question in 1830, if it might not be possible to substitute for them the method Avhich I had made trial of on animals, with the view of obliterating the vessels. The conclusion I had arrived at, that a pin, needle, thread, or any foreign body whatever, left at rest from one to four days transfixed through a vein, arrested the circulation there Avith as much certainty as a ligature, naturally led me to try the processes which MM. Davat and Fricke proposed at a later period. But recoiling before the dangers of phlebitis and purulent infection, I conjectured that the venous bundle, (pacquet veineux,) strangulated upon a pin, might not be less efficacious, while at the same time it would be a protection against such results. a. Position of the Patient.—The patient may either stand in the erect posture, rest upon his knees, be seated, or lie down. This last position, preferable in every other respect, has the inconveni- ence of not permitting the varicocele to be so prominent. It is ne- cessary that the scrotum should have been previously shaved,. The surgeon commences by identifying the vas deferens, which, situated in the rear of the cord, presents itself there under the form of a hard, elastic and regular stem (tige) of the size of a crow's quill OPERATIONS REQUIRED FOR VARICES. 405 and the compression of which causes a pain similar to that pro- duced by any pressure upon the testicle. b. First Stage.—Having satisfied himself upon this point, the upper part (racine) of the scrotum is seized behind, while care is taken that the thumb and forefinger have a firm hold upon the vas deferens, and that the veins in front remain free. With the thumb and forefinger of the other hand we then draw towards us, and isolate the venous bundle while approximating it more and more to the integuments, in such manner that, being thus temporarily transformed into a sort of membrane placed edgeAvays (de champ) on the side of the scrotum, it encloses the veins in its anterior mar- gin, and the vas deferens in its posterior border. The fingers re- maining fixed betAveen these two borders, serve as a point of sup- port for the passage of the pins. An assistant seizes and holds one of the extremities of the tegumentary fold betAveen the two orders of organs mentioned, while the operator holds the opposite ex- tremity. c. Second Stage.—Having besmeared the point of the pin with some unctuous substance, the surgeon inserts it transversely under the veins, and as near as possible to the anterior portion of the cu- taneous border, and passes immediately a noose of thread under its extreme points. Another pin is placed in the same manner, at the distance of an inch from the first, and the operation is termin- ated. Although we may, if necessary, commence by the pin aboAre, I would advise, nevertheless, to insert that beloAV first, since it is always easier to find at this place, the space which separates the veins from the vas deferens, than it is in the vicinity of the ring. It is, moreover, important to avoid the tAvo extremes, of placing them too high or too Ioav, or too near or too far apart; if too near the testicle, the loAver pin might pierce the tunica vaginalis, and give rise to a purulent inflammation, or an abscess in this small sac; if too near the ring, Ave might run the risk of not entirely separating all the veins of the cord, and of alloAving some of those behind to escape; if too near together, the two pins might ultimate- ly form but one wound, which would then be too large and too difficult to heal; to place them at a greater distance apart than I have recommended, Avould require them to be fixed too near the testicle below, and too near the inguinal canal above. d. Third Stage.—As I have said in the article Varices, I have long been in the practice of strangulating the veins upon the pin, as in the suture for hare-lip ; but in the fear of not effectually ob- literating the vessel, I have adopted the plan of employing circular strangulation for varicocele, as well as for varices in general. An assistant consequently seizes the pin by its tAvo extremities, and raises it with sufficient force. If he is afraid of pricking himself, or if the operator requires more room, the fingers of the assistant may be replaced by an erigne Avith a double blunt hook. In what- ever manner the pin may be raised up, it is necessary to flatten doAvn on the sides the tissues Avhich it embraces. A cord of two or three threads waxed together, is immediately placed first above, 406 NEW ELEMENTS OF OPERATIVE SURGERY. and then brought below the pin. Its two portions being passed like a simple knot, one over the other, are then drawn together with force, in order to strangulate circularly all the parts behind the pin, which latter by this means projects forward, drawing with ft a noose of vessels. The point of the pin being snipped off by means of a cutting nippers, the operation is finished. It is also a matter of little consequence whether its head is turned in this or that direction. e. Fourth Stage.—We may, if so disposed, withdraAV the pins at the end of five or six days, and then leave the wound to cicatrize; but it is more secure to Avait until all the strangulated tissues are separated under the form of an eschar. During that time, the pa- tient may go about and pursue his ordinary mode of life. If the inflammation should be moderate, it is not even necessary to make any topical application to the scrotum. After the fall of the eschar, the ulcer which results from it should be treated like a burn in the fourth degree. The whole of the treatment by this mode lasts nearly a month, and the eschar comes away, or may be removed, from the tenth to the twentieth day. /. Fifteen patients, (September, 1838,) affected with varicocele, have been submitted by me to this operative process ; they have all been cured. There are four of them whom I have seen re- peatedly, and one of these Avas operated upon in 1834. They have not the slightest appearance of a return of the disease, and in none of them did internal phlebitis occur. I have twice seen abscesses form in the vaginal tunic, and that when I have placed the lower pin too far doAvn. In two others, the cord assumed considerable development and hardness about the ligature, which was caused in one of the cases by violent excesses in his diet, and in the other, probably, because I had deemed it advisable, for greater security, to strangulate the tissues again on the thirteenth day. These ac- cidents, which Avere unattended with any other results, were re- lieved without sensibly prolonging the period of the final cure. One patient only, a young man who was almost an idiot, and who left the hospital at the moment when the inflammation had reached its highest intensity, because I insisted that he should stop jumping all day in the court-yard and drinking to excess, Avent off without my ever being enabled to know Avhat became of him. g. In fine, I can conceive nothing more simple than this pro- cess. The operation, Avhile it is exceedingly easy, is finished in a second of time, and causes scarcely the slightest pain. If we re- move the constriction as soon as the veins appear to be obliterated, the patient may'be free by the eighth day. If, to be better assured of a radical cure, we Avait until the strangulated tissues are detach- ed, there will be no room to doubt of its efficacy. It is a method, therefore, more convenient in its application, both for the patient and the surgeon, than that of M. Breschet. As to the accidents it may cause, they are evidently the same as those of any other mode of strangulation ; in this respect it is proper to arrange this method in the same class with those of MM. Reynaud, Sanson, and Bres- OPERATIONS REQUIRED FOR VARICES. 407 chet. A thrust of the pin and a turn of thread constitute the Avhole operation. VII. None of the modern methods of compression appear, up to the present moment, to have been followed by formidable acci- dents ; while those by acupuncture, or incision of the veins, have frequently caused death. A fundamental difference, then, exists between these tAvo orders of operative processes. By compression, either as M. Reynaud understands it, or with the forceps of M. Breschet or M. Sanson, or by the mode that I prefer, the coats of the veins inflame upon their exterior only ; and their walls being held for a considerable length of time in contact, become adherent, and ultimately blended together, before the purulent secretion has had time to establish itself upon their interior surface. It is alto- gether the reverse in acupuncture or incisions. Here the patholo- gical process Avhich it is designed to bring about, establishes itself at the first—not on the external, but on the internal surface of the vein ; from whence it follows that the pus, if any is formed, may mingle with the blood and infect the system. I should, however, remark, that internal phlebitis of the scrotum, spermatic cord, and penis, which I have often observed under circumstances disconnected with varicocele, has never been followed by that train of symptoms of poisoning which accompany it every where else. Can there be, in those regions, a particular arrangement of nature to prevent purulent infection ; or were not the cases, observed by me, those of exceptions to the general rule ? Certain it is, that the puncture of the veins of the cord does not appear to have been attended, in the hands of M. Fricke, with those internal accidents which it has fre- quently given rise to when it has been applied to the veins of the limbs. [Varicocele—Obliteration, Ulceration and Wounds of Veins, &c. J. L. Petit (Du Varicocele, et de sa Cure Radicale, par le Docteur J. Helot, Archiv. Gen. de Med., Sept., 1844, p. 3) mentions a case of varicocele in which the bunches of dilated veins of the cord and scrotum, had acquired in their aggregate volume the size of a child's head! In regard to atrophy of the testicle Avhich some have asserted to be a consequence of varicocele, the observations of MM. Breschet, Landouzy and Helot (Loc, Op. cit., p. 5) only go to shoAV that the testicle on the side affected is softer and somewhat diminished in size. Another constant symptom according to M. Landouzy (Op. cit.) is an abundant cutaneous exudation from the side of the scro- tum affected, and sometimes also a species of eruption, says M« Helot, on the corresponding part of the thigh, (Ib.) The general opinion entertained, and Avhich is corroborated bv the observations of MM. Morgagni, Sir Astley Cooper, &c, and also by those of our author, M. Velpeau, (Vid. text supra,) that varicocele is far more frequent on the left than right side, because 408 NEW ELEMENTS OF OPERATIVE SURGERY. on the right side the spermatic vein enters the vena cava ascendens in a direction almost parallel Avith the axis of the vessel, i. e., with the course of the blood, while the left spermatic vein empties into the emulgent at a right angle, i. e., in a direction perpendicular to the current of the blood Avhich comes from the loins, is contested by M. Helot. So also does this author deny the alleged predispo- sition to varicocele on the left side, because of the compression made on the operative vessels on this side by the stercoral matters accumulated in the iliac portion of the colon, as Callisen (t. II., p. 112) and J. L. Petit pretend. The ccecum, according to M. Helot (Loc. cit., p. 11,) ought to have a similar effect on the right side, in which location however varicocele is exceedingly rare. In rela- tion to the pressure of these faecal matters on the veins of the cord, their effect too, says M. Helot, ought to be more pernicious when the patient is in a horizontal position, the reverse of which is the fact. Besides, a collection of these matters and constipation are not common in young men, who are the most frequent subjects of vari- cocele. He nevertheless admits the prevalence on the left side, but confesses his ignorance of the cause. Delpech even denies that varicocele is observed among young men, except in rare instances. M. Helot asserts that he is satisfied from the observations he has made at La Charite under MM Velpeau and Ricord, that it oc- curs most frequently between the ages of 10 and 35, which agrees with the experience of M. Landouzy, (Loc. cit., p. 13.) Varicocele consists more, M. Helot thinks, in the abnormal development of the venous branches than in the dilatation of the principal trunks. He does not consider it proved by any means that masturbation and excessive venery are a frequent cause of this disease, nor that it is more frequent in hot climates; since M. R. Marjolin in his Thesis (1837) establishes the fact that 60 out of every 100 in France have it to a greater or less degree. M. Helot also doubts with M. Ricord if blenorrhagic epididymitis be a common cause of varicocele. It is true however, he thinks, that Araricocele as M. Blandin asserts (Diet, de Med.) may be transmitted by an heredi- tary predisposition. A diagnostic mark is the power of separating with the fingers each of the varicose cords, Avhich are semi-fluctu- ating, knotty, and resembling a bunch of leeches, all upon, but dis- tinct from, the testicle. He disapproves altogether of preventive surgical operations, and advises to leave the disease to itself or a suspensory. The great point is to know when to operate and when not—nor should an operation ever be undertaken except in a case of extreme necessity which very seldom happens. The annoying pain must be subdued by palliatives, and is no more a reason for a surgical operation than the pain of corns is for amputating the toe. When palliatives fail, and the tumor is enormous, and the pain so intolerable as to disable the patient from attending to his pur- suits, and where the accidents are serious and imminent, there only is an operation justifiable. In a case where a varicocele of inconsiderable size but of long OPERATIONS REQUIRED FOR VARICES. 409 standing, in a gentleman of education and otherwise of sufficient moral firmness, had by the continuance of pain greatly impaired his general health, and caused a permanent melancholy or hypo- chondria, Dr. Mott at his earnest solicitations was induced to re- move the testicle on the side affected, which brought about a radi- cal cure and entire restoration of strength and spirits and general health. Process of Rolling up the Veins, (l'enroulement de veines,) a New Process for the Cure of Varicocele, proposed by M. Vidal de Cassis.—M. Vidal, having adopted the process of M. Reynaud, modified it in the following manner : a thread of silver was passed by means of a needle behind the spermatic cord in its fold of skin, and kept well separated from the vas deferens. This thread Avas knotted upon a small roll of bandage acting as a cushion; a canula was adjusted above the knot which answering to the stick of the old artery compressor, served from time to time to increase the constriction, or to diminish it Avhen the pains Avere too severe. Towards the 15th day all the veins were cut by the thread, and to remove this, all that was necessary Avas to wait for the ulceration of the integuments, or to divide the cutaneous bridge under which the ligature was situated. After employing this mode for some time he abandoned it as objectionable because of its not effecting a perfect cure, but on the other hand exposing to a return of the dis- ease ; since it interrupts the venous circulation at a particular point only of the spermatic cord, so that the circulation may thus be re- established in the obliterated veins. He now proposes the foliow- ing method, (See account of his memoir, Bull, de Therap., Mai, 1844.— Archiv. Gin. de Med., Sept., 1844, p. 108, &c.) 1. A [strong] silver thread is passed behind the cord by means of a needle, as in the process of M. Reynaud as modified by M. Vidal. 2. Another silver thread [of less size] is passed in front of the cord in the same manner and through the same openings. The venous bundle is thus placed between two threads, under the skin, [constituting a sub-cutaneous ligature. T.] 3. The two threads are tAvisted together at each of their ex- tremities ; " as this torsion is continued the tavo threads are more and more tightened, and tend to form a cord Avhich makes a certain degree of resistance. This metallic cord, in turning on its axis, makes traction (entraine) during its movement of rotation, upon the parts included between the tAvo threads which compose it. The veins are by this means rolled up upon this double thread, after the manner of a rope upon a capstan. The greater the number of turns made the higher the testicle mounts upward, while the laxity of the cellular tissue of the scrotum favors the movement of ascension." 4. Finally a small roll of bandage (petit globe de bande) is placed upon the skin, and the two ends of the rolled up metallic cord are fixed upon this plug (tampon) by another torsion, then a canula is passed underneath, as in the process of M. Reynaud modified as above by M. Vidal. 410 NEW ELEMENTS OF OPERATIVE SURGERY. It will be better, M. Vidal says, to allow the threads to cut through the skin, for Ave shall then not only have a division of the veins of the cord at different heights, but also that of the superficial veins, running between the cord and the skin, the strangulation of Avhich presents another obstacle against a return of the disease. M. Vidal appears to think that the radical cure of varicocele should be attempted in all cases, inasmuch as its continuance occasions more or less pain, and great fatigue from exercise, and sometimes serious inflammation, atrophy of the testicle, impotency, (fee. On the other hand, the editors of the Bulletin de Therapeutique, com- menting upon this process, think that in a great majority of cases patients are made quite comfortable and free of pain, by properly contrived suspensories, [See in Vol. I. of this American Edition, a suspensory used with great advantage at the Seaman's Retreat, New-York. T.] While the surgical processes of a ligature upon the spermatic cord are known in two or three instances, (and it has happened probably in several others,) to have caused death by phlebitis or other accidents ; [in one case death by tetanus. T.] Considering, therefore, the general harmlessness of this disease, surgeons prefer the palliative mode, or, if an operation is to be re- sorted to, they would recur then, and not till then, to the processes of MM. Gagnebe, Ricord, Reynaud and Vidal. It is due to our author, M. Velpeau, to say that at the sitting of the Paris Academy of Medicine, Aug. 6th, 1844, (Journal des Con- naissances Medico-Chirurgicales,Seyt. 1st, 1844, p. 126,) he, as one of a commission to Avhom the memoir of M. Vidal above-mentioned had been referred, reported upon this new process of enroulement de veines, in which report it is stated that two of the committee had examined, at the Hospital of Lourcine, two patients upon whom M. Vidal had operated with success by his method. The reporter adds, however, that the process is not so simple as those that are known; that it is not more dangerous than the processes of MM. Breschet and Reynaud, (of Toulon ;) but that it is at present im- possible to decide if it exposes less to a return of the disease. M. Curling (London Lancet, June 15th, 1844, p. 388) has cured several cases of Varicocele by making pressure at the external ring by means of the moc-main truss, whereby the gravitation or hydro- static pressure of the blood in the dilated spermatic veins Vas prevented. Excision of all the lower part of the scrotum, preserving to it its natural, oval convexity downwards, is another mode recently made trial of for the cure of varicocele, under the expectation that the permanent retraction obtained by the curtailment and diminution of this envelope, would effectually keep up the testicles, and ulti- mately by its compression, cause the varicose venous bunches of the cord to resume their normal calibres. The idea appears to have first suggested itself to our author, M. Velpeau, many years since, from having noticed the salutary contraction of the scrotum produced by the cicatrix left after an accidental sloughing of the teguments in a case at La Charite, in Avhich M. Velpeau had ope- OPERATIONS REQUIRED FOR VARICES. 411 rated on the varicose veins by his process Avith pins. However, he accords (See Report in the Clinique Chirurgicale in the service of M.Velpeau, a la Charite, in the Journal des Connaiss., &c., de Paris, Decemb., 1844, p. 223, &c.) the first conception and the priority of the operation of excision of the scrotum to M. Bransby Cooper of London, about the year 1840. From seeing a case at Paris, which had been operated upon by M. Cooper, though leaving a bad ci- catrix, M. Velpeau was induced nevertheless to make trial of it at La Charite. If, hoAvever, Ave are to believe the statements in the report of M. Velpeau's Clinique, as furnished to the Journal des Connaissances, (loc. cit.) but which, from the rather acerb tone in which the commentaries of the anonymous reporter, M. A. G.,are couched, must be received, we think with caution, M. Velpeau had at that time, viz., up to Nov. 14,1844, performed this operation on three patients, in all of whom the contracted scrotum had again become elongated by the weight of the testicles and enlarged veins, in fact reproducing the disease in as bad a state as ever. It is due however to our author, to state his mode as it is therein given, (loc. cit.,) of performing Avhat he denominates the English Process. The patient being laid on his back, the surgeon seizes the lower por- tion of the scrotum, and raises it up vertically, so as to crowd the testicles back, Avhich he does without any difficulty, upon the pubis, in order to remove them out of the way of the instrument. He then stretches in a transverse direction the fold of scrotum which had been just raised up, and does this Avith such force, that it rea- dily becomes transparent to the light. The limit beyond which the excision is to be made, is established either by means of the fore-finger and thumb of an assistant, or by two sounds, one on ei- ther side, which compress the fold of scrotum betAveen them, and are kept firm upon it by having their extremities made fast. A few lines beyond this curved line of demarcation are inserted at short distances from each other, ten pins ; and on a line a short dis- tance beyond these again the bistoury rapidly makes the required excision, the thread for each pin being fastened around its extre- mities the moment after the knife has cut beyond the point Avhere it is inserted. The sutured parts are then dressed with the perfo- rated linen spread with cerate, and a compress and appropriate bandage. The cicatrization is usually completed in a few days. Pathological Diagnosis to be obtained from Varicose Veins.—It would, a priori, as it seems to us, be a rational pathological infer- ence to assert that Avhere the venous trunks externally become hy- pertrophied on the abdomen to the extent that they sometimes do, though incomparably less so than on the loAver extremities, that this disorganization resulted from some internal organic difficulty and obstruction ; the same as the hemorrhoidal dilatations, tumors, and bleedings indicate to a certainty more or less organic derange- ment of the liver, lungs, and other viscera. Thus Ave find a case related (London, Guy's Hospital Reports, October, 1844,) of a carpenter, aged 36, Avho, after many excesses, Avas received into the hospital for ascites, and in the right side of 412 NEW ELEMENTS OP OPERATIVE SURGERY. whose abdomen the superficial veins had acquired the size of the finger. Death occurring shortly after abstracting a large 'quan- tity of a clear greenish liquid, shoAved an enlarged liver, but espe- cially an enlargement of the right kidney, which Avas four times its normal dimensions, and filled Avith fungosities and tubercles of brownish, reddish, and yellowish color ; while the vena cava as- cendens was filled to the extent of 6 or 8 inches with a similar fun- goid substance, extending into the right auricle, with thickening and degeneracy of the coats of the cava and other marks of exten- sive degeneration throughout the principal venous trunks of the ab- domen. M. Guerin, in remarking (Gaz. Med. de Paris, June 7, 1815, Tome XIII., p. 363,) on the paper of M. A.Berard, (See our abrege of this paper supra, under arteries,) in the Archives Gen. de Med., (Janvier, Fevrier, et Mars, 1845,) on a new form of aneurismal varix, in Avhich an aneurismal intermediary tumor is formed much more frequently, M. Berard thinks, than authors suppose, between the vein and artery,observes that the close juxtaposition (intime ac- collement) of those two vessels, (an anatomical condition indispens- able for their simultaneous lesion to take place,) renders it difficult for us to comprehend the ulterior development of an aneurismal canal between them. M. Guerin also adds that the gradual disten- sion, in the form of a pouch, of the cellular tissue between the cica- trix of the skin and the wound of the superficial wall of the vein, seems to be a phenomenon much more in relation with what we know of the organization of these parts. Wounds of the Veins, &c.—The Lateral Sinus of the Brain Ulcerated.—Mr. Syme, in a communication to M. Liston, which the latter surgeon referred to at a meeting of the Royal Medical and Chirurgical Society of London, April 11,1843, (Cormack's Journal, Oct. 1843, p. 945-6,) states that he tied the carotid in a boy, for bleeding from the ear after suppuration. The patient died, and an opening was found into the lateral sinus just above where it passed into the internal jugular. Mr. Bloxam (loc. cit.) has also seen a case of an abscess communicating with a vein. Obliteration of large Venous Trunks, Vena Cava, SfC—Dr. Pea- cock exhibited to the Anatomical Society of Edinburgh, at their meeting, Dec. 20th, 1842, (Cormack's Journal, Feb. 1843, p. 170,) a specimen of complete obliteration of the vena cava ascendens, taken from a woman aged 47, who died laboring under general dropsy and hematemesis. The lower extremities were edematous, the left lung diminished, and bound doAvn by fibro-cartilaginous ad- hesions, the heart healthy, the liver small, and covered with a net- work of dilated veins, which also ramified upon the abdominal surface of the diaphragm, the kidneys atrophied, and in an advanced stage of granular degeneration, and the veins in the substance of the uterus and in the broad ligaments distended by hard decolorized coagula, which were also found in the iliac veins, and in the vena cava ascendens, as far as the sulcus hepatis. At this point the trunk of the vena cava Avas impervious, and converted into a hard white cord of about the thickness of the little finger. The coats OPERATIONS REQUIRED FOR VARICES. 415 of the vein and its different branches were thicker and firmer than natural, and its canal throughout Avas contracted. The clots were regularly laminated, somewhat resembling the fibrinous layers of an aneurism, and adhered to the sides of the vessel. The coats of the vein became gradually thicker as it advanced towards the heart, till the two sides entirely adhered. The obstructed portion extended from the point of entrance of the hepatic veins, to im- mediately below the right auricle. The vena azygos, as well as the spinal and lumbar veins, were greatly distended. These ap- peared to have been the channel by which the circulation was main- tained. From the net-work of dilated veins which existed on the liver and diaphragm, Dr. Peacock conceived that the portal system assisted in facilitating the backward Aoav of the blood. There was no enlargement of the abdominal veins. He considered the immediate cause of the obstruction or obliteration to be inAamma- tion of the vascular coats, (i. e. phlebitis.) Remarks.—If the entire mass of blood that returns to the heart through the ascending cava, constituting at least three fourths, if not more, of all the venous blood of the body, inasmuch as it com- prises nearly all that comes from below the clavicles, can be thus totally cut off for (as it must have been) a very considerable period of time, to alloAV of such obliteration to take place—it is, we con- ceive, an a fortiori argument in favor of the ultimate practicability of yet preserving the life of the patient when a ligature has been placed upon the arteria innominata, which furnishes perhaps only one half the supply furnished to the neck, upper extremities, and head. This interesting case of Dr. Peacock, furthermore, estab- lishes the important fact, that even so large a venous trunk as the cava ascendens, laboring under all the disadvantage of walls or coats of great tenuity and weakness, when compared with arterial trunks of corresponding calibres, may nevertheless undergo the complete process of agglutination, consolidation, and obliteration. This, therefore, is another acquisition from pathological anatomy, in favor of the entire success which it is hoped may one day attend the operation of the ligature on the arteria innominata and all other great arterial trunks. Rupture of the Right Internal Jugular into an Abscess.—As one of the evidences of the necessity of early preventing or removing all pressure by tumors, abscesses, &c, upon tissues so crowded as those of the neck are Avith large arterial, venous, and nervous trunks, and other vital canals, as the thoracic duct, trachea, oesophagus, &c, we may, as a suitable illustration under the head of veins, in ad- dition to what has already been said by the author on a still more important subject, viz., phlebitis, pus, and air in veins, &c, instance the case related by Mr. Alexander King of Glasgow, (Cormack's Lond. & Edinb. Month. Journ. of Med. Science, March, 1843, p. 1, &c.; the case belonged to Mr. John BroAvn, surgeon,) of death in a boy, aged four years, in consequence of an actual rupture of the right internal jugular into an abscess Avhich had formed in this part of the neck after an attack of scarlatina. This abscess was 414 NEW ELEMENTS OF OPERATIVE SURGERY. preceded, as is common in scarlatina, by an extensive tumefaction of the oblique chain of sub-cutaneous lymphatic glands, extending from the parotid to the scapular extremity of the clavicle. It broke of itself on the 16th day, by a small opening through which the contents of the abscess were freely evacuated, so that the swelling gradually subsided, until on the third day after this, blood Avas found to ooze from the aperture in a full stream. The Avails of the ab- scess were very tense, and the tumor now about the size of a hen's egg was larger, the mother said, than before; it occasioned par- oxysms of coughs and dyspnoea, and then became more tense and prominent. Pressure on the carotid did not alter its size, but on the tumor itself, brought on a fit of coughing immediately, without appearing to displace any of its contents. The pulse extremely quick and feeble, and occasionally intermitting; countenance pale and blanched. Pressure to the tumor by compresses and bandag- ing, in order to facilitate coagulation, was attempted; but, as it brought on incessant coughing, it was first abandoned, then tried again ; but the tumor continued to increase the evening of the same day the surgeon had been sent for, on account of the hemorrhage. The tumor, in fact, now interfered so much, by its size, with respi- ration, that the bandaging had to be again relaxed; but upon re- moving this altogether, in order to proceed to an examination, the child was seized with a violent paroxysm of coughing, during which the anterior wall of the tumor gave way to the extent of two square inches. A thin coagulum, about the size and thick- ness of a crown piece, was ejected, followed by an immense gush of blood. " I instantly," says Mr. King, " introduced the first two fingers of my right hand into the opening, and surrounded the fin- gers and the tumor with cloths, and very little blood was afterwards lost, although my fingers could not get either to the upper or lower orifice, in consequence of the lower part of the tumor being covered by the parotid gland and sterno-cleido-mastoid muscle. When my fingers were first pressed into the abscess, I felt blood flow freely downwards from above, and propelled upwards with a great force, during each forcible expiration. A state of syncope followed in a few seconds, and he expired shortly afterwards." Dissection was made ten hours after death. The swelling had entirely disappeared, and the skin which had previously covered the tumor, had contracted in every direction, so that it could hardly be conceived that so much distension had ever existed. The tumor from the lobe of the ear downwards was divided into two sacs, which communicated very freely. The one extended below the digastric muscle and parotid gland, and to the base of the skull; while the other had the parotid gland for its posterior wall, the sterno-mastoid muscle for its external, and the platysma, fasciae and skin for its anterior wall. Dividing through the parotid, which was sound and healthy, and the posterior belly of the digastric, a dis- tinct view of the course of the hemorrhage Avas obtained. Nine tenths of an inch (continues Mr. King) of the external wall of the in- ternal jugular vein, commencing two lines below the base of the OPERATIONS REQUIRED FOR VARICES. 4l5 skull and extending downwards, was completely removed, as if by a sharp scalpel. The external wall, and even the margins of the opening, Avere perfectly healthy, and of the normal pearly white color. The common carotid was also perfectly healthy ; so were the walls of the abscesses and all the surrounding tissues. Remarks.—A case so unparalleled could scarcely have been di- agnosed by any one. The attempt at a ligature would probably have ended fatally by hemorrhage before the lesion could have been cut down to and secured above and below it; while compres- sion was defeated by the regurgitation or reAux of blood from the right side of the heart during the paroxysms of the coughing. Nor, (as Mr. King says,) could the ligature have been applied to the wounded vessel between the laceration and the base of the skull. Add to all Avhich, the child, had the laceration been free- ly exposed, would probably have suffocated on the spot, from unavoidable inhalation of air into this large venous trunk. So no blame could any Avay attach to the surgeons. Professor Fer- gusson of London, (See M. Liston's recent memoir on a variety of False Aneurism) relates a somewhat similar case. In this also no operation was resorted to, because of the debility of the child, which died suddenly from hemorrhage. On dissection, the blood Avas found to have proceeded from an ulcerated opening in the lin- gual artery near its origin from the carotid. Such facts should indeed, as Mr. King says, impress surgeons with the extreme danger of opening as is so often recklessly done, ab- scesses in the neighborhood of large vessels. Scrofulous Abscess with Perforation of the Jugular Vein, and death. —Dr. Hoffman, also (Caspar's Wochenschrift, March 30th, 1844— quoted in Cormack's Journal, July 1844, p. 632,) relates the case of a child aged five, in whom scarlatina was followed by abscesses in the chain of sub-cutaneous lymphatic glands, on the right side of the neck, and Avhich glands, on both sides of the neck from the pa- rotid to the clavicle are, as is Avell known, and as we have already said, usually found involved in severe inflammation and tume- faction in that form of eruptive fever. Though a certain suspicious tremor and bruit accompanied the fluctuation of the tumor, it was nevertheless punctured, when a copious stream of blood immedi- ately issued out and revealed the true nature of the mischief. At first the discharge was of a dirty red color, doubtless from the ad- mixture of pus, but soon changed to pure blood, terminating in a few minutes in death, notAvithstanding the compressing means used. The corresponding external jugular vein was found perforated like a sieve to the extent of three quarters of an inch of its calibre, the portion of the vessel above and below this point, being also disco- lored and soft. The abscess being situated over the vein had in fact extended to its Avails and perforated them. Ossification and obliteration of the Vena Porta.—M. Gintrac re- lates a case received in the hospital at Bordeaux, (Jour, de Med. de Bordeaux, quoted in the Gazette Med., de Paris, March 1844^ and Cormack's Lond. fy Ed. Journal, July, 1844, p. 621,) also la- 416 NEW ELEMENTS OP OPERATIVE SURGERY. boring under ascites, like the one above and with dyspnoea, palpita- tions, and abnormal sounds of the heart. After death there Avere found the following appearances on dissection : the heart of large size and the lining membrane of the aorta reddened and containing cartilaginous deposits ; the liver pale, small, and with irregularities upon its surface ; the gall bladder occupied by a moderate quantity of thin yellow fluid, and the gall ducts natural; but the vena porta above the point of junction of the splenic and superior mesenteric veins, was filled by an old and pretty firm clot adhering to the lining membrane, and of a dark color. At the same point the coats of the vein presented several osseous laminae of an angular form. They Avere situated betAveen the inner and middle coats and slightly adherent. All the veins of the abdomen communicating with this vessel, Avere gorged with blood and varicose. M. Gintrac thinks with good reason that the ascites was the consequence of the obli- teration and ossification of the vena porta, and remarks that though this obliteration Avas complete, yet the secretion of bile was not sus- pended, but only altered, Avhile the nutrition of the liver had evi- dently been arrested, and that consequently the blood of the vena porta seems to have a share in the nutrition of the liver, and not to be exclusively indispensable to the secretion of bile. Cicatrices of Arterial and Venous Wounds.—M. Amussat is sa- tisfied, from his experiments on animals, and his observations on man, (RecherchesExperimentales sur la Formation de Cicatrices Ar- terioles et Veineuses, presented to the Academy of Sciences of Paris, Feb. 20, 1843. See Journ. des Connaiss., &c, of Paris, Mai, 1843, p. 215-216,) that surgeons are too much in haste to plug up wound- ed arteries and veins, and do not depend sufficiently upon the efforts of nature. He believes, with J. L. Petit, that such wounds will, of themselves, if properly treated, frequently form spontaneous solid cicatrices. This memoir strongly corroborates the views of our au- thor in the text, especially the cases of the cure M. Velpeau relates, (see our vol. I.,) of hemorrhage and aneurismal tumors consecu- tive upon wounds of the brachial artery in bleeding; but in M. Velpeau's cases, indirect compression over the wounded part was the means employed. M. Amussat states that arterial cicatrices are never formed by the immediate reunion of the lips of the Avound of the vessel, but al- ways by the interposition of a fibrinous clot, which becomes ag- glutinated to the border of the opening, afterwards indurated and organized, and then takes all the characters of the walls of the artery with which it becomes identified. To obtain solid and permanent arterial cicatrices, we should, says M. Amussat, properly support the clot, weaken the impulsion of the heart, and preserve the part in a state of complete immobility; in a word do the same as for fracture of the bones, that is, fulfil all the conditions requisite to procure legitimate (veritable) consolida- tion. These experiments on animals, and some facts he has noticed on man, have proved, he says, that venous cicatrices are formed on man OPERATIONS REQUIRED FOR VARICES. 417 as upon animals. The only practical result to be deduced from this fact, is the necessity of maintaining a proper degree of compres- sion, for tAvo or three days or more after the Avound of the vein. In regard to the opinion M. Amussat expresses, that it had been generally considered an established fact that arteries Avould not firmly, (solidement,) [and spontaneously,] cicatrize; Ave consider this surgeon to be laboring under a great error, inasmuch as such spontaneous agglutination, consolidation and reunion, must have been familiar to every one from time immemorial, in all wounds of smaller trunks, particularly Avhen aided by direct or indirect com- pression. We perceive by the importance he attaches to a diminution of the impulsion of the heart, and to compression, that M. Amussat fully appreciates, (without, however, Ave believe, specifying it in his Memoir,) the new and successful mode of curing aneurism by these means, first made known in Dublin, by Dr. Hutton, in the year 1842, (See our note on this method above,) i. e., a year be- fore M. Amussat's Memoir was given to the public. In a more recent memoir of M. Amussat, communicated by him to the Academy of Sciences, October 28, 1844, (see Journal des Connaissances Medico-Chirurgicales, de Paris, December, 1844, p. 259, et seq.,) upon the subject of Avounds of the blood vessels, and especially the question, what are the phenomena that are im- mediately noticed at the extremities of arteries and veins that have been completely divided through by a large and transverse wound^ has, by the researches Avhich he instituted to resolve this problem, felt himself authorized to come to the folloAving conclusions :— 1. When an artery, thus divided transversely in a large Avound, :eases spontaneously to bleed, it is an error to suppose, as most per- sons do, that this is effected by a spasm, erethysm, or contraction, of the artery. 2. The cessation of the hemorrhage is caused by a physical im- pediment, a clot of blood which shuts up and completely obstructs the extremity of the vessel. 3. This gives the appearance to the cut end of the artery, of a small red conical or mamellar point, a sort of stump which is lifted up at every pulsation of the heart. It is the plugging clot, (bou- chon obturateur,) seen in animals as well as man. 4. This bouchon or plug or clot is a species of cap (capuchon) or hollow cone, agglutinated (soude) to, and identified with, the border or periphery of the artificial opening, and particularly Avith the cel- lular membrane. The arterial tube is thus in fact prolonged into the clot, and terminates in a cul-de-sac. If this conical clot is divided transversely at different distances betAveen its apex and the extremity of the divided artery, we find a hole or central canal Avhose diameter diminishes in proportion as we recede from the place Avhere the vessel was divided. This fact explains perfectly the progressive diminution ahvays noticed in the jet of the blood and also accounts for the plugging up of the artery. 5. The fact of the formation of this clot is of great importance in 27 418 NEW ELEMENTS OF OPERATIVE SURGERY. surgical practice ; for instead of searching for the gaping orifice of a divided artery, as Ave are taught in lectures and books, we must look for the clot and not for an arterial opening (lumiere) as in dead subjects after operations upon them. 6. Hence the difficulty of finding these conical projections in those who. are not familiar Avith operations on the living body and living animals, and hence the dangers Avhich ensue. The department of vivisections therefore imperatively demands the attention of stu- dents. 7. Therefore, also, Ave should not abandon too hastily the search for these pointed clots, otherwise, notwithstanding compression and tamponing, dangerous consecutive hemorrhage may occur. More recent experiments on dogs by M. Amussat, (read to the Academy of Sciences of Paris, Dec. 16, 1844.—Vid. Archiv. Gen. de Med., Paris, Jan., 1845, p. 108,) show that in the spontaneous cessation of hemorrhage after Avounds of arteries, the plugging clot (caillot obturateur) forms even in the largest trunks, as the carotids for example, though both may be divided at once. Even in this last case death is not produced immediately, but life maintained for some minutes during Avhich the animal retains all his faculties, and the spontaneous clot is formed whether the animal dies from or survives the hemorrhage. This clot is formed by tAvo separate clots, one outside (exterieur) the other interior which consists of a coagulum similar to that formed after artificial means of occlusion. (See our notes on this subject of the internal and external clot, under the head of arteries, supra.) Arteries.—Blood.—Professor Huenefeld of GrafsAvald, in his late work, (Chemie und Medicin, Sec, Berlin, 1841, p. 118,) draAvs atten- tion to the curious fact of the lining membrane of the arteries being composed of fibrinous protein, and hence not liable to be acted upon by weak alkaline solutions. Whereas if it had consisted of the albuminous protein, it could not have Avithstood for any length of time the incessant contact Avith alkaline blood. M. Velpeau, in a letter to the Academy of Sciences of Paris, in vindication of his claim of priority for his method of treating vari- cose veins and varicocele, and a copy of which has been trans- mitted by the Professor of La Charite to Dr. Mott and myself, thus expresses himself under the head of varices and varicocele; It was in the year 1840 that M. Davat (of Aix) alleged that I had availed myself of his process for the treatment of varices.- This process consists in the passage of a pin underneath the vein Ave wish to obliterate, then of a second pin which crosses the first at a right angle, and which twice transfixes (traverse) the vessel through and through and in the direction of its length. I never (says M. Velpeau) employed the process of M. Davat, and I never made any claim to its invention, although the tAvo ele- ments of which it consists are evidently based upon my researches on the subject of the acupuncture of veins, published in 1830. The proof that my process for varices does not belong to M. Davat, lies in this, that this physician himself speaks of it as follows THE LYMPHATIC SYSTEM. 419 in a memoir published by him in 1836, (Traite Curatif des Va- rices) :— " M. Velpeau, at La Pitie and La Charite at Paris, and M. Franc, at the hospital of Saint Eloi at Montpellier, have employed a method (un moyen) which, though as simple and innocent as mine, (le notre,) appears to us to be far from possessing the same efficacy. Already, in our first trials, (travail,) though we occupied ourselves but very little with this mode of compression, because we Avere aware that it had been proposed by M. Velpeau, (Medecine Operatoire, 1832,) we made known some experiments which were but little favorable to it," (p. 2.) And further, (p. 20): " to the process of M. Velpeau there is in my opinion these objections, viz., its uncertainty (infidelite) unless the constriction is made with a sufficient degree of force and con- stantly, and because, in the contrary case, of its being attended Avith as much danger as the immediate ligature." We thus see (says M. Velpeau) that M. Davat, far from claim- ing this process, does himself attribute it to me, quotes it from me, and repudiates and denounces it five or six years after I had pub- lished it. SECTION VI. THE LYMPHATIC SYSTEM. The operations required by the lymphatic system are applicable only to the ganglionic (i. e., glandular) portion of this part of the organization. But as on the other hand the diseases of the lym- phatic glands which occasionally call for surgical aid, almost all of them present themselves under the form of tumors, I shall have an opportunity of speaking of them while treating of this last men- tioned class of affections. 420 NEW ELEMENTS OP OPERATIVE SURGERY. SECTION VII. THE NERVOUS SYSTEM. Though most authors upon operative surgery have neglected to treat of the nerves, they are nevertheless liable to a number of dis- eases which often require its interposition. Among the affections of the nervous system, there are two espe- cially Avhich I cannot omit to treat of in this point of view: These are the neuromas (les nevromes) and the different kinds of neural- gia. The nature of neuromas and tumors of the nerves being still a subject of dispute Avith pathologists, induces me to consign (rejeter) them also to the class of tumors. I shall consequently at present treat only of operations which are admissible for neuralgia, in other words of the section and excision of nerves. It was natural to suppose that in destroying the continuity of the sensitive nerves, we should thus prevent the transmission of the pain to the brain, and succeed in curing the neuralgia. As the nerves on the other hand have no retractility, it was apprehended that after being divided they might reunite anew, and that their mere division Avould not be followed by any permanent relief. Ex- perience unfortunately has too well confirmed these anticipations. •It Avas on that account that the idea suggested itself of destroying a sufficient portion of the nerve to render its reunion impossible. Caustics and the hot iron recommended to carry out this recom- mendation have the serious inconvenience of making too large a cicatrix and horribly disfiguring the patient. In our times the cut- ting instrument has generally been substituted for them. By means of an incision in the track of the wrinkles (rides or ruga) of the skin, the muscular fibres or the principal vessels, we are enabled to lay the nerves bare at their exit from the bone, to divide them before they have given off any branch, and to remove a portion of them of the length of some lines. The wound cicatrizing by the first inten- tion, the scar, after the cure, is lost in the folds of the skin, and the continuity of the nerve being effectually destroyed, it seems impos- sible that the neuralgia should not be arrested. It is far from being true, however, that clinical observations on this point have never contradicted the theory. Often, and too often, the disease does not yield either to excision or incision performed in the very best manner, and there are numbers of persons who have been no more benefited by one of these operations than by the other, no more than they have been by deepest cauterizations. There was at the Hospital of St. Antoine, in 1829, a man of about 45 years of age, who, for the space of fifteen years, had been affected by a tic douleureux, and Avho had undergone successively the sec- tion and excision of all the nerves of the face, but without experi- NERVES OF THE HEAD AND NECK. 421 encing any relief whatever. As, however, more fortunate results have been stated, we may, Avhen Ave have unavailingly made trial of all other modes of treatment, and the sufferings of the patient are exceedingly acute, suggest to him the exsection of the nerves as a last resource, which it would be uncharitable, perhaps, to de- prive him of in certain cases of obstinate neuralgia. CHAPTER I. NERVES OF THE HEAD AND NECK. So common are neuralgias of the head, and so excruciating is their pain, that it has often been proposed, when all our resources of hygiene and pharmacy have failed, to have recourse to cauteriza- tion, or the section or excision of the nerves supposed to be affect- ed. There are, moreover, a great number of the nerves of the head which it might be advantageous to subject to this treatment. The chief of these, besides the branches from the cranium, are the frontal, infra-orbitar, inferior dental, the facial and some branches of the superior dental. Article I.—Nerves of the Cranium. Many authors have mentioned neuralgias established in the head as a consequence of wounds, and which have yielded only to inci- sion or excision. A young girl, for a long time subject to convul- sions, epilepsy, and neuralgia of every variety, Avas instantly cured by an incision which Pouteau ((Euvres Posthumes, t. II., p. 83, 86, 92,) made above the mastoid process, the part upon which the pa- tient had received a blow a long time before. In another patient, Pouteau had recourse, in the same way, to three incisions upon dif- ferent points of the cranium, and was not less successful than in the preceding case. The same author succeeded Avith a similar operation performed upon the cranium of a young man, aged 24 years, Avho had fallen upon his head sixteen years before. In these three cases, Pouteau confined himself, it is true, to incision, but he tamponed the Avound, and did not unite by the first intention. Article II.—Nerves of the Face. The face is the part upon which the section or excision of the nerves is most frequently performed. It is probably also the region where the operation is least apt to succeed. § I.—The Frontal Nerve. When we wish to derive all the advantage possible from the 422 NEW ELEMENTS OF OPERATIVE SURGERY. cision.of the supra-orbitar nerve, we should seize it at the moment when, as it emerges from the supra-orbital notch, it is reflected backward close to the bone, and before the outer and inner an- astomosing branches are given off from it, for the purpose of in- osculating with the surrounding nerves. In that part it is covered only by the skin, a thin lamellar tissue of cellular substance, and some pale fibres of the orbicularis palpebrarum muscle. The artery which runs by the side of it is not of sufficient size to create any apprehension of wounding it, and in the neighborhood there are no other organs that the instrument can encounter. Should we not be enabled to identify the nerve at first, all that will be required to determine its position will be, to recollect that the groove or hole which gives passage to it, is situated at the union of the inner third with the outer two-thirds of the upper orbitar arch, that is to say, at about an inch outside of the root of the nose, and that by following the border of the orbit with the point of the finger, from the nasal process to the temporal process of the frontal bone, we have it al- most constantly in our power to ascertain its exact locality. A. The operator, placed behind the patient, raises the eye-brow with his left hand, and while an assistant depresses the lids, he again makes himself sure of the position occupied by the diseased nerve, seizes a straight bistoury with the other hand, and holding it as a writing-pen, directs the point upon the internal orbitar pro- cess, draws the instrument upwards, then outwardly, and divides all the tissues down to the bone to the extent of an inch, a little above, and in the direction of the adherent border of the eyelid; he then gently separates the edges of this semi-lunar wound; fin- ishes the section of the nerve if it is not completed ; hooks up the anterior portion Avith a good pair of dissecting forceps; isolates it, and excises a sufficient extent of it to prevent the possibility after- Avards of a reunion of the two extremities. Nothing noAv remains in the way to prevent our proceeding at once to reunion of the integuments by first intention. The loss of substance Avhich the nerve has undergone, gives us, so far as that is concerned, every security on this head. As, however, the least infiltration of extraneous fluid into tissues so flexible and so easy to become disunited, as are those of the eyelid and orbit, might lead to purulent collections and dangerous inflammations, it appears to me more prudent that the Avound should be left to suppurate. We are to dress it then loosely Avith a plumasseau besmeared with ce- rate, or, if there be hemorrhage, we use the perforated linen and balls of lint, and that for the first dressing only. It afterwards requires no other attention than ordinary simple Avounds, and cica- trization is soon accomplished. B. In a patient Avho suffered horrible pain in the orbit, from a Avound of a lance in the forehead, M. Larrey (Clin. Chir.,t. I., ou Descot, Op. cit.) destroyed every symptom of tetanus by a di- vision of the frontal nerve ; and the same operation has succeeded, in one out of tAvo cases, Avith M. Warren. Hennen and M. Guth- rie, (Archiv. Gen., t. XXV., p. 94; et Mackenzie, Maladies de; NERVES OP THE HEAD AND NECK. 423 Yeux,) who, folio wing the recommendation of Beer, confine them- selves to the simple section, have not succeeded; Avhile, by uniting cauterization with it, M. Riberi (Bellinghieri, Arch. Gen. de Med., 2e serie, t. VII., p. 209) Avas enabled to cure his patient. § II.—Infra Orbitar Nerve. This nerve being more deep-seated, surrounded with important parts, and spreading out like a fan upon its exit from the bones, is much less easy of excision than the preceding ; it is also much less subject to neuralgia. Two modes may be folloAved to effect the object. A. By the Mouth.—In prolonging upwards for the space of an inch the groove which unites the lip to the jaw, Ave traverse all the upper part of the canine fossa, and reach the root of the nerve, which is found in the direction of the first molar tooth, at the distance of three or four lines beloAV the orbit. The bistoury, which should be used at first, should now, for the last stage of the operation, be replaced by the straight scissors. The principal ad- vantage of this method, which Avas practised by M. Richerand, and who went to the extent of scraping the bone Avith his instrument, is that of leaving no mark on the face ; but it has the disadvantage of allowing only of a simple section of the nerve, Avhen in fact it Avould be desirable to excise it. B. By the Face, the instrument divides, from the skin to the bones, all the soft parts Avhich compose the cheek ; and it is this, undeniably, Avhich makes it more objectionable, at least among persons of the female sex. Fortunately, however, by folloAving the natural furrows of the face, in the place of adhering exclusively, as M. Langenbeck (Biblioth. de Chirurgie, ou Nosolog. und Therap.) advises, to the direction of the fieshy fibres, it is in our power to obtain a cicatrix Avhich will scarcely be observable. I. Operative Process.—The patient should be seated, and ar- ranged, and supported as for all other operations performed upon the face. Armed Avith a straight bistoury and placed in front, the surgeon makes at the bottom of the naso-jugal furrow, that is, from the groove or a line which extends obliquely from the ala of the nose to the middle of the space Avhich separates the prominence of the cheek (pommette) from the corresponding labial angle ; he makes, I say, in this direction, an incision an inch and a half in length, commencing at the outer side of the ascending process of the maxillary bone ; he divides at first the skin only, and soon after meets the facial vein, Avhich he pushes aside outAvardly ; he then comes to fatty tissue ; then to the levator labii superioris, Avhichhe pushes backwards and inAvards ; then the levator anguli oris, under the inner border of Avhich the nerve often lies concealed, now makes its appearance. To enable the operator to separate all these dif- ferent parts, he must use a steel grooved sound, Avithout any cul- de-sac. Detaching the filaments or tissues Avhich still conceal or may conceal the nerve affected, he finally divides it very near the 424 NEW ELEMENTS OP OPERATIVE SURGERY. infra orbitar foramen, and excises a portion of it, Avhich finishes the operation. II. M. Warren, Avho has performed this operation tAvice, suc- ceeded but in one case. M. A. Berard, (Godin, Journal des Conn. Med.-Chir., t. III., p. 442,) Avho thought the T incision preferable, did not, hoAvever, succeed Avith it in the case of neuralgia in which he employed it; Avhile M. Andre, (Hamel, Theses, in 8vo, t. XXV.,) for a case of old infra-orbitar neuralgia in a lady who fell under his care, was obliged to resort to deep cauterization. § III.—Superior Dental Nerve. Being derived from the second branch of the fifth pair, the nerves of the upper dental arcade forbid the division of their trunk, Avhen they become the seat of neuralgic pain; but it is some- times practicable to attack them at the source of the disease. M. C, from the neighborhood of Cusset, was recommended to me in 1835, by M. Giraudet, now a practitioner at Tours. For fifteen years this patient had suffered from pains in the right side of his face, Avhich nothing could assuage. These pains commenced in the spot which is usually occupied by the last molar tooth. In passing my finger on this region, I thought I perceived a slight granulation, Avhich, when touched, immediately caused a violent access of suffering. There existed a possibility of obtaining re- lief by excising the region thus touched. By means of a pair of long, cutting nippers, curved suddenly and nearly at right angles on the borders near their cutting extremity, I embraced the whole posterior extremity of the margin of the jaw, and removed it at a single stroke. The pains Avere soon assuaged, and a year after- wards I received from M. Giraudet a letter, announcing the entire cure of our patient. § IV.—Inferior Dental Nerve. The inferior maxillary nerve emerges from the jaw by the fora- men mentale under the boney groove which separates the alveolar processes from the canine tooth and the first molar. A. Process of the Author.—Nothing is more easy than to reach it at this point. While with one hand the surgeon reverses the lip outAvard and backward, he incises by means of a straight bistoury in the other, layer after layer and from above doAvmvards, the tis- sues Avhich are found at the bottom of the maxillo-labial groove. The teeth just mentioned will be his guide. In a short time, that is, at some lines in depth, he encounters the nerve, and isolates it to the extent of a quarter of an inch, by removing from the jaw the posterior portion of the soft parts Avhich cover it, and then excises it in the same manner as has been said of the frontal nerve, and makes use of no dressing afterAvards. B. The bleeding however is quite troublesome by this process, for which reason M. Berard (Godin, Jour, des Conn. Med. Chir., t. III., p. r NERVES OP THE HEAD AND NECK. 425 442) preferred making a T incision reversed, laying open the Avhole depth of the tissues on the side of the chin ; it appears, also, that the patient operated upon by this surgeon was perfectly cured. To apply the red-hot iron to the skin opposite the mental foramen, as Museux (Bull, de la Fac. de Med., 1.1.) declares he has done Avith success, or immediately to destroy the nerve with caustic potash, as Andre (Ilamel, Oper. cit.) did successfully in a man upon whom Marechal had unavailingly performed the section of the dental (maxillo-dentaire) nerve, would neither be as simple nor as certain as this kind of excision. C. When the neuralgia is seated at a greater depth, M. Warren (Journal des Progres, t. XII., p. 270) has no apprehension of at- tacking the trunk of the maxillary nerve itself, and excising a por- tion of it in front of the pterygoid muscles. A crucial excision of the skin, the parotid gland, and masseter muscle, enabled him to apply the croAvn of a trephine upon the coronoid process, and by means of a probe to raise up the nerve above the dental canal, and excise about three lines of it with the scissors. The accompanying artery was wounded and tied without difficulty. The patient, Avho had been only temporarily relieved, but not cured by other exci- sions, and Avho suffered excessive pains, ceased to be troubled im- mediately after the operation, and has continued ever since in ex- cellent health. On the dead body this operation is not very difficult. In mak- ing trial of it, I have found it would be better to incise the parts in a semicircular, and oblique direction from the lobule of the ear to the border of the jaw and front of the masseter, Avhich latter it would be advisable to divide, and to raise up its fibres from behind fonvard; the trephine, applied upon the base of the coronoid pro* cess on a line Avith the sigmoid notch, falls exactly upon the nerve, and may even be made to divide it with the same stroke. D. If the neuralgia Avere seated in a single tooth, Ave might, after the plan of M. Fattori, (Rev. Med., 1825, t. I., p. 294,) trephine the side of the alveolar process, and thus destroy the filament of nerve which is implicated. But the excision of the part in such cases is at the same time more certain and more expeditious. § V. Facial Nerve. The portio dura of the seventh pair, spreading out as it does, upon almost every point of the visage, would naturally, at first sight, be supposed to be more frequently the seat of facial neuralgia than the other nerves, and consequently it is the one which has been often frequently excised. A. Its temporal-facial branch, the only one which surgery has ventured to attack', crosses the neck of the condyle of the jaw at the point Avhere the lobe of the ear unites to the integuments of the face. It is in this place that we should lay it bare. An incision slightly oblique, is made from before backwards or almost vertical,' Avhich commences at the zygomatic process, and terminates on the' 426 NEW ELEMENTS OP OPERATIVE SURGERY. posterior border of the jaw above its angle. We have to divide successively the cellulo-adipose tissue, an aponeurotic layer and some slight prolongations of the parotid gland, before finding the nerve, which is separated from the bone only by lamellar and fila- mentous cellular tissue. By this method Ave are sure to avoid the temporal artery ; and should the transverse facial artery be Avound- ed, its compression would be too easy to make the hemorrhage from it cause any disquietude. B. The other, the cervicofacial branch, being lost, as it Avere, in the parotid, presents too many anomalies in its position, Avhile the trunk itself of the facial has been considered too deep-seated, and surrounded with parts too important to think of excising these nerves. We may, as I think, Avithout rashness, appeal from this decision. C. I ha ye often ascertained on the dead body that the trunk of the facial nerve could be laid bare without danger at its exit from the cranium and before it has furnished other branches than the filaments of the mastoid, digastric, and stylo-hyoid. For that purpose, the operator has only to make a vertical incision an inch and a half long between the mastoid process and the lobe of the ear ; then in coming doAvn to (en rasant) the anterior face of the osseous projection and the corresponding edge of the sterno-mastoid muscle, a depth of 6 to 10 lines, he has to divide, layer by layer, the teguments, the cellular tissue, and the parotid gland, which latter is to be turned forward. The lips being drawn apart, we perceive the nerve at the bottom of the Avound, nearly in the middle of the space which separates the temporo-maxillary articulation from the apex (sommet) of the mastoid process, and where it seems to take a direction tovvards the border of the inferior maxillary bone. The division and even the excision of it is then in every respect as sim- ple and easy as that of the frontal, and it is clear that this section, in itself, presents all the security desirable under such circum- stances, if it be true also that- these different excisions of the nerves are, in fact, the actual remedy for facial neuralgia. I purposely suggest some doubts as to these excisions, because the facts yet as- certained are not sufficiently conclusive in their favor. If, in some cases, they have been folio Aved by a marked diminution, or even the entire subsidence of the pains, Ave have much more frequently observed that they procured no relief, or assuaged the anguish but momentarily. I have mentioned the case of a man who Avas subjected to all these operations on both sides of the face, and Avith- out experiencing any appreciable advantage from them. M. War- ren had a patient, in Avhom, after the excision successively, of the frontal, infra-orbitar, and facial nerves, only temporary relief was obtained. Boyer communicated to me a similar observation. The patient in Avhom he excised successively the four principal nerves of the face, though at first slightly relieved, was no more cured than the one of whom I have spoken. Moreover, if it be true that the frontal, infra-orbitar and mental nerves, in fact, that all the branches of the fifth pair are exclusively nerves of sensation, (sen- NERVES OP THE HEAD AND NECK. 427 sitive,) while the seventh pair is alone charged with the office of presiding over the muscular movements of the face, then is it evi- dent that the section of this last can have no other effect than to paralyze the muscles of the face, while to the other three only, must our attention be directed in whatever concerns neuralgia. Article III.—Nerves of the Neck. Up to the present time I believe no one has undertaken the sec- tion or excision of the nerves of the neck. M. H. Berard however has related to me the case of a woman Avho suffered so severely in the sterno-mastoid or carotid region, that she earnestly entreated that some operation might be performed which might relieve her of her distress; a small deep-seated tumor was perceptible which appeared to be situated upon the pneumo-gastric nerve. This wo- man, however, died I believe without having had anything done for her. Having also myself observed a nervous tumor in the same region, and Avhich appeared to belong to the great sympathetic nerve, I shall, in treating of operations applicable to tumors, de- scribe the process which is to be followed to enable us to reach down to these nerves. I may make the same remark in regard to what concerns the section of the nerves of the thorax. [Division of the Par Vagum on one side without causing death, and followed by recovery.—I understand that very recently and within a few months, Dr. McClellan, an eminent surgeon of Phila- delphia, in removing an enlarged parotid gland from below the angle of the jaw, and which had extended to some distance down into the neck, was obliged, from the par vagum on that side being embedded in the tumor, to exsect and actually take away about two inches of this important nerve Avithout producing apparently much inconvenience to the respiratory or other functions. Finding such an unprecedented result from the exsection of so important a nerve, which, as far as Ave are informed, had never before been interfered with on the human subject, but on the contrary ahvays avoided with extreme caution ; the surgeon designedly left the wound open for some days, in order that other surgeons of Philadelphia might satisfy themselves, by inspecting it, of the truth of what had occur- red. The fact is thus placed beyond dispute, that all the vital func- tions of this important pair of nerves may in living man be per- formed by one nerve alone, which could have scarcely been anti- cipated from the pathological and physiological views hitherto entertained. It is true that experiments on quadrupeds had satisfactorily estab- lished the fact that life may be sustained even after division of one of the par vagum; but never before was this fact proved, we be- lieve, on living man,until accidentally ascertained, as we have above described, by the surgeon of Philadelphia. Nevertheless Dr. Mott has ahvays scrupulously avoided Avound- ing or dividing this nerve in all his surgical operations; and is sat- isfied that such ought to be the rule in every case where it is pos- 428 NEW ELEMENTS OP OPERATIVE SURGERY. sible so to do, notwithstanding the pathological fact established by Dr. McClellan. In this case of Dr. McClellan, he thinks the func- tions of the nerve, on the diseased side, may have been interrupted, or to a certain extent annihilated, before the operation was per- formed. Its situation in the tumor in Avhich it was imprisoned and compressed, Avarrants this inference. T.] CHAPTER II. NERVES OF THE LIMBS. Article I.—Nerves of the Thoracic Extremities. § I.—The Fore-arm. We may have occasion in the arm to make the division of the radial, ulnar, or cutaneous nerves, and even that of the median nerve. A. Ulnar Nerve (nerf cubital.) In 1832 Lauth wrote me that he had practised the excision of the ulnar nerve three times in epi- leptic patients; the operation succeeded in one of the cases, but failed in the two others. The paroxysms in the first case were ushered in by an aura epileptica, while in the others this did not occur. If we wish to repeat this operation, whatever may be the indication, the limb should be placed in the same position as for tying the arteries. The parts Avould be incised in the same place and in the same manner as for this last operation. After having divided the integuments and a first aponeurotic layer, then pushed to the inner side the flexor carpi ulnaris, and divided a second fibrous layer, we should find the nerve in the form of a white cord within and a little behind the artery. After having isolated and raised it, we should excise from it a fragment of at least from two to four lines in length. If we should limit ourselves to dividing it transversely, its two ends would soon reunite and there would be nothing to hope from the operation. In a case thus treated by M. Cairoli, (Arch. Gen. de Med., 2 ser., p. 137,) Professor Viviani saw the neuralgia reappear at the expiration of a few days. In the case of a gardener, noticed by A. Dubois, (Descot, Affections Locales des Nerfs, 1825,) and Avho had the ulnar nerve above the Avrist divided by the cut of a pruning knife, the paralysis lasted but a very short time. Excision more formidable than the division as respects the paralysis which it should seem it ought to produce in the third or fourth fingers, has not, hoAvever, been always followed by it. A young man had in this manner a portion of his ulnar nerve and the corresponding artery destroyed above the wrist by an accident. A paralysis Avhich continued for six weeks in the NERVES OF THE LIMBS. 429 two fingers, mentioned, afterwards gradually disappeared. When I saw the young man again, a year after, he felt nothing more of it. B. Radial nerve. Among the examples of the section of the radial nerve, there is one related by M. A. Cooper, (Arch. Gen. de Med., 1838, t. II., p. 183,) in Avhich the operation was performed for a neuralgia caused by a contusion of the thumb, and attended with success. A similar fact is related by M. Wilson, (Swan, Ma- ladies des Nerfs, p. 117.) M. TeeAvan, another English surgeon, (Arch. Gen. de Med., loc. cit.,) has been equally successful in ordi- nary cases of neuralgia. But it was a cutaneous nerve and not the radial which M. Wilson, divided. The operation in such cases exacts precisely the same precau- tions as in the ligature upon the radial artery. Except that the in- cision should be made outside of the track of the artery, since the nerve is found nearly in the middle of the space Avhich separates the outer edge of the radius from the course of the vessel. As the radial nerve is of infinitely less importance than the ulnar, we might without any apprehension, excise a long portion of it. In a young lady v/ho was exhausted by the pain, A. Petit (Verpi- net, Journal de Med.,t. X.; Descot, p. 18) effected a complete cure in his patient by producing a large eschar by means of the hot iron applied upon a cicatrix which included the radial nerve. § II.—The Elbow. The nerves which lie in the neighborhood of the veins in the bend of the arm, have been so frequently charged with causing se- vere accidents resulting from bleeding, that early attention was di- rected to the subject of their division. It is an operation, however, which has not been subjected to any surgical rule, and one which Avas no longer thought of until M. Hamilton (Arch. Gen. de Med., 1838, t. II., p. 174) again dreAV public attention to it in 1837. * A. The Cutaneous Nerves.—The section of the cutaneous nerves has been performed by M. Watson, M. SherAvin, and also by M. Wilson to remedy accidents from bleeding. M. Crampton, hoAV- ever, in dividing for this purpose the cutaneous nerve in a young lady obtained only an imperfect cure. I. Upon the supposition that we were not disposed to operate upon the point whence the pain originated, Ave might find the ex- ternal cutaneous or musculo-cutaneous nerve above the fold of the arm between the biceps and the anterior border of the supinator radii longus, (long supinateur.) An incision, two inches in length, slightly oblique from above downwards, and from behind forwards, would, after having divided the skin, sub-cutaneous fascia, and aponeurosis, necessarily conduct to this nerve, after reaching which we should excise a portion of sufficient length. II. For the internal cutaneous (cutane interne) nerve, the inci- sion Avould require a little more caution on account of the neigh borhood of the artery. Carried obliquely from the middle of the 430 NEW ELEMENTS OP OPERATIVE SURGERY. loAver part of the biceps to an inch beloAV the internal condyle of the humerus, it should not go beloAV the aponeurosis, since the in- ternal cutaneous (cutane interne) nerve is invariably situated at this point in the thickness of the sub-cutaneous layer near the me- dian, ulnar and basilic, veins. [See a note of Dr. Mott on Avounds of the cutaneous nerves in bleeding and the operation, Vol. I.] III. The Ulnar Nerve, (nerf cubital.)—Many of the nerves of the arm have long been submitted to the operation of excision; the ulnar (cubital) alone, however, as it appears to me, has had this operation performed upon it at a prescribed point of its track. The operation was performed by Delpech (Revue Med., 1832,1.1., p. 80) in a lady who for a long time had suffered from a neuralgia which appeared to proceed from an ulcerous affection of the wrist. Hold- ing the arm in such a manner as to turn the elbow fonvard, Del- pech made an incision an inch and a half in length, betAveen the olecranon and the inner condyle, (epitrochlee,) over the immediate track of the ulnar (cubital) nerve. This nerve was soon exposed to view, then divided on its upper part, and a portion excised. The pains immediately subsided, and ultimately disappeared. The com- plete paralysis which at first took place, Vecame reduced to a slight numbness of the third and fourth fingers, which, hoAvever, retained all their mobility. If the excision of the radial (nerf radial) and the median (me- dian) has been performed upon the continuity of the arm, as M. Richius supposes, it has been in the case of tumors, of which I shall speak further on, and not. for neuralgia. As it is the tumor which serves as the guide in such cases, I have not to discuss that subject in this place. The case related by M. Larrey belongs rather to the cutaneous nerves than to the radial (radial.) Article II.—The Nerves of the Lower Extremity. The excision of the nerves of the foot, unless they should be the seat of some nodosity or tumor, could not be subjected to any fixed rules as regards a surgical operation. The case is different, however, with the nerves of the leg or thigh. § I.—Nerves of the Leg. There are four nerves of the leg which may be cut down to, and divided by the surgeon, viz.:—the internal saphena, (saphene in- terne,) the external saphena, (saphene externe,) the anterior tibial, (tibial anterieur,) and the posterior tibial,'(tibial posterieur.)' A. The Internal Saphena, (saphene interne.)—If the internal saphena should be the seat of violent and obstinate pains, as in two patients in whom Sabatier was disposed to employ cauterization, nothing would be more easy than to excise a portion of it. We should do this on the point itself from whence the suffering appear- ed to proceed, as, for example, where a cicatrix or ancient lesion of the tissues was found on the leg. If not, we should seek for the NERVES OF THE LIMBS. 431 nerve above the parts where the pains usually existed. We might reach the nerve by means of an incision an inch or tAvo inches in length made upon the track of the vein of the same name. The nerve is almost constantly found upon the posterior face of this ves- sel. Nor would there be any serious inconvenience in excising with the same stroke the vein as well as the nerve, if the surgeon should meet with any difficulty in distinguishing the former. Only it Avould be necessary in that case to apply a ligature upon the lower end of the vein, if the Avound was to be closed by first in- tention. It is unnecessary to add that this nerve, both on the foot. and as high as above the knee, follows, as in the leg, the course of the vein. B. The External Saphena (saphene externe.)—In supposing that the suffering should be confined to the outer part of the foot, or the loAver third of the leg, it would be practicable to excise the external saphena after the same rules Avhich I have laid doAvn for the internal saphena, that is, it would suffice to incise the integu- ments on the track of the vein bearing the same name, tOAvards the fibular border of the foot behind the corresponding malleolus or outside of the tendo Achillis. Higher up Ave Avould not arrive at it with any certainty, except by making an oblique or transverse incision about tWo inches long on the outer and loAver side of the calf. Cutting down to the aponeurosis, we should be enabled to recognize its trunk, the two roots of Avhich unite a little higher up. C. Anterior Tibial Nerve, (poplite externe, ou tibial anterieur.) —This nerve, supplying all the dorsal region of the foot, and tra- versing the Avhole anterior portion of the leg, may be attacked with neuralgia, or pains sufficiently acute to suggest the idea of dividing it or excising a portion of it. Nicod (Journ. de Med., Nov. 1818) says that the nervous accidents caused by this nerve becoming compressed between the fragments of bone in a fracture of the leg, caused the death of the patient. The operation, be- sides, being attended with a good deal of difficulty upon the instep and the whole anterior part of the leg, would not be entirely free from danger. I would, therefore, recommend it to be performed below and behind the head of the fibula, where the nerve loses the name of the external popliteal. The limb, slightly flexed, should be turned upon its inner side. An incision, carried from the termination of the popliteal space to the beginning of the anterior inter-osseous fossa of the leg, so as to follow the groove which separates the tendon of the biceps muscle from the root of the gastrocnemius ex- ternus, then to cross the external and anterior surface of the fibula im- mediately beloAV the head of this bone, would perfectly fulfil our in- tention. To arrive at the nerve, the surgeon would thus have to di- vide successively the skin, sub-cutaneous fascia and aponeurosis • se- parating the tissues apart by means of a sound, he Avould then disco- ver the nervous cord between the gastrocnemius externus, which lies within and below, the tendon of the biceps, which is found above 432 NEW ELEMENTS OF OPERATIVE SURGERY. and outside with the head of the fibula, and the posterior border of this bone, or of the peroneus longus muscle Avhich is seen in front. In case of difficulty, we might Avithout danger cut doAvn to the bone through the whole thickness of the peroneus itself, so that in searching from the head of the bone to eight or ten lines below, it would be impossible not to find the nerve. After raising it up on a grooved sound or an erigne, it should be excised in the same manner as Ave have said of others. Its excision at this point would have probably saved the patient of Nicod. Certain it is, that the patient operated upon in this manner by M. Yvan, (De-s- cot, These No. 233, p. 43, Paris, 1822,) Avas promptly and radically cured of an ancient neuralgia of the leg. D. Posterior Tibial Nerve, (nerf tibial posterieur.)—The excis- ion of this nerve could not be performed Avithout real danger, ex- cept between the termination of the calf and the beginning of the plantar surface of the foot; and it is behind the internal malleolus that the operation Avould be most practicable, or the least danger- ous. The leg is to be placed in demi-flexion on its outer side. The surgeon divides through the integuments, sub-cutaneous fascia, and aponeurosis, at about six lines behind the posterior border of the internal malleolus, and to the extent of two inches and parallel to the axis of the limb, in the same manner as for cutting doAvn upon the posterior tibial artery. Situated behind and outside of this artery, and in the midst of a loose cellulo-adipose tissue, this nerve is recognized by its yellow color and its size and cord like appearance. The absence of pulsation, and the difficulty of com- pressing it, enable us, moreover, to distinguish it from the vessel. Having raised it upon a sound, or secured it with an erigne, we should excise a portion of it with strong scissors, in the manner al- ready described. In performing this operation, Delpech (Lancette Francaise, t. V., p. 457-458; Rev. Med., 1832, t. I., p. 72) made his incision too' near the edge of the bone ; but the skill of the operator easily tri- umphed over this difficulty. It appears that the patient recovered perfectly. A fact to be noticed here is, that the foot, at first be- numbed and almost insensible, finally regained to a great degree its faculty of motion and feeling. It results, therefore, from this, that the excision of the anterior tibial nerve (tibial anterieur) Avould not probably cause a permanent paralysis of the extensor muscles of the toes, the loss of the movements of extension, and the establish- ment of a pes equinus, as was at first imagined. As to the section of the saphena nerves, it could only interfere with the sensibility of the integuments, and this, it might be hoped, would not be of long duration. § II.—Nerves of the Thigh. Among the nerves of the thigh, there are scarcely any other than the great sciatic whose excision could be attempted. NERVES OF THE LIMBS. 433 A. I have however read, in a volume recently published, that a surgeon, not content Avith having divided the sciatic nerve for a neuralgia of the leg, tried also to make the section of the femoral nerve ; but it was found, after death, that he had missed it. To sav that the division of the femoral nerve in the thigh ought not to be" attempted, would be entirely unnecessary, since, as all anato- mists knoAV, it divides itself into an infinity of branches, immedi- ately upon its arrival at the groin. B. As to the sciatic nerve, it is of so large a size, and it nour- ishes of itself so great an extent of parts, that the very idea of its excision, or even of its simple division, has in it something fright- ful. The sufferings from the sciatic have, on the other hand, a character so violent and of such obstinacy in certain patients, that one Avould be almost tempted to make trial of anything to put an end to them. We must, therefore, not be too much astonished to learn that the excision of this nerve has actually been performed, and that a surgeon of Italy has had the courage to recommend it. It was in 1828 that M. Malagodi (Arch. Gen. de Med., 2e serie, t. VI., p. 114) had recourse to this operation for the cure of a neu- ralgia Avhich nothing had been able to relieve. The limb was placed as in the operation for a ligature upon the popliteal artery; the surgeon then made along incision, from the middle third of the thigh to the hollow of the ham. Dividing through the integuments, sub-cutaneous fascia, and aponeurosis, he soon came between the biceps muscle, which is found upon the outside, and the semi-mem- branosus, which is situated upon the inner side. Continuing to divide the tissues layer by layer, and then substituting the end of the sound for the bistoury, he soon reached the nerve, in the form of a large cord of a slightly yellowish color. The uppermost part of the region of the ham should be preferred in such cases: 1st. Because in this place the tAvo branches of the sciatic, if it be that they have already separated, are still in close approximation to each other; 2d. Because the popliteal vein and artery, besides being ahvays deeper and situated more Avithin, are here much farther distant from the nerve than in the hollow of the ham itself. After having properly isolated the sciatic nerve and passed his finger underneath, M. Malagodi performed the section of it in the upper angle of the wound. Numerous accidents ensued. The wound was five months cicatrizing ; the limb, at first completely paralyzed, was a long time in recovering its sensibility ; but it finally regained its functions, and the patient Avas, as Ave are told, perfectly cured at the expiration of a year. I should not wish that this account would induce others to un- dertake such an operation, unless in a case of necessity ; nor Avould I even assert that it could ever be indispensable ; I would remark, only, that the case related by M. Malagodi ought to be registered and that the question merits the investigation of surgeons. 28 434 NEW ELEMENTS OP OPERATIVE SURGERY. Article III.—Excision of the Extremity of the Nervous Trunks at the Bottom of Ancient Wounds on Cica- trices. We find, among those who have been amputated or wounded, patients who complain of excruciating pains when any one touches their scars, or the end of the stump. The observations of M. Lar- rey have shown that the nerves, after amputations, in becoming agglutinated together or adherent to the cicatrix itself, are liable to tumefaction and a peculiar change at their extremities. In these cases, the constancy (la fixite) of the pains and their circumscribed extent, and the manner in which they are propagated, induce us to suppose that the excision of the parts might be calculated, in some cases, to afford relief. It is an operation, however, Avhich has hitherto never yet been attempted, and Avhich it Avould be difficult, moreover, to arrange under any established rule of operative sur- gery. M. Champion, who was tempted to undertake it upon the sciatic nerve, for an obstinate neuralgia in the stump of a thigh which he had amputated, finally gave it up. M. Palmer (Ency- clograph. Med., 1836, p. 41) had a case of convulsions and ago- nizing pains in the stump after amputation, but the excision of an inch of the fibular nerve, which protruded from the cicatrix in a state of hypertrophy, afforded but partial relief. I have no other instance at present to cite in favor of this operation. [Exsection of the Median Nerve, &c. This Avas first performed in America by Dr. Mott. Dr. Darling, demonstrator of Anatomy at the University of New York, suggests to us a mode of reaching the median nerve which, as far as Ave are acquainted, is not laid doAvn in any surgical work. It is this :— " An incision, from an inch and a half to tAvo inches in length should be made along the ulnar border of the tendon of the pal- maris longus muscle, a little aboAre its insertion into the annular hgament. The integument, superficial fascia, and aponeurosis of the fore-arm being successively divided, the median nerve will be brought into vieAV, situated behind, and rather tOAvards the ulnar border of the tendon, Avhere it may be readily distinguished from the tendons of the flexor sublimis, by its whiteness, or by pinch- ing it with a forceps, Avhen great pain will be experienced in the thumb, the index, and middle fingers. If the hand be now slightly flexed on the fore-arm, the palmaris longus may be pushed to the radial side, and a portion of the nerve be easily exsected. It is perhaps unnecessary to add, that the upper section must be made first. In cases where the palmaris longus is Avanting, the nerve can readily be exposed by making the incision three-eighths of an. inch from the ulnar side of the tendon of the flexor carpi radialis." This is certainly far preferable to, and much safre than dividing NERVES OF THE LIMBS. 435 the trunk of this nerve, high up in the arm, upon the inner side of the biceps fiexor cubiti muscle. Electro-Puncture in Neuralgia.—M. E. Hermel, (Annales Me- dico-Psychologiques, Paris, Janv., Mars & Mai, 1844.—Journ. des Connaiss., Paris, Juillet, 1844, p. 27—8,) as an evidence of the successes which electro-puncture has had in his hands, in the treat- ment of some of the severest forms of neuralgia, almost all of them lumbo-sacral and sciatic, accompanied in some instances with par- tial paralysis, gives eight cases in which perfect cures were speedily effected by electro-puncture, Avhen all the usual modes of depletion, purgation, «fec, Avere of no avail. He says nothing, hoAvever, of the still more formidable and dis- tressing forms of neuralgia, knoAvn as tic-douleureux. Neverthe- less, he is inspired with full confidence in the value of this remedy, and while he promises to supply fresh evidence thereof, meamvhile comes to these conclusions :—1, That eleclro-puncture is applicable to idiopathic or essential neuralgias ; 2, The violence of the pains is not a counter-indication to the employ of this therapeutic agent; they have never in any case been aggravated by its use ; 3, The paralysis which supervenes in the progress of idiopathic (essen- tielles) neuralgias, yields to the same treatment. Inutility of Exsection for Neuralgia.—M. Berard, has seen (Malgaigne's Manuel de Med. Oper at, 4th edit., Paris, 1843, p. 150,) an infra-orbitar neuralgia, return after having exsected three inches (nine millimetres) of the nerve, and SAvan has seen the tAvo ends of a nerve in a horse reunite, (lb.,) after having exsected a segment near nine inches long ! M. Malgaigne suggests, (lb.,) whether it might not be advisable after dividing the nerve to detach both ends by dissection, and fold them back on the trunk so as to form a noose, or to interpose be- tween the ends a small fleshy flap from the immediate neighbor- hood, the better to interrupt, when the cicatrization is completed over this, the continuity of nervous influence. M. Bonnet of Lyon, proposes in the frontal nerve to divide it freely down to the bone by a sub-cutaneous incision, (lb., 151—152.) M. Malgaigne, for the infra-orbitar nerve, prefers also the sub-cu- taneous section on the groove of the nerve in the floor of the orbit, after which he tears out the divided fragment from its groove by means of a forceps, applied to the portion of the nerve laid bare, and divided a little below the orbit, (lb., p. 153.) M. Bonnet makes only a sub-cutaneous division of the nerve, (Ib.) Amputation of the Fingers and Arm, for Concussion of the Nerves of Sense.—Amputation has been had recourse to, but Avithout any benefit whatever, in cases for example, Avhere the little finger from a mere bloAV, has Avithout any external lesion been folloAved by se- vere neuralgic pain, and finally Avasted aAvay. Dr. Wigan, in a case of this kind in a lady Avho struck her little finger against a garden roller, amputated it, but finding the distress continue in two others, amputated them also, Avith a like unsuccessful result. Neu- ralgic pain in every part of the body came on, and the patient died 436 NEW ELEMENTS OF OPERATIVE SURGhKi. a martyr, (Proceedings of the Medical Society of London, March, 1845.—London Lancet, May 3, 1845, p. 505.) Mr. Crisp proposes in such cases, (lb., loc. cit.,) the possible advantage of removing a certain portion of the nerve, from the remarkable effect known from this kind of operation on the lame foot of horses. According to Mr. Pilcher, (lb., loc. cit.) the nerves of the or- gans of sense, as of the eye, may become paralytic by pure concus- sion, i. e., by a bloAV without any ecchymosis or change of struc- ture. M. Dendy, however, (lb., loc. cit.,) has known a family, the members of which Avere so delicate, that slight pressure on the surface produced a kind of thrombus. It is difficult to determine, hoAvever, how far neuralgic and paralytic diseases of the nerves are dependent on the influence of the nervous centres, or on local causes. Surgery in most such cases seems to have less resources than internal constitutional treatment, and external applications. Remarkable Ganglionic Transformation of the Nerves.—M. Ser- res of Montpellier, communicated to the Academy of Sciences of Paris, April 3, 1843, (See Journ. des Connaiss., Sec, de Paris, Mai, 1843, p. 216,) the results of observations made by him upon a re- markable ganglionic transformation of the nerves of organic and animal life in two young men examined after death, one shown to him by M. Manec, at Salpetriere, in 1829, the other recently by Drs. Petit and Sappey. JBoth had died of_ typhoid (entero-mesen- terique, improperly so called by French writers) fever. All the nerves of the limbs, and face, and the intercostals and lumbar nerves, were occupied in their course by numerous ganglionic enlargements (renflemens ganglionnaires) of the form and external physical cha- racters of the superior cervical ganglion. The posterior branches of the spinal nerves Avere affected Avith this transformation to the same degree as the anterior branches ; Avhile the nervous branches of communication betAveen these abnormal enlargements appeared to the naked eye to be unaffected. The number of these ganglions was less on the nervous filaments of the great sympathetic, than on those of the nerves of relation of life ; but nevertheless, so consi- derable as to entirely change its aspect. The nerves that form the lumbar and sacral plexuses, the great sciatic nerves, and the two pneumo-gastric, Avere those upon which this transformation Avas the most extensively developed. For example, the great sciatic nerves, in their course through the upper part of the thighs, (le long de la partie superieure des cuisses,) had acquired the size of the hu- merus, (le volume de l'humerus,) and their external surface was completely embossed by the inequality in the size of the abnormal enlargements. In neither case did the structure of the cerebro-spinal axis, pre- sent any trace of alteration; Avhich, says M. Serres, is another ar- gument against the opinion of Gall that the spinal marroAV of man and vetebrated animals is of a ganglionic structure. Dr. Petit adds that the groove on the inner border of the ribs, for the passage of the intercostal vessels and nerves, Avas increased in width and depth; produced doubtless by the ganglionic enlargement of the intercos- NERVES OP THE LIMBS. 437 tal nerves, and Avhich, as well as the inequality of development of these abnormal ganglions generally, seemed to shoAV that the de- generation had been a long time in progression. Nervous Substitutions.—At the sitting of the Academy of Sci- ences, of Paris, Jan. 6, 1S45, (Gaz. Med. de Paris, Janv. 11,1845, p. 28,) Dr. Tavignot, in a communication on the subject of " substitu- tions veineuses," remarks that considering it noAV to be established by a great number of experiments, that Avhen a nerve is divided, and its two cut extremities are placed in juxtaposition, it recovers its continuity, and re-acquires its functions, he asked himself the question, if Avhat took place betAveen the tAvo extremities of the same nerve, would not equally happen between the extremities of different nerves when placed in juxtaposition ; to solve which pro- blem, he undertook a series of experiments, by Avhich he established the following facts:— 1. If tAvo neighboring nerves are included in the same ligature, with the view of dividing them both at the same time, there is de- veloped betAveen their four cut extremities a sort of nerve-like ganglion, (ganglion nerviforme,) Avhich is common to them, and in which the fibres of the tAvo nerves and their functions appear to be blended; 2. If the section of two nerves that are separated but a short distance apart, is made in such a manner, that the upper extremity of one is placed in contact with the lower extremity of the other, the result is the formation of a nerve which preserves its functions entire. The practicability of thus engrafting one nerve upon another be- ing established, a route is opened for new experiments calculated to give greater elucidation to the physiology of the nervous system. The fact had already been established in respect to the practica- bility of uniting, or engrafting by suture, the cut extremities of an extensor tendon of the middle finger to those of the adjoining fingers, which last thus served to execute the movements required of the wounded finger,(See Vol. I.,p. 409,410,&c.;)but Ave are not aAvare to what object of practical utility, so far as a neAV direction to, or chan- nel for, the distribution of the nervous fluid, either in neuralgia or any other disease, this engrafting of nerves could be applied. It seems to be evident that in neuralgic affections, as of the face, at least, which often involve so great an extent of nervous distribu- tion, the grafting of two adjoining nerves in the manner described, could not afford any relief to the disease. It appears that at the same meeting of the Academy of Sci- ences, (Gaz. Med. de Paris, Jan. IS, 1845, p. 46,) that M. Flou- rens claimed priority of Dr. Tavignot, on the subject of engrafting nerves, having made and published many years since a series of experiments similar in every respect, as to their character and re- sults, to those of M. Tavignot. He has thus seen effected the union of many nerves crossAvise, (reunion croisee,) for example, that of the superior Avith the inferior nerves, of the brachial plexus, and even that of the cervical nerves Avith those of the pneumo-gastric. In 438 NEW ELEMENTS OF OPERATIVE SURGERY. every case the union was complete, and in some of them there Avas a perfect restoration of the functions, (Vid. Memoires de V Academie des Sciences, Paris, Tome XIII., p. 14, et suiv., and the work of M. Flourens, entitled, Recherches Experimentales sur les Fonclions du Systeme Nervtux, &c.,p. 272, et suiv.) Influence of the Sympathetic.—Dr. Procter, in a late memoir, (Medico-Chirurgical Review, Jan., 1845, p. 112,) emboldened by the remarkable discoveries of the motor, excitor, and respiratory sys- tems of nerves, those of Dr. M. Hall on reflex-action, and on the direct poAver of the medulla oblongata and medulla spinalis over the sphincters and muscles of the body, and those of Flourens and Phi- lip, on the non-dependence of the circulation upon the cerebrospi- nal system, advances the novel and ingenious doctrine that the im- mediate duty and office of the great sympathetic and its branches is to regulate the contractility of the blood-vessels. Dr. Procter alludes to the important fact that though nerves from other sources frequently accompany arteries for a long portion of their course, they never transmit either large or small branches to them, so that their juxtaposition must be referred to some other cause than for affording facility for influencing their movements. While on the contrary, the sympathetic is emphatically the nerve of these vessels, enmeshing and penetrating them on every side, and following their minutest ramifications to their ultimate distribution. Hence, says Dr. Procter, in those great systems of organs, or great organs in which large and sudden supplies of blood are required, as the heart, sto- mach, boAvels, and organs of generation, we have the ganglionic or sympathetic system very fully developed, and in a ratio, he thinks, to the amount of blood supplied to the different organs. On the contrary, where a reverse condition of things exist, as in the extre- mities, this nerve decreases in size, and in fact often appears to be wanting. He points out also as indicative of peculiarity of func- tion, the remarkable difference in the ganglia of the sympathetic and those of the spinal nerves. In the former, the ganglia are ob- long and smooth, and the nerves come out of them like elongations or tails ; the spinal are globe-like and the nerves enter and leave them in bundles or fasciculi. Dr. Procter rationally suggests, that in debility and exhaustion of those organs supplied by the sympathetic, the tonic, stimulating treatment, directed to the restoration of the nerves themselves, Avould be most efficient, instead of the prevailing depleting system generally pursued. He alludes, in confirmation of this, to the ana- logous beneficial results produced by strychnia and the electric or galvanic influence upon functional disorders in some of the organs over Avhich the sympathetic, and that alone, has control. So the value of strychnine on paralysis, carbonate of iron in neuralgia, &c, may depend solely upon their direct action on the sympathetic and its distributions. T.] AMPUTATION OP THE LIMBS. 439 SECTION IX. AMPUTATION OF THE LIMBS. Part First.—Amputation in general. Amputations being the last resource of surgery, should not be performed but as a desperate remedy, (en desespoir de cause.) Al- ways in itself a serious operation, it necessarily involves the mutila- tion of the patient. Nevertheless, in cases which seem to require it, the practitioner, without forgetting that the aim of surgery is to preserve, not to destroy, and that Ave acquire more honor in saving a limb than in skilfully performing a great number of amputations, ought not to keep out of view that it is better to sacrifice a part than to let the whole perish, and that patients prefer life with three limbs than death with four. The necessity of sacrificing a portion or the totality of a limb must have been experienced at every epoch. It Avould seem, how- ever, that in former times this operation Avas rarely undertaken. The Hippocratists give but few details on this subject, and Celsus is the first Avho has furnished us with a tolerably accurate description of this operation. The ancients, being but imperfectly acquainted with the circulation of the blood, and ignorant of the means of guarding against hemorrhage, must have had constantly before them the apprehension of a fatal termination as often as the ques- tion came up of taking off a limb of any considerable magnitude. On the other hand before the discovery of gun-poAvder, national wars being less destructive in their tendency, naturally rendered amputation less frequently necessary than it has become since. At this early period they confined themselves to the separation of the dead parts, without touching the living tissues, and this practice Avhich Avas continued among the surgeons of the middle ages, is also recommended by Fabricus ab Aquapendente. Though the ancients rarely speak of amputation except in cases of gangrene or corroding (rongeants) ulcers, we find, hoAvever, that they had at an early period become aware of the necessity of divid- ing the tissues above the mortified parts. Celsus (De Re Med.,hb. VII., eap. 33,) formally recommended it, and Archigenes of Apa- mea appears to have performed it frequently. Ahvays alarmed at the idea of hemorrhage, they invented a thousand contrivances (at the present day forgotten,) by Avhich they could prevent it, and thus made amputation an operation so terrible that many among them preferred abandoning their patient to certain death. Some commenced with securing the vessels by inserting a ligature throuph the Avhole thickness of the limb ; others by strangulating the entire contour of the limb itself and sprinkling cold Avater upon it. The 440 NEW ELEMENTS op operative surgery. operation being finished they burnt the surface of the stump Avith a red hot iron or Avith boiling oil. Albucasis, less timid than the others, says :—" When we cannot preserve a limb we must cut it off as high up as the sound part (jusqu'au sain) since the death of the whole body is a greater evil than the abstraction of a limb." Guy (Traict. 6, Doctr. I., chap. 8, p. 469) advises that we should cut a little above the diseased tissues, " at the place where upon introducing the tent there shall be found a resisting texture and pain," (au lieu auquel on aura trouve avec la tente introduite fermete et douleur.) For that purpose the limb was first held firm by the assistants; the soft parts were then divided with a razor doAvn to the bone ; after which the lips of the wound were protected by a compress that they might not be injured by the saw ; finally the surface of the stump was cauterized with red hot iron or boiling oil. It is not certain, however, that this method Avas adopted by Guy de Chauliac, for he soon after adds :—" As for myself I envelop the Avhole mortified limb with a plaster, and I keep this on until the separation is complete, (la jointure soit fondue,) and that it falls off of itself; Avhich is more humane in the physician than if he cut it off, for Avhen it is cut off there always remains behind a grudge in the mind of the patient who thinks that it might have been pre- served to him," (Operat. cit, p. 466.) It is doubtless this passage which has given rise to the idea that Guy strangulated the limb or a bone on a line Avith the articulation by means of a ligature, in order to bring about its separation, an error which M. Dezeimeris (Diet. de Med., 2d ed., t. II., p. 479) has established in the most conclusive manner. Notwithstanding the efforts of Pare to induce the adoption of the ligature upon the vessels after amputations, Pigray, Dionis and Rossi, still prefer the actual cautery in certain cases ; but this bar- barous practice has long since been proscribed from surgery. At the time of Hippocrates (Op. cit, p. 466) amputation of the limbs was most usually performed at the joints, (articles.) This practice prevailed also among the Arabs, for we are told in their Avorks that if the disease (corruption) extends to the neighborhood of the joint, amputation must be performed at the joint itself by means of a razor or other instrument in place of the saAV, (Diet, de Mcd., 2d ed., t. II., p. 479.) The method of Celsus, though advo- cated by Gersdorf of Strasbourg, and by De Cervia a long time before, and by Maggi and some others afterwards, was however abandoned by most practitioners; insomuch so that in the seven- teenth century Botal had the courage to eulogise a surgeon Avho was in the practice of placing the limb upon the cutting edge of a hatchet, fixed in a solid position, and then letting fall upon it from an elevated point another hatchet to Avhich an additional Aveight was given by attaching to it pieces of lead. Finally, to set out from Ambrose Pare and Wiseman, the practice in this respect has entirely changed; since Avhich time amputation of the limbs has become much less dangerous. AMPUTATION OF THE LIMBS. 441 CHAPTER I. INDICATIONS. The cases that require amputation demand the most careful con- sideration, and will become, it is hoped, less and less numerous in proportion as the healing art advances, and the correct mode of treating diseases shall be more and more diffused. Article I.—Limbs almost entirely divided. If the limb is in great part separated from the body in conse- quence of the wound itself, the idea riturally suggests itself imme- diately of completing the amputation. It is important, hoAvever, not to decide upon it too precipitately; I have shown in the chap- ter on anaplasty, how many organs Ave have it in our power to re- store, Avhen there had been reason to suppose that their removal Avas indispensable. In the case of the fingers when held only by a small strip of skin, and Avhich reunite perfectly well, the question, as M. Champion says, has long since been put at rest by all practitioners. I have before me as many as thirty examples of this kind gathered from the practice of others, and I could augment the number by a dozen cases taken from my OAvn, among Avhich there was one in Avhich from the contusion with Avhich the wound Avas complicated, it Avas apprehended that the attempt at reunion Avould prove abortive. Of all these facts the most curious is that related by Bagieu, (Exam, de plus. Parties de la Chirurg., 1757, 2 vol., 12mo,) where a ring finger reunited with the nail turned round in front. The patient mentioned by Forestus, (Bonet, t. III., 140, liv. 2, obs. 51,) had had the whole hand divided with the exception of the outer and posterior portion. In that of Charriere, (Gaz. de Sante, 1780, No. 24, p. 95,) the four last bones of the metacarpus had been di- vided by the stroke of a hatchet, and were retained only by a small strip of skin near the thumb. In one of those of Bagieu, (Op. cit., t. II., p. 596,) the wound went through the entire thickness of the two last metacarpal bones. Salmon (De Artium Amputat. rar. ad- mittenda, § 19, sect. 2, 1777) relates cases in which the right fore- fingers had been bitten by an ass, and Avere nevertheless restored. Harbicht (Bibliot. Chir. du Nord, p. 188-189) relates tAvo cases where the hand Avas almost entirely cut off, in one of them by a contusion, but Avhich notwithstanding recovered. I have elsewhere cited the observations by Jung and Hoffman. In another case, (Mercure de France,1755, 1.1., p. 202 ; Planque, t. XXVII., p. 49,) it Avas the Avrist Avhich Avas restored, after having been almost en- 442 NEW ELEMENTS OF OPERATIVE SURGERY. tirely separated. In a patient of Talabere, (Ques. et Obs. Chi?-. Prae, These de 1804, p. 17, § 42, Strasb.,) all the muscles of the middle portion of the right fore-arm, the radius, and the radial and inter- osseous arteries had been divided by a sabre-cut, but were never- theless restored. An arm, Avounded in the same manner by a bul- let, was, if we may believe Forestus, restored in the same Avay by J. Carpius, (Bonet, t. III., p. 126, liv. de Forestus, obs. 24,) and Demarque (Traite des Bandages, 347) Avas no less fortunate in a patient Avho had had the arm divided by the cut of a pruning knife. The surgeon, Desire, (Bonet, t. VII., p. 528, obs. 81,) succeeded equally well in a similar case. The same occurred with a Avounded patient, treated by Seeliger, (Anc Journ. Med., t. LXVL, p. 356 ; et Bibliot. Chir. du Nord, 116,) though there Avas a considerable destruction of the soft parts; and Bordenave (Suppl. a la Chirurg. d'Heister, p. 50, art. 8, in octavo) has collected a number of facts of the same kind. The case of a foot, the greater portion of which was separated, and yet reunited, is related by Ledran, (Consultat. Chir., p. 61, plaie dermere le gros orteil jusqu'au petit.) Cartier, (Medical Facts and Observations, t. IL, London, 1792,) Avho relates a similar case, says the wound was complicated Avith luxation of the foot hiAvards, and he mentions having seen a man aged 60, with fracture and solution of continuity at the loAver part of the leg, and Avhich left nothing remaining but a small portion of the gastrocnemii or of the soleus, recover in thirty-six days. To understand what reliance Ave ought to place upon these facts, and Avhat is their actual value, I refer to the examination I have made of them under the article on organic restitutions. Article II.—Gangrene. Though sphacelus formerly was the only lesion for Avhich am- putation Avas deemed necessary, it is not in reality the one Avhich most frequently requires it, though it still constitutes one of its most positive indications. Before this can happen, it is neces- sary that the gangrene should have attacked the entire thickness of the part, and that it should at least be so deep-seated as to leave no hope of saving the principal tissues, (les elements principaux.) In its connection Avith amputation, gangrene involves a question which some moderns have attempted to solve in a Avay quite dif- ferent from that of the ancients. Pott and (before him) Sharp earnestly insisted that we should ahvays wait until the organism had arrested the progress of the mortification, before Ave should think of amputating; otherwise they contend that Ave run the risk of seeing the gangrene invade the stump, and may thus perform a painful operation Avhen there is no necessity for it. This manner of vieAving the subject, based as it is upon an accurate observation of facts, should be adopted as a general, but not as an absolute, rule. MM. Larrey, (Clin.-Chir., t. III., p. 520-553,) Yvan, (Dissertat No. 425, Paris, an XIII.,) LaAvrence, (Medico-Chir. Transactions, vol. VI., p. 184,) Dupuytren, (Lecons Orales, etc., t. IV., p. 262-265,) AMPUTATION OP THE LIMBS. 443 Gouraud, (Prineip. Op., etc., 1815,) Guthrie, Chaussier, (Bullet, de Ferussac, t. XIV., p. 362,) Labesse de Nancy, (Archiv. Gen. de Med., t. XVIL, p 307,) Macdermott, (Journ. des Progres, t. X., p. 235,) and Busch, have clearly shown that it is sometimes prudent to adopt an opposite line of conduct, and to perform the amputation before the gangrene is arrested. That this subject may be well un- derstood, it is proper to consider separately each kind of gangrene. § I.—Inflammation. It rarely happens, at the present time, that the surgeon allows inflammation to go on to the extent of producing gangrene in the body of the limbs. Deep, free, and numerous incisions, the liberal application of leeches, and large temporary blisters, mercurial oint- ment, regulated compression, and extensive dilatations, almost con- stantly arrest the progress of the evil, not only under the skin, but betAveen the muscles and in the tendinous and synovial sheaths. The great articulations only Avould constitute the exceptions, and to these I shall return farther on. Nevertheless, if the gangrene shall not have ceased, and may have proceeded to the extent of involv- ing the entire thickness of the part, the finger or foot for example, still, if it shall not appear to be complicated Avith inflammation of the large vessels above, there is good reason for amputating ; other- wise we must put it off. A young man, in the year 1824, was re- ceived at the hospital of the Faculte for a Avound under the ankle, (sous-malleolaire.) Gangrene commences ; the limb is amputated ; gangrenous patches make their appearance on the stump, and finally upon the thigh. The patient dies, and it is found that there has been phlebitis, together with metastatic collections of pus in the interior. § II.—Hospital Gangrene. The species of gray gangrene, known under the name of hos- pital gangrene, does not by any means always require amputa- tion. Ulcers around the nails are so frequently the seat of it, as to lead to the belief that there is a necrosis of the phalanx and necessity of amputating the finger. Free cauterization, hoAvever, of all the bleeding or mortified surface, by means of the nitric acid of mercury, or even by the red-hot iron, has always enabled me, in such cases, to arrest the disease and preserve the ringer provided the bone was not yet necrosed. I have ascertained that the same method applies equally well upon other parts of the members; but if the surface Avhich is to undergo the transmutation (a modifier) should be very extensive, the red-hot iron is to be preferred, since the application of a large quantity of the acid upon the Avound might not be unattended Avith danger. Supposing that the dis- eased limb should have to be amputated, previous cauterization, nevertheless, should not be omitted, since this gangrene is of a character to attack the wound from the operation as well as the 444 NEW ELEMENTS OF OPERATIVE SURGERY. primitive wound. Though Paulct (Pierron, These No. 112, Paris, 1814) and others may have flattered themselves that they saved their patients by amputating, I have to remark that many of those in whom the dressing Avas confided to me, at the hospital of Tours, in 1816 and 1817, Avere re-attacked with gangrene after amputation. § III.—External Violence. If the violence Avhich has caused the mortification is a simple constriction or strangulation of the limb, it is perfectly useless to wait for the limitation of the gangrene. A young man, aged 24, who had been bitten by a viper, strangled his leg Avith a cord. The limb mortified and separated, and the sphacelus proceeded no far- ther, (Delacroix, Arch. Gen. de Med., 2e serie, t. II., p. 587.) In a similar case,M. Petitot (lb., p. 592) amputated above the gangrene, and succeeded. The patient upon whom Park (Excisions of Vari- ous Joints, 1805, p. 64) amputated, after having tied the artery for popliteal aneurism, also recovered. A young man Avas attacked with gangrene in consequence of a contusion of the femoral (cru- rale),artery ; he Avas amputated, and recovered, (Melang. de Chir., p. 212.) Josse (Ibid., p. 243) also speaks of another case, in Avhich the femoral artery, wounded by the fragments of a fracture,brought on gangrene, and in Avhich amputation Avas attended Avith the same advantage. I^have performed amputation in six cases Avhere the mortification caused by wounds was constantly extending: tAvice in the arm, and four -times in the thigh. M. Erard at Saint Mi- hiel, and M. Thomas at Revigny, have both, as M. Champion writes me, amputated the thigh under similar circumstances; and all their patients recovered. Other practitioners, however, have been less successful. A traumatic lesion was succeeded by gangrene ; the leg, says M. MaWe, (These de Concours, Strasb., 1836, p. 26,) was amputated, and the patient died with an emphysema of the stump. I tied the femoral artery for a popliteal aneurism, and gangrene of the leg supervened; amputation AAras performed at the thigh: in the evening the stump became emphysematous, and on the folloAving day the patient died. A similar case has just been published by M. Lauchlan, (Gaz. Med. de Paris, 1838, p. 487.) Unless, therefore, we should decide upon it, as is recommended by Mehee, (Plaies d' Armes-a-Feu,o. 214,) on the very first appearances of mortification, I should advise, in cases of ligature of arteries or aneurisms, that Ave should not proceed to amputation until after the limitation of the gangrene. If the process of obliteration of the ves- sel is already going on during the operation, (sous le couteau,) the amputation will not arrest it, and the gangrene Avill continue. If the process is suspended, and we do not amputate, the mortification will be arrested of itself. The patient of M. Thomas (Arch. Gen. de Med., 2e serie, t. XII., p. 490) was cured in consequence of this fortunate coincidence. The same may be said of that of M. Camp- bell, (Gaz. Med. de Paris, 1833, p. 151 ;) also, doubtless, of those of M. Delaunay, (Bulletin de la FaculU, t. VI., p. 197,) Delpech, AMPUTATION OF THE LIMBS. 445 (Precis des Malad. Reput. Chir., etc.,) M. Sedillot, (Malle, These de Concours, Strasbourg, 1836, p. 25,) and M. S. Cooper. § IV.—Spontaneous Gangrene. Were spontaneous gangrene always dependent upon a diseased condition of the large arterial trunks, Ave ought by no means to amputate until its progress has been arrested. If the cause remains, it is evident that the removal of the dead portion will not prevent the remainder from becoming gangrenous. I amputated in the body of the first bone of the metatarsus, in a case of gangrene from old age, [gangrena senilis,] in the great toe. The foot Avas soon attacked, and the patient died. Another case had been af- fected with gangrena semilis for four months. I amputated at the knee; the flaps of the Avound mortified, the gangrene extended to the thigh, and life terminated on the thirty-second day. But I am satisfied that the vessels are not ahvays obstructed in spon- taneous gangrene. Among the numerous examples I have in my possession, I select the two folloAving:—A thin, small-sized Avoman, aged 54, died at the Hospital of La Pitie, in 1833, of a gangrena senilis which occupied the whole fore-arm. The most minute dis- section in this case did not enable me to detect the least de- gree of lesion "either in the- arteries or veins.- When I-entered upon service at La Charite, in March, 1835,1 found a patient there in Avhom spontaneous gangrene had successively invaded the legs, the thighs, one arm, and the nose. All the vessels that could be identified Avere, nevertheless, found permeable, nor did the heart appear to be diseased. It is manifest that the etiology of gangrene requires farther investigation. If we can suppose that the large arteries remained permeable in the limb in the cases operated upon by Hennen arid by McCready, (France Med., 1.1., p. 96,) in one of those of M. Josse, (Mel de Chir., p. 20,) and in many of those that have recovered, though the gangrena senilis Avith which they were attacked had not become limited when amputation was per- formed, this condition of things did not exist in a great number of other cases. Moublet (Bull de la Fac, 7e annee, p. 227) and M. Roux, (Voyage a Londres, p. 53,) each cite a case where the arteries Avere so entirely obliterated that no ligature became neces- sary after the amputation. A fact of the same kind is related by Ansiaux, (Clin. Chir., 2e edit., p. 278,) and I have collected elseAvhere (Journ. Hebd. Univ., t. I. et II., 1830, 1831,) a number of others. Here is one of the most singular and, at the same time, one of the most curious. M. Champion Avrites me :—" I have am- putated the leg in a case of gangrene of the leg supervening from a slight kick from a horse upon the middle and outer part of the thigh. The patient was about 60, thin, but strong and robust. The mortification presented all the characters of dry gangrene • the femoral and popliteal arteries indicated no pulsation, and I deemed it proper to wait until nature should trace out for me the demar- cation of the disease before I proceeded to amputate, although 446 NEW ELEMENTS OF OPERATIVE SURGERY. she clearly indicated that the external violence was the determining cause. None of the three arteries emitted blood during nor after the operation; I found the posterior tibial only, to Avhich I applied a ligature around a small plug of Avood, Avhich, as I had no wax, I introduced into the extremely narrow aperture of the ossified vessel. The superficial soft parts alone, on the outer side of the leg, presented tAvo small arteries for the ligature. Union was effected by the second intention, and the patient at present enjoys perfect health. I do not know an analogous fact, and I consider it one that possesses some interest for medical jurisprudence." I Avill remark here, that the three cases that died out of the seven in Avhich M. Porter (Gaz. Med. de Paris, 1833, p. 866) states that he amputated the leg for gangrene Avhich had not become limited, did not die from the effects of the extension of the mortification. In all of them the stump retained its vitality, (est reste vivant,) and without any trace of gangrene up to the termination of life. Unless Ave adopt the precept of Wiseman, that Ave ought to amputate before the appearance of delirium, in order that the pa- tient may have sufficient strength to sustain the operation, it is ex- ceedingly difficult on this subject to lay doAvn rules. For my own part, I regulate myself by these principles; if the general health is good, and the digestive functions unimpaired, if the arteries pul- sate as usual, and are free from pain under pressure, and the dis- ease progresses sloAvly, do not Avait for the gangrene to become limited; but Avhether the pulsations are perceptible or not, should the arteries on the large veins seem to be the seat of an irritation, of a diffused inflammation, and violent and continued pains, and should the pulse be irregular, the tongue slimy, and the boAvels constipated, be not in a hurry, but allow the disease to become arrested. When amputation is once decided upon in cases of non-limited gangrene, the surgeon should always operate at a sufficient distance from the disease. Without this precaution, he would inevitably leave germs of sphacelus Avithin the stump, and I do not think that any one would then attempt union by the first intention. § V.—Congelation. In gangrene from congelation, [i. e., from freezing or cold. T.] Ave should always wait until it becomes limited, before amputating. In these cases, the disease is entirely external, and the vital action has a constant tendency to restrict it to narroAV limits. If the limb is not of large size there is no serious inconvenience, even in giving time to the eschars to become slightly detached, (de s'isoler un peu.) We may amputate as near the disease as the flaps to be formed will admit. The operation has then every chance of success. In 1838, I saAV a case of a peasant in Avhom all the fingers came aAvay in this manner. The excision of the head of the bones of the metatarsus in this cr.se Avas sufficient to alloAV the soft parts to cover the bones perfectly. [For some observa- AMPUTATION OP THE LIMBS. 447 tions on the subject of mortification and amputation of the ex- tremities from the effects of intense cold, cases of which are so abundant at this port of New-York, for example, every year in vessels making our coast during the severe tempestuous weather of Avinter and spring, vide a note in Vol. I. of this American Edi- tion. T.] § VI. Deep burns are in the same relation with congelation, and should be subjected to the same rules. I have amputated imme- diately above the elbow in a Avoman Avhose fore-arm had been burned up to the humerus, and the operation succeeded very well. In the case of a soldier, (Delatouche, Oper. cit, p. 45,) amputation was performed above the carpus and tarsus in all the four extremi- ties for gangrene from cold. §VII. When a traumatic lesion is the cause of the accident, when it proceeds from the rupture of an artery or the division of the vein and principal nerves of the limb, or from mechanical strangulation of the part; Avhen, in fine, mortification does not seem to be con- nected Avith any general lesion or any internal or concealed cause, Ave cannot perceive Avhat great advantages are to be obtained by procrastination. In such cases the gangrene is to be considered as a cause of gangrene, and as soon as it is Avell established the patient cannot be otherwise than benefited by a speedy removal of the mor- tified parts. If the gangrene on the other hand arises from the spontaneous obliteration of the artery or principal vein of the limb, it is perfectly clear that the amputation will not prevent it from extending. Suc- cess then depends upon chance; and under such circumstances prudence requires that Ave should wait. Everything, therefore, depends upon our accurately distinguishing these two classes of circumstances from each other. § VIII.—Aneurisms. For aneurisms and wounds of large vessels we now have means of success more simple than amputation. If Fenelon (Bagieu, Examen de plus. Qu. de Chir., t. I., p. 141) Avho died from the immediate effects of a puncture of the femoral artery, in presence of the sur- geons of the court, had lived a century later, his wound would have inspired but little disquietude; and it is surprising that the preacher whom M. PI. Portal (Clinic Chir., t. I., p. 181) speaks of should have escaped from becoming the victim to a similar accident. The ideas of Petit and Pott on this subject are rarely applicable to the present times, and cannot be adopted except in cases Avhere the gangrene is imminent or already established. Aneurism of 448 NEW ELEMENTS OP OPERATIVE SURGERY. itself does not necessarily involve amputation of the limb unless the tumor be too voluminous and has caused degeneration to the sur- rounding parts to such depth that the ligature to the artery Avhich is the seat of it presents not the slightest chance of success. When secondary hemorrhages, after applying the ligature, have super- vened from ossification of the arteries; or Avhen the principal nervous trunks have been divided or the vein closed at the same time Avith the artery; Avhen the muscles shall have become soft- ened (reduits en bouillie) or disorganized in any manner whatever, the articulations also in the neighborhood involved, and the bones friable and more or less completely destroyed; aneurism and arte- rial diseases may then have no other resource than amputation. It was for these reasons that it was found advisable to disarticulate the arm in a case at the Val-de-Grace, in 1812, and that M. Auchin- gloss recently found himself obliged to recur to the same operation for an arterial lesion in the hollow of the axilla. I have stated above what we have to expect from amputation Avhen gan- grene has attacked the limb after the operation for aneurism. If M. S. Cooper has been successful, it. is because the mortification of the limb had less tendency in his case to extend itself upward, than in that of M. Lauchlan and mine. Article IV__Fractures and Luxations. §1- Compound Fractures (les fractures compliquees) are among the accidents Avhich most frequently require amputation of the limbs. To justify this, hoAvever, it is necessary that the injury should be accompanied with serious lesions of the soft parts. A. When outside of the articulations, and so long as the artery, vein and principal nerves are not ruptured, and the muscles preserve a portion of their continuity, it is advisable to delay. If fragments or splinters of bone are detached and buried in the midst of the tissues, they, are to be removed. If either extremity of the fractured bones protrudes outside and we cannot reduce it in spite of the dilatations which sound practice authorises, it is proper to remove it by the saw, (see Exsections.) Even though the muscles be contused and reduced to a pulp, it does not, therefore folloAV, provided the tendons of some of them remain uninjured and the circulation of the fluids beloAV the fracture is not interrupted, that the limb should necessa- rily be sacrificed, especially if it is an upper extremity. Three adults having fractures of this description were cured without amputation in 1829 and 1830, at the hospital of St. Antoine while I was in service there, though two of them, suddenly seized with delirium,tore off the dressings,and marched into the hall,on the sixth or eighth day from the accident. I saAV a young man at the hos- pital of Perfectionnement who had nearly all the muscles of the ante- rior and inner side of the arm and the skin on this part also stripped off and lacerated, by an injury from a spinning machine, and who, AMPUTATION OP THE LIMBS. 449 though he had at the same time the radius and ulna fractured in two or three places, finally got well and saved his limb. In pri- vate practice we should never lose sight of these facts ; that, Avith care and proper regimen and all the resources of a judicious treat- ment, it is rare that compound fractures immediately require am- putation. A woman, thrown from a carriage, had the left leg crushed ; the bones and centre of the limb were reduced to a pulp, (en bouillie ;) the livid color Avhich extended to the thigh, and the swelling and tension, joined Avith the slight degree of pain that the patient com- plained of, induced the assistants to propose amputation. Seeing no wound of the skin, I applied a bandage and resolvents. No accident supervened, and the cure took place as in a simple frac- ture. Another Avoman came into La Charite, Avho had been crushed in a diligence ; amputation seemed urgent, and I was sent for. The right thigh which was mashed, as well as the knee, was transformed into a sort of bag of bones, (sac de noix,) and as moveable as the limbs of Punchinella. An enormous effusion of blood occupied its whole extent, but the skin was only excoriated. The compressing bandage, and afterwards the starch dressings were applied, and everything went on as Avell as in a simple fracture. B. I have seen so many of these cases that they never noAV give me any alarm, and I never amputate under such circumstances, not even though the fracture implicates the large articulations. In throwing herself from the fourth story, a young Avoman fell on her feet before striking her forehead upon the pavement, and crushed the tarsus and the inferior extremities of the bones of both legs. I found the tibio-tarsal regions completely reduced to a pulp, while the fracture of the cranium precluded at first all idea of ampu- tation. This Avoman Avas submitted to the treatment with the starched bandage, (compression inamovible,) and was perfectly cured. But if the soft parts are extensively crushed and lacerated down to the bones, the question assumes another aspect. Wherever the injury involves an extensive articulation, the foot, knee, hand and elboAV for example, amputation is then to be preferred. In the lower limbs it should be performed, even though the joints are not laid open. In the arm, on the contrary, it is rare that fractures complicated with wounds and lacerations of the soft parts, do not admit of preserving the limb, provided the articulations are unin- jured. A man was admitted into the hospital with the humerus comminuted. The muscles Avere ruptured. The skin open in two places appeared filled Avith pulp. The arm already emphysema- tous, was tumefied as high up as the shoulder. An abundant he- morrhage took place, but still the artery Avas felt at the wrist. I applied the immovable dressing, and the patient recovered without any accident. A Avoman similarly situated, and who had refused to undergo amputation, had recovered in the same way a few months before. C. We must not, hoAvever, in these cases go too far. In the 29 450 NEW ELEMENTS OP OPERATIVE SURGERY. lower extremities especially these grave injuries but too often re- quire amputation. Of three patients in this state received at the hospital of St. Antoine, and in whom I Avas anxious to save the leg, two died in the course of a few days, and the third owed his preser- vation to amputation performed on the fourteenth day on account of gangrene. It is true that a fourth, though immediately ampu- tated, nevertheless died on the seventh day; but in him there was so little vital action after the operation, that he was scarcely con- scious of Avhat was done to him. The emphysema, Avhich is some- times added to the other complications of fracture, even from the first day, and before the appearance of any symptom of gangrene or inflammation, is one of those accidents which under such cir- cumstances most emphatically indicate amputation. Though no person has hitherto pointed it out, I have noticed it in six cases, and three out of the five in Avhom the leg was the seat of the dis- ease, died. Against the numerous facts stated by Bardy (Thdse No. 176, Paris, 1803) and De la Touche, (Sur I'Amputation, 1814, Strasbourg,) to shoAV that in cases of comminuted fractures with lacerations of the soft parts, amputation is scarcely ever necessary, M. Bintot (These No. 306, Paris, 1827) has adduced others not less conclusive, going to prove directly the reverse. § II.—Luxations (or dislocations.) Dislocations, complicated Avith laceration of the soft parts, ate sometimes followed by symptoms so formidable and appalling, that they were at an early period placed amongst the cases that impe- riously require amputation. The remark of an army surgeon, which made so vivid an impression on the mind of J. L. Petit, and which was to the effect, that every dislocation of the foot, with la- ceration of the integuments and protrusion of the bones externally, was fatal unless amputation was performed immediately, has unfor- tunately since that time been but too often confirmed. The agonis- ing sufferings which come on when the infiammation sets in, the gangrene which is frequently the consequence of it, and Avhich no- thing can check, and the most excruciating torments terminating in death, which last seems alone capable of arresting the march of the disease, have been deemed to be reasons quite sufficient to justify the surgical law upon this subject. Experience has, nevertheless, demonstrated that this rule has numerous exceptions; which J. L. Petit himself has taken the pre- caution to point out. M. Laugier, (These No. 51, Paris, 1828,) M. Arnal, (Journal Hebdomad. Univ., t. I., IL, III.,) &c., have also fur- nished additional evidence of this fact. If the laceration is not ex- cessive ; if the bones are merely luxated without being broken; if the nerves and principal vessels are not ruptured; if, in fine, gangrene should not appear inevitable, we should replace the parts, exsect the bones, or have recourse to dilatations, and not at first pro- ceed to amputation, except under an opposite condition of things; that is, where the teguments, tendons, ligaments and* capsules of the AMPUTATION OF THE LIMBS. 451 joints are extensively lacerated, the bones and soft parts at the same time both torn and crushed, (dechires et broyes,) or violently con- tused, (violemment contus,) and the articulation too much impli- cated or of too little importance to be saved without the risk of danger. A. As to the election which is to made in these cases between exsection (resection) and simple reduction, this is shown by the state of the parts. In the upper extremities, says M. Champion, I prefer simple reduction to exsection, because this latter is so fre- quently followed by anchylosis. Exsection, whatever may be the locality of the luxation, becomes absolutely necessary wherever the extremities of the bones are denuded of their periosteum, and dry (dissechees) and shattered, (brisees.) In twenty-six of these cases collected by M. Patry, (These No. 289, Paris, 1837, p. 26,) from La Motte, Coligny, Dupuytren, A. Cooper, and Thierry, three only died. In the foot, even reduction may be preferable ; though the formidable accidents Avhich follow wounds Avith luxation of the tibio-tarsal articulation, would induce me to adopt, Avith M. Cham- pion, exsection to simple reduction, if the latter was attended with the least difficulty, seeing that the removal of the extremities of the bones is so poAverful a means of preventing the accidents of infiam- mation. Of seven cases thus treated, and which are related by Deschamps, Hey, Moreau, Cooper, de Bungay, MM. A. Cooper, Josse and Bintot, one only proved fatal. At the knee, however, amputation should be preferred to all other means, and exsection should not be attempted except in persons who are not obliged to get their living by some severe and laborious occupation. I will return to this subject farther on, in treating of amputations in par- ticular, and of exsections. Among these cases, [of reduction. T.] though there may be some who will die that might have been saved by amputation, there will be a much greater number who will survive and preserve their limbs. B. A remark to be attended to here is this, that whether we have to treat a fracture or a compound dislocation, should amputa- tion become necessary, we must, as in cases of non-limited gan- grene, perform it very high up. I cannot understand how Lassus, (Pott, Traite des Fractures, 2e edit., p. 181) should have said that it is better to remove the contused parts on a line with the frac- ture, than to go to the trouble of sawing the bones above it. It is so seldom, under such circumstances, that the fractured bone is free from all cracks, (felure,) and that the cellular tissue, aponeurosis, and muscles are not disorganized at some inches above the appa- rent lesion, that there would be real danger if we did not amputate higher up. A slater had his foot crushed by the Avheel of a car- riage. I amputated the leg after the expiration of a few hours, and I performed the operation at three inches above the malleoli, after having asked myself the question, from the contusion appear- ing so circumscribed, if it would not have sufficed to have taken off the foot at the tarsus. The mortification of a part of the tegumen- tary ruff, (la manchette tegumentaire,) and the livid color from 452 NEW ELEMENTS OF OPERATIVE SURGERY. extravasation, (la teinte ecchymotique,) which soon attacked the sub-cutaneous tissues of the stump, snowed us that lower down the operation would have failed from the effects of the gangrene. In another patient the leg Avas shattered at its lower third. I am- putated beloAV the knee at six inches above the apparent lesion. Death ensued, and enabled us to ascertain that the contusion ex- tended under the skin up to the thigh, especially on the outside. A third patient was more fortunate; though the leg only had been injured by the wheel of a diligence, I amputated the thigh ; never- theless, strips and pieces (pelotons) of mortified cellular tissue ulti- mately sloughed off from the stump. The same rule applies to those cases where the contusing body has separated the limb from the rest of the economy, or so to speak, has itself performed the amputation. If, under such circumstances, Ave do not also remove with the wounded parts themselves, all the neighboring tissues (toute l'atmosphere contusive) which have been injured by the blow, we may be prepared for gangrene of the integuments, dif- fused phlegmon, and mortification of the cellular tissue, together with denudation of the bone. § III.— Wounds from Fire-arms. No wounds more frequently require amputation than those from fire-arms. It is not that the projectiles lanced by poAvder have in themselves anything of a poisonous nature, as some surgeons have supposed, since the time of A. Ferri, or as the vulgar are also too prone to believe ; but because they lacerate, tear, contuse, or cut into (escarrifient) the tissues they traverse or strike. A. A ball, or biscaien, a grenade, or the bursting of a bomb or howitzer, carrying aAvay a part of the thickness of the limb, in- cluding the vessels with it, requires amputation ; Avhile a similar wound effected by a cutting instrument would not, perhaps, make it necessary to have recourse to such mutilation. If the same mis- siles had struck the body of the arm or thigh so as to reduce the muscles to a pulp, without breaking either the skin or bones, still amputation would be necessary, unless the attrition should be ex- ceedingly circumscribed, and the vascular and nervous trunks un- injured. B. Wounds complicated with fractures in an especial manner, in- dicate this extreme alternative. In the joints, if the destruction is considerable, there is no time for delay. A difference of opinion among practitioners exists only where the joint is not greatly ex- posed, and where the osseous extremities have merely been tra- versed or fractured (brisees) by a ball. In these cases we must be governed by the circumstances, thus :—where we have it in our power to pay every necessary attention to the patient, and the ball has merely passed through the wrist, elbow, instep, shoulder, &c, fracturing the articular extremities without lacerating the tendons and other soft parts; ought we not then to endeavor to save the limb? On the contrary, on the field of battle, in hospitals crowded with AMPUTATION OP THE LIMBS. 453 the sick, and when some fatal epidemic is prevailing, and Ave can neither obtain quiet nor repose, nor those assiduous cares which are so indispensable, and where the fracture, too, is complicated with splinters of bone, and the ligaments, synovial tissues and ten- dons are bruised and torn, amputation is more advantageous to the patient than temporization. M. Labastide, (These sur les Blessures par Armes-d-Feu,) de sirous of sustaining the principles of Bilguer, has, it is true, collect- ed quite a great number of examples to prove that such wounds at the Avrist, elboAV, foot and knee, have not always rendered ampu- tation necessary for the recovery of the patient. Similar cases no- ticed at the Maison de St. Cloud, among the wounded of July, as treated by Dupuytren, have been published by M. Arnal, (Journ. Hebd., 1830-1831. t. I., p. 385; t. IL, p. 497; t. Ill, p. 5, 33.) Faure, Percy, Lombard, and Leveille, (Soc. Med. d' Emulat, t. V., p. 192-234,) have also reported analogous cases; but hoAV many reverses might Ave not oppose to these unhoped-for successes ! C. The gardener of the director of one of the theatres of the capital, had a part of the metacarpus and fingers carried aAvay by a musket which burst in his right hand. He was brought to the St. Antoine, and begged me to save the thumb and fore-finger, which were left; I yielded to his solicitations. Serious symptoms supervened and death Avas not prevented by the amputation of the arm fifteen days after. One of the wounded of July had his heel perforated by a ball, and the tibio-tarsal articulation laid open on its posterior and outer part. As there Avas not much destruction of the parts, we were desirous of preserving the limb. On the 18th day the patient died. Another patient also admitted into La Pitie, had a large wound Avith fracture of the elbow, and an opening in- to the point. Amputation was not performed, and the patient per- ished like the others, from the effects of purulent infection. A young man in my service had the osseous extremities of the articulation of the knee obliquely traversed by a ball, at the taking of the Hotel-de-Ville; there were no splinters (esquilles) nor any lacera- tion of the soft parts. After a month's care we were compelled, nevertheless, to have recourse to amputation of the thigh, which did not prevent death from taking place thirteen days after. It is, to say the least, probable, that had amputation in some of these cases been performed at the very onset, life might have been saved. D. It is not in the neighborhood of the complex articulations only, that wounds from fire-arms, accompanied Avith fracture and with lesion of the synovial cavities are so dangerous; they are scarcely less formidable in the middle portions of the long bones, es- pecially in the lower extremities. Thus a simple ball, which breaks at the same time the tibia and fibula, and detaches also a certain number of splinters, is almost always a case for amputation. Where there is one patient, under such circumstances, who refusing to be operated upon, gets Avell without amputation, there are ten that die if the soft parts are at all injured or violently contused. 454 NEW ELEMENTS OP OPERATIVE SURGERY. E. The Thigh.—In the thigh the indication is much more posi- tive. Ravaton says, if Ave do not amputate, this fracture almost ahvays proves fatal. Schmucker maintains, that in cases of this nature, only one patient is saved out of seven. Lombard holds the same language. M. Ribes, (Gaz. Med.de Paris, 1831,p. 101,) who has seen none recover, gives the history of ten cases, in Avhom the utmost care could not prevent a fatal issue, and mentions, also, that at the Hotel des Invalides, in an aggregate of 4.000 cases, there was not a single patient that had been cured of this kind of wound. M. Yvan pointed out two to him in 1815, in Avhom, however, fistu- lous openings formed, and Avho ultimately succumbed from the consequences of their fracture. I notice that M. Gaultier de Clau- bry, (Journ. Hebd. Univ., t. V., p. 479 ; Journ. Gen. de Med., t. LVII.,) formerly a surgeon of the Imperial Guard, is on this point of the same opinion as M. Ribes, and that in the army of Spain al- most all the soldiers that had fracture of the thigh died unless am- putation had been performed immediately. Out of eight treated by M. S. Cooper after the.battle of Oudenbosh, one only survived, and he never was enabled to make much use of his limb. Percy, Thompson, MM. Larrey, Guthrie, and J. Hennen, express them- selves nearly in the same terms, and the events of July, 1830, en- abled most of the surgeons attached to the hospitals of Paris to re- cognize the truth of this melancholy prognosis. Though one of the cases of wounds of this kind was saved by M. Lisfranc, at La Pitie, and another by Dupuytren, I had not the same good fortune ; there Avas but one only received in my Avards, and the fracture appeared to be quite simple; nevertheless we could not prevent death, Avhich put an end to his sufferings on the 38th day. Somme, (Journ. Hebd. Univ., t. I., p. 221,) during the events at Antwerp in Oct. 1830, cured 2 cases out of 8, without amputation. Lassis, (Gaz. Med.de Paris, 1830, p. 322,) and other surgeons of Paris and Brussels, have published other cases not less fortunate ; but Ave must not forget, that among us, as in Belgium, even where Ave have had it in our power to bestoAV the same at- tention that we habitually do to patients in private practice, the instances of success have, nevertheless, been exceedingly rare, and the limb saved has generally been so deformed, that its loss would scarcely have proved a greater source of affliction to the patient. It is to be remarked, also, that a fracture of the thigh is so much the more dangerous in proportion to its proximity to the middle portion of the bone, both because the splinters and fragments (les eclats) shivered off are more common in that part, and also on ac- count of the number, arrangement, and force of the muscles. It is painful, Avithout doubt, to mutilate a patient, in Avhom the limb might have been preserved; but the argument drawn from certain unlooked-for cases of recovery, in patients who had refused the operation, has it, in fact, all the value usually accorded to it ? Admitting that in ten persons Avounded in this manner, four are cured; it is certainly a good deal. But in submitting all of them to amputation at the beginning, is it not to be presumed that two- AMPUTATION OP THE LIMBS. 455 thirds of them at least Avould have been saved ? I leave it to con- scientious men to decide Avhether the saving of the life of two or three persons in the vigor of age, is not preferable to a deformed limb, Avhich can only be saAred, perhaps, in four cases [out of ten,] and at the risk of a thousand dangers. Article VII.—Various Affections. § I. Necrosis and caries also, either in the middle par., or in the ar- ticular extremities of the bones, find their last resource in amputa- tion. To justify this, hoAvever, it is necessary that the evil should be extensive, ancient, and accompanied Avith sufferings and suppu- ration which are exhausting to the patient; that it should occupy a joint or large surfaces, and be surrounded with fistulous ulcerations or deep-seated devastations in the soft parts ; that the bone should be diseased throughout its Avhole texture, (epaisseur,) if it is in the continuity of the limbs; and that Ave cannot count upon any repro- ductive action from the periosteum: but it is important, in such cases, not to forget that the organism possesses great power, and that art, at the present day, has at her command the means of re- moving the bones in part, without removing the limb, provided the soft parts are in a condition to be preserved, (See Trephining and Exsection.) § II.—Cancerous Affections. Spina ventosa, osteo-sarcoma, and colloid, (colloide,) hydatid and erectile degenerations, affecting the bones, also frequently require amputation. These affections are of such a malignant character, that we deem ourselves particularly fortunate in being enabled to destroy them effectually, even at the sacrifice of the part in which they are seated. Unless they should occupy an exceedingly su- perficial, long, or small-sized bone, easy of excision, Ave should not hesitate a moment about amputating. If the soft parts are also implicated in the degeneration, amputation becomes a case of ne- cessity. It is the same Avith fungus haematodes, as soon as it is found impossible to extirpate it in its totality, Avithout altering the continuity of the bone or bones of some important regions of the limbs. M. Hervez de Chegoin (Journ. Hebd. Univers., t. II.,p. 117) has clearly established, that extirpation or amputation, Avhere practi- cable, is the only effectual remedy—for example : for sanguineous fungoid tumors, made up of heterogeneous tissues and encephaloid matters, and Avhen they have reached to a certain depth in the or- gan—except that Ave must take care not to confound them with simple erectile tumors, which at the present day are cured by much milder means. As to cancers, properly so called, it is not required that they should have penetrated to the bones before we proceed to amputation. If they are large and immovable, and go deeper 456 NEW ELEMENTS op operative surgery. than the integuments, and implicate the aponeuroses, muscles, ves- sels and nerves, we should compromise the life of the patient by attempting to preserve the limb. The greatest misfortune in all these cases is, that amputation itself is no certain security, always, against a return of the disease. A young man, in other respects in exceedingly goorl health, came to La Charite for an enormous fungus haematodes upon the calf of the leg. Through fear, I con- cluded to amputate at the femur ; but the wound of the stump had not yet healed, when the disease had already invaded the remaining part of the thigh. §111. Nor do exostoses and fibrous tumors, Avhether of the species ele- phantiasis or othenvise, unless they should be exceedingly volu- minous, or should have compromised the general healthand destroy- ed the natural functions of the part, or cannot be taken away sepa- rately and completely distinct from the bone, and from the neigh- boring organs most essential to the maintenance of life in the rest of the limb, absolutely require amputation. § IV.— White Swellings, (tumeurs blanches.) g|. Numerous observations have shown that white SAvellings yield more frequently than had been generally imagined, to the resources of a judicious therapeutic, and that Ave should not, so long as the caries or suppuration of the articular surfaces is not clearly estab- lished, have recourse to the removal of the limb, until Ave have ex- hausted upon the disease all the means that our judgment enables us to suggest. The phrase white swelling is, moreover, one of too vague an import, at the present day, to have any value as an indi- cation of amputation, (Jeanselme, Arch. Gen. de Med., 1837.) It is upon the character of the disease and of the tissues affected, and not from the title of white swelling, that Ave are to make up our judgment upon the propriety of amputation in diseases of the joints, (arthropathies.) If the capsule has been for a long time filled with pus ; if there are fistulas existing about the joints, and the friction made on the surfaces leave no doubt as to the extent of the ne- crosis or caries; if, also, the ligaments and surrounding fibrous layers are destroyed, and an ichorous fluid escapes in large quan- tities, and a fungoid or fatty degeneration has involved the syno- vial membrane and most of the soft tissues; if the limb be atrophied both above and below, and is luxated, or has a tendency to become so; if, in a word, it is manifest that the bones and the cartilages have been for a long time the seat of a deep-seated, destructive alteration in the parts ; then is amputation indicated: though the cure, even where all this mischief exists, does sometimes ultimately take place in the articulations, especially in those of the fingers. § V.—Suppuration. Unless suppuration should derive its source from some disease AMPUTATION OP THE LIMBS. 457 in the bones, it rarely happens, whether it be of long standing or recent, superficial or profound, or is ever so abundant that it ren- ders amputation absolutely necessary. Regimen, judicious medi- cation, incisions and suitable dressings, ought to be sufficient to dry up its source. In the contrary case, we should look for the cause in the general condition of the patient, or trace it to some internal lesion; in which case amputation would but hasten the progress of the disease. We admit the dangers of those suppurations which sometimes invade the greater portion of a limb, and are ordinarily the result of inflammation of the synovial capsules, the tendinous sheaths, or inter-muscular tissue ; and every person has been en- abled, on this head, to make observations similar to those of Lecat, (Proprietes des Nerfs, p. 202.) But as these dangers are not al- ways present, as death is not always their inevitable result, and as it is practicable to make successful resistance against or entirely to prevent them in a good number of cases, suppuration of the soft parts, without degeneration of the bones, ought not to be ranged among the indications for amputating the limbs. I have, more- over, had an opportunity of witnessing three patients on whom it was performed, and Avho sank as rapidly, or more so even, than they would have done had they not been operated upon. In the two first a suppuration, which numerous incisions had not been able to arrest, occupied almost the Avhole of the fore-arm ; in the other, the evil, which did not approach so near the wrist, had reach- ed to above the elboAV. They were all amputated at the arm, and they died before the fifteenth day, with purulent deposites in the viscera. Infine, if the suppuration is purely local, and the destruction of the tissues slight, amputation is not indispensable ; and should it be kept up by constitutional disease, (une disposition interne,) it will not succeed. § VI. Corroding ulcers, lupus, and phagedenic sores, (les esthiomenes) of the legs, Avhich formerly constituted one of the principal indica- tions for amputation, do not in reality require it, or do not exact it at least, but in a very small number of cases, as Avhen the skin is destroyed and the muscles laid bare, (disseques,) to a great extent around most of the limb ; nevertheless, it is proper that the patient should desire the operation, and that he should be convinced that there is no hope of curing him by any other mode. §VII. In Tetanus, for which M. Larrey, (Clin. Chir., t. I.,p. 27 a 131,) M. Del Signore (Arch. Gen. de Med., t. IL, p. 298) and some others have had the courage to employ it, is it possible that any advan- tages could be derived from it ? Would it not rather be aggravated than cured by the removed by the limb ? I am aware that a man from the country was saved in this manner by Dubois, that Levesque-La- source (Bull, de la Fac. de Med., 7e annee, p. 100) has published a 458 NEW ELEMENTS OF OPERATIVE SURGERY. similar fact, and that Ave find here and there in periodical publica- tions other examples of success obtained in the same manner. Nevertheless tAvo of the patients operated upon by M. Larrey died notwithstanding the amputation, and the state of the third leaves the matter in doubt as to the real nature of his disease. If in itself the Avound Avhich has caused the tetanus should be of so serious a nature as to justify an extreme measure, the access of this frightful disease Avould Avithout doubt weigh in the balance as a determining motive. But in other cases I should be so much the less disposed to folloAv the example of our celebrated military surgeon, inasmuch as amputation is, as is knoAvn, in itself a potent cause of the very disease for Avhich it is here proposed to employ it as a remedy. [Amputation for Tetanus.—As illustrative of this subject the fol- loAving facts may be useful:— Sir Geo. Ballingall (Outlines of Military Surgery, Edinburgh, 1844) gives an important fact which he derived from Deputy In- spector Marshall, to shoAV that the statements touching the produc- tion of tetanus by punctured wounds have been greatly exaggerated. Out of one hundred cases of arrow wounds at Ceylon, (East Indies,) Mr. Marshall did not, even in the heat of that climate, which as we see in all tropical countries, constantly predisposes in all diseases to complications of tetanus, trismus, spasms, convulsions, &c, meet with a single case of tetanus ! Dr. Casper of Berlin (vid. Casper's Wochenschrift—also Journ. des Connaissances, &c, Paris, Aout, 1844, p. 74) relates the case of a man aged 35, who having had a corn removed from the little toe of the left foot by too deep an incision, continued notwithstanding the pain which ensued to do his duty as a domestic where he was employed, until he had to^take to his bed. M. Casper found the patient complaining of no other symptom than the pain in the part from whence the corn had been extracted, and in place of it a vesi- cle filled with blood, the foot also being swollen throughout its whole extent. In a day or two came on difficulty of sAvalloAving, stammering, and difficulty of articulation, though preserving all his mental consciousness perfectly. Tetanus followed with death the same evening. Pus was found effused under the integuments, and the mucous bursa over the articulation was filled with blood; but no lesion Avas discovered on the branches of the fibular nerve which are distributed to the toes. Dr. Aberle (Jour, des Conn. Med. Chir., Paris, Nov., 1844, p. 208) relates an instructive case in which it finally became necessary to amputate the medius finger for a wound from a splinter (echarde) under the nail, which the patient, a female aged 22, had supposed she had extracted. The paroxysms of tetanus which had continued daily for Aveeks, and Avhich were kept under and ultimately reduced to one a Aveek by repeated small enemata of equal parts of spirits of turpentine, olive oil, and mucilage of gum arabic, finally returned with all their force and induced the patient to consent to the opera- tion. Immediate relief was obtained, but to the dismay of all it was found that though the wound on the point of the finger had AMPUTATION OF THE LIMBS. 459 cicatrized a portion of the splinter (echarde) Avas found buried in the nerve ! The patient recovered completely. Mr. Miller, Professor of Surgery in the University of Edinburgh, in a case of traumatic tetanus (Cormack's Lond. and Edinb. Monthly Jour, of Med. Sc, Jan., 1845, p. 22, &c.) in a girl aged 7, from injury to the right middle finger caused by a cart Avheel passing over it, and in Avhich case unequivocal tetanic symptoms developed themselves on the 20th day after the accident, in trismus and pain of the jaws, opisthotonos, rigidity of the upper extremities and ab- normal muscles, immediately on the day of their appearance per- formed amputation at the metatarso-digital articulation. The case was then treated Avith large doses of the cannabis Indica, (Indian hemp,) sometimes to 30 drops of the tincture (equivalent to three grains of the resinous extract) every half hour, together Avith bags of cold ice to the upper part of the spine. He places much reliance on Indian hemp, as from his experience in this case its extraordi- nary anti-spasmodic and narcotic effects, though it may be compara- tively useless as an anodyne in ordinary cases of disease, are Avholly exempted from the objections to opium, morphine, aconite, &c. For instead of constipating the boAvels it creates an inordinate appetite, (especially in convalescence,) Avhich enabled the Professor during the treatment, which hoAvever was prolonged to tAvo months be- fore the tetanus was subdued, to administer constantly a supply of wholesome nourishment (strong beef tea) to replenish the exhausted excitability necessarily caused by such severe and morbid exercise of the muscular poAver of the whole system of voluntary muscles. He recommends also careful attention to evacuation of the bowels, but above all early amputation of the injured part upon its cardiac aspect. To shoAV the poAver of the cannabis Indica in controlling muscular spasm, and the extent also to which morbid muscular power is developed in tetanus, it may be remarked that large as the doses were on this young and slender girl, none of its unpleasant effects Avere produced. Dr. O'Shaughnessy, from what he saw of the virtues of the Indian hemp in India in tetanus, Avas induced to com- mend it strongly to the notice of British practitioners, (See British and Foreign Medical Review, July, 1840, p. 225,) and it is worthy of further trials after those of Mr. Miller given above, as a valuable adjunct to early amputation—instead of the disturbing herculean doses of opium, Avine, alcohol, &c, formerly in vogue in tetanic affections, especially in traumatic tetanus. T.] §XII. The bite of rabid animals is also, in the estimation of some, a case for amputation. M. CalloAvay (Clinique des Hopitaux, t. I., p. 16) had no qualms about taking off in this manner the arm of a person who had been bitten in the hand, and who, by the Avay, (par parenthese,) died nevertheless of hydrophobia in eight hours after. At farthest Ave should never think of it, except for a finger for example, unless the wounds are so extensive, complicated and 460 NEW ELEMENTS OP OPERATIVE SURGERY. deep that we cannot cauterise or in any other manner excise their whole track; the amputation also should in such cases be performed immediately, as in a lady whose case Avas transmitted to me by M. Champion; for after the absorption of the virus has once taken place, how can it be of any utility ? Article VI.—Amputations out of complaisance, (amputations de complaisance.) Anchylosis, complete or incomplete, deformities of different sorts, ancient ulcers that are incurable, or where the cure is not permanent, or any annoying condition whatever of certain parts of the limbs, often induce patients to demand relief from them at whatever sa- crifice, though their life and general health are not in any manner endangered. As a general rule, a discreet physician ought, in such cases, to resist the entreaties of persons Avho consult him. There is evi- dence, in fact, to show that the operations which are denominated those of complaisance terminate sufficiently often in an unfortunate way. In 1821, there Avas received into the Hospital of St. Louis, a man of robust make, in the vigor of age, and in other respects enjoying the most flourishing health, but with the firm resolution of having his thigh cut off for an anchylosis of the knee, Avhich ob- liged him to use a crutch. After having remonstrated Avith him in every possible way, and traced out to him as black a prospect as could be portrayed of the dangers to which he would be ex- posed, M. Richerand finally acceded to his entreaties; the ampu- tation Avas one of the most simple ; no local accident supervened; but an ataxic fever, which soon supervened, ended, neverthe- less, in death on the fifth day. Pelletan cites a similar fact. I saw some quite as striking at the Hospital of Tours, from 1815 to 1820, and M. Gouraud, then surgeon-in-chief of that establishment, finally came to the resolution, as Dupuytren did afterwards, of giving a flat denial to these pressing requests of patients. In 1825, a coun- tryman who had been an old soldier, annoyed at having a large leg, and carrying a dry ulcer (ulcere sec) behind the malleolus, presented himself in the wards of the School of Medicine Avith the idea of having his limb amputated. It Avas in vain that M. Roux endeavored to alarm him, and to make him feel the rashness of his project; nothing could shake him. The operation presented nothing peculiar ; the first days went off as Avell as could possibly be desired; but constitutional symptoms supervened, and the man died at the end of the Aveek. What is Avorse, amputations of the least importance in themselves, those of a finger or toe for example, have not unfrequently been followed by similar results. In 1829, there was received in the Hospital of St. Antoine, a shoemaker whose left fore-finger had been for a long time held firmly and immoveably fixed upon the palm of the hand. I ope- rated upon him, and this patient, who did very well at first, and amputation of the limbs. 461 finally recovered, was, during fifteen days, so severely affected, that on two different occasions I thought there was no hope for him. A young peasant girl came into La Charite to have an am- putation of her left fore-finger, which was retracted backwards, and adherent to the dorsum of the metacarpal bone; she died of phlebitis and of purulent peritonitis on the eighth day after the operation ! Nothing is more common than examples of this kind, and there is no practitioner who has not had occasion to see them. From thence has arisen a question among modern observers which the ancients seem never to have thought of: ought a practitioner to limit himself to simple explanations'! Is it not his duty positively to refuse to perform operations which are not indispensable ? At Paris, many surgeons have answered negatively, and violently op- pose those who amputate under such circumstances. For myself, I find the question badly stated, and here is another one which may be brought into consideration. Does humanity allow that we should condemn a man to carry forever an infirmity which renders life a burden, merely because that in the attempt to get relieved of it, he may be exposed to more or less serious dangers ? If that were the case, we should never interfere with lupus, nor tumors of any kind Avhich are developed upon different points of the body; for they are rarely dangerous in themselves, and the operations we are obliged to employ to remove them may give rise to for- midable accidents, or even cause death. Far be it from me to justify those Avho are in haste to perform amputation of the limbs for lesions Avhich do not absolutely require it, and for simple annoyances, and merely because the patients wish to be relieved of them; but I Avould ask if it be not conform- able to a sound surgery to have recourse to it for deformities Avhich we cannot otherwise get rid of, when those deformities are of a character to destroy the natural uses of an important part of the body, to give rise to pains, and to make them a source of trouble and continual suffering, and when the patient also has decided upon it, and maturely reflected upon the consequences which may result from his determination ? Dominique de Vic, (Governor of Amiens, (Essais Historiques sur Paris, par Sainte-Foix, t. V., p. 108,) in 1586, having had the fleshy portion of his leg carried aAvay, and being thus incapacitated from mounting his horse without experiencing the most acute pains, went into retirement for three years. Hearing that Henry IV. required the services of all his subjects, he caused his leg to be amputated, sold a part of his property, went to find his prince, and rendered him signal services at the battle of Ivry, and on many other occasions. Can he be blamed ? A captain of marine having lost his foot, had the leg cut off near the knee, because, says Pare, (CEuv. complet, liv. XII, chap. 29,) he found it too long. Villars, as cited by Briot, (Hist, de la Chir. Milit, p. 185,) did the same. Ought Sabatier to cast reproaches upon these practitioners, he who so long felt the embarrassment of 462 NEW elements of operative surgery. too long a stump to the leg ? I would not like Odier (Man. de Med. Prat., p. 362,) go to the extent of amputating the fore-arm for a simple neuroma, (nevrome,) nor for an anchylosis of the wrist which caused no pain, nor for a false articulation, unless under cir- cumstances altogether peculiar ; but I should decide in favor of it in the folloAving cases. § II.—Anchylosed Fingers. Whether deformed, flexed or extended, straight or deviated, an ankylosed finger is not only a useless organ, but a perpetual source of trouble, pain and accidents. If there be no other remedy, am- putation is allowable. I have performed it seventeen times, and of these, fifteen of the cases were cured. § II.—Supernumerary Fingers. Without being as annoying as those that are ankylosed, super- numerary fingers are enough so to justify their removal. I have amputated them on the thumb and little finger, and the little toe, and have had no reason to regret doing so. I saw—it is now twenty-four years since—a child of four days old, who had seven fingers on each hand; the thumb and little finger were double; I amputated them successively, and united by first intention. In 1837,1 amputated, Avrites M. Champion, the two great toes that were double upon the child of the preceding case, and I separated apart the middle and ring fingers, Avhich had been united at their two sides. In conclusion, I do not know what remark to make of the case of a double thumb, in a child of 3 years, amputated at the joint by Ch. White, and which was reproduced to the extent of causing W. Bromfield to amputate it a second time, which, how- ever, did not prevent its reproduction again! § III.—Toes raised up or angulated, (orteils releves on coudes.) Whatever may be the deviation of any one of the three middle toes, it is rare if they are at all prominent that the person does not experience pains, and an extreme degree of annoyance in walking or wearing shoes. In such cases, should the patients demand it, I amputate. I have performed it on five persons, two of whom were students of medicine, and although in one of these it was followed by some aecidents, they all got well. § IV.—Ankylosis of the Large Joints. So long as there is a chance of curing ankylosis, of assuaging the pains, or of putting the patient in a condition to walk, though it should be with crutches, I decline an amputation of the limbs properly so called; other AVise I am governed by circumstances. A man from Provencti who, in consequence of successive inflamma- amputation op the limbs. 463 tion of the joints, (arthropathies had the hips, knees and feet an- kylosed (soudes), with the legs and thighs bent into a serpentine direction, so as to be unable to stand erect, or to seat himself, or lie upon his side, obliging him thus to pass his life upon his back, sought in vain at Lyon, Nimes, Avignon and Toulouse for a sur- geon who Avould amputate his two thighs, and then came to Paris with the hope of attaining his object. I, like the others, at first re- fused. " Though a cripple, I might then, said he to me, be en- abled to occupy myself and live. But as I now am I do not exist. Amputation you say might kill me ; that is not so certain. Besides I suffer, and I do not wish to live if I am to remain as you see me. Therefore I leave here either my legs or my body!" The two amputations Avere attended Avith complete success, and he returned as happy as a god ! § V.— Ulcers with Loss of Substance. In consequence of extensive burns, gangrene, phlegmonous ery- sipelas, or old ulcers, it may happen that the integuments through- out the whole circumference of a limb are destroyed, together with the aponeurosis and some of the muscles, to such extent as to ren- der cicatrization forever impossible. If the patient desires it, am- putation is applicable here also ; but in all such cases I wait for the patient himself if he is an adult and has his reason, or in the con- trary case for his parents, to demand the operation. I do not de- cide upon it but at their entreaties, and after having pointed out to them all its dangers and chances. CHAPTER II. PRELIMINARY CAUTIONS.—(Soins PrESalaWes.) Article I.—Counter-Indications. Before amputation is performed it is not only necessary that the disease which requires it should be one that cannot be cured in any other manner, but also that we be enabled to remove the whole of the disease, and with a rational prospect of saving the life of the patient, (Malle, Contre-lnd. aux OpCr., Strasb., 1836.) M- When the disease is a cancerous affection, it is important to make ourselves assured that there exists no germ of it in the viscera. If a diseased condition of the lymphatic glands is observable at the upper part of the limbs, and that the color of the skin, the state of 464 NEW ELEMENTS OP OPERATIVE SURGERY. the respiration and digestion, or any other symptom whatever indi- cates that the disease is not confined to the surface, amputation is useless and would only serve to hasten the development of lesions analogous to those we desire to relieve. §11. Pulmonary phthisis, necrosis (Mehee, Plaies d'Armes-d-Feu, etc.) caries of the vertebral column, (Lassus, Fract. de Pott, p. 181, 1788,) abscesses from congestion, any organic lesion of the heart, liver, stomach, or genito-urinary passages, &c, extreme prostration, (epuisement profond,) intestinal ulcerations in considerable num- bers and of long standing, coincident or not with a colliquative diarrhoea, are, unless in a case of urgency, (see Vol. I. of this work,) so many positive counter-indications, (Delatouche, Dissert, sur I'Am- putation, Strasbourg, 1814.) In fine, in all cases where in the re- moval of a limb we leave in the organization a disease of such gravity that death will almost inevitably follow, we ought to abstain from the operation. When it is for a scrofulous, syphilitic or rheu- matic affection, we have to apprehend that it will soon be repro- duced in other parts of the limbs, and may oblige us, if we propose to follow it up, to perform successively a number of amputations. We ought, therefore, in such cases to have at least a strong rea- sonable prospect of being enabled to limit the progress of the gene- ral disease, in fact to retard its advancement and ultimately to extir- pate it effectually. Prudence, for example, does not permit us to amputate a limb affected with rheumatic or syphilitic caries or necrosis, if other parts and some of the articulations are already the seat of swellings, pains, and other primary symptoms of a similar affection. §111. In regard to scrofula, however, it had been for a long time noticed that the removal of an important part from the body was often followed by a favorable change in the general health of the patient; that after the cure debility has been succeeded by mani- festations of strength, and of the most flourishing health. This is a change which we may readily comprehend: an abundant sup- puration, protracted pains, and a disorganized condition of the articulations, constitute a morbific cause calculated continually to impair the functions, and cannot fail of keeping up in the economy a sufficient degree of disturbance to impede the development of the natural resources of the system. In removing, therefore, this real cause of suffering and danger, it is very natural that the health should afterwards be re-established; that nature ceasing to be dis- turbed and embarrassed in her efforts, should then be enabled to suppress less serious lesions, and to preponderate over a morbid process whose principal source has been destroyed. AMPUTATION op the limbs. 465 §IV. One of the first questions to decide is to know if there are really any internal diseases existing, and to ascertain their nature, for if these be incurable amputation is inadmissible. The next question is to determine the source of the mischief, for if this be external then amputation is formally indicated, but if elseAvhere, the contrary. As often as a local affection is the result of general disease, we must entirely subdue this latter before thinking of removing the former, which, according, to correct practice, does not alloAV of amputation until it becomes reduced to what exists of it externally. A minute examination of the patient before coming to a final decision, is so much the more important, inasmuch as most of the diseases which require amputation rarely fail of producing a reaction to a greater or less degree upon the internal organs, and of thus giving origin in the viscera to abscesses, tubercles, ulcerations, indurations, and numerous other morbid determinations, (foyers morbides,) whose exact appreciation or detection is far from being always an easy matter. §V. It is well nevertheless to remark that the debility which is found to exist in certain patients, is not in itself an absolute counter-indi- cation to the operation. All observers know that it is not in the strongest subjects, and those Avho have the greatest appearance of health, that amputations succeed best. A certain degree of ex- haustion produced by protracted pain, even diarrhoea itself when it is not kept up by any internal organic lesion, are in general favor- able rather than unfavorable conditions. It Avould seem that in the first case the organization in possession of its whole forces, revolts at the mutilation Avhich it has suffered; while in the other, the affection upon which it had exhausted all its resources, being re- moved, it has no other task to perform but to dissipate the subse- quent disorders which it was not in its power to prevent. §VI. When we have under consideration recent traumatic lesions, there may be a number of serious wounds in the same patient. Ought we then to amputate ? and if there are several limbs to be removed, should all this be done on the same day ? Bagieu relates that in a man who had both legs crushed, it was decided upon to remove the one most injured first; but that by mistake the other was taken off and the bad one got Avell! I amputated the leg of a man who had just fallen from a second story. He died on the fourth day with a laceration of the liver, (avec le foie dechire.) In another case of Avound it was proposed to amputate both legs; I objected to it. After death it was found he had twelve ribs and six of the verte- 30 466 NEW ELEMENTS OF OPERATIVE SURGERY. brae fractured ! If the two hands or two feet are the only parts wounded, we may amputate them immediately. Though the ac- companying wounds are not in themselves mortal, still Ave should amputate. If other parts seem too seriously compromised, then wait and do not amputate immediately. Article II.—The Period to Amputate. In the last century surgeons were zealously occupied with the question whether after severe wounds by fire-arms or otherwise, it was better to operate immediately or to wait for the constitutional reaction. Faure, (Prix de V Acad., t. H.,p. 337, et Mem. de I'Acad. de Chirurgie, t. IL, p. 323, 1819,) Boucher, (Mem. de I'Acad.de Chir., t. IL, p. 199, 1819,) Bilguer, (Abus de I'Amputation des Mem- bres, Sre, traduit par Tissot,) Leconte, (Prix de I'Acad. Roy. de Chir., t. III., p. 357-367,) Schmucker, (Richter, Biblioth. Chir.,t. IV., p. 1,) and De la Martiniere (Mem. de I'Acad, de Chir., t. IV., p. 133) particularly discussed this question during the controversies that took place. And although almost every surgeon since that period has treated of it, no one has yet been enabled to come to an absolute decision. §1. The partisans of immediate amputation, among whom we must reckon Van Gescher, (Necessite de I'Amputat., &c, 1767, in Dutch,) Fabre, (Differents Points de Physiol, p. 279,) Briot, Prog.de la Chir. Milit, p. 189,) M. Durand, (These No. 198, Paris, 1814,) M. Jacquin, (These No. 54, Montpellier, 1831,) and M. 0. Gouraud, (Demonstr. des Prineip. Operat, 1815,) maintain that immediately after the wound the patient is found in the most favorable condi- tions possible. There is then, say they, no fever, suppuration or inflammation; the affection is entirely local; while at a later period the swelling of the limb, often gangrene, a violent reaction, tetanus, and a thousand other accidents may cause death before we have the opportunity to amputate. Even though this primary reac- tion may be calmed, the copious suppuration, and the separations of the muscles and the fistulous passages which may have been established together with the induration and disorganization of the tissues, ordinarily render the operation of a more serious character. §11. To sustain their position, the partisans of consecutive amputation, among whom are to be ranged, Mehee, (Inutility de I'Amputat. det Membres, Paris, 1800,) Lassus, (Trad, du Traite des Fract., de Pott, p. 181,) M. Delatouche, (Amputat. dans les Cas de Fract, etc., Stras- bourg, 1814,) and Leveifle, (Soc. Med. d'Emul.,t. V., p. 192,) main- tain, on the contrary, that in the first moments the organism is too intensely disturbed, a»d under the control of a commotion tQo via- amputation of the limbs. 467 lent to admit of the possibility of success from any operation Avhat- ever, and above all that we run the risk of sacrificing limbs which it would have been easy to have preserved; whilst after having combated the first symptoms, should amputation become necessary, we have at least nothing to reproach ourselves with. Besides that the question under this form is misplaced, the two opinions, taken literally, appear to be equally remote •from sound practice. When amputation becomes absolutely indispensable, there is no doubt that it is better to perform it promptly than to put it off, and Faure, himself, (Prix de I'Acad. de Chir., t. III., p. 337, edit. 1819,) who defends with so much zeal the cause of consecu- tive amputations, does not take opposite ground to this opinion. Bagieu (Exam, de plus. Quest, de Chir., t. I., p. 137, 12mo.) and Leveille have in this respect gone much farther than him. On the contrary Avhen there is any chance of saving the limb, and its de- struction is not inevitable, we may temporize and resist the general symptoms, reserving our decision to amputate, after the reaction is subdued, to those cases only in which we cannot obtain a cure by any other means. §111. On examining the subject more closely, it is also evident that Faure has not treated the question in a proper point of view. It is true that his ten cases of wounds all of them had fracture ; the first, the ninth and tenths in the leg ; the second in the thigh; the third in the knee; the fourth and fifth in the fore-arm ; the sixth in the humerus ; the seventh in the metacarpus; and the eighth in the heel; but the wound from the fire-arms was not sufficiently serious in any oifthem to extinguish all hope of saving the part. In regard to these cases the difficulty was to know whether amputa- tion was indispensable, and not whether it should be performed at an earlier or later period. The result about which this surgeon made so much noise, does not therefore in any manner prove that amputa- tion, when once admitted to be necessary, is less dangerous after than before the access of the general symptoms. We may, in fact, deduce from it a totally opposite conclusion. What, in truth, did he gain by thus temporizing ? Nine out of his ten patients were reduced to the necessity of losing a limb, and that after five or six weeks of severe suffering, and after running the greatest danger of losing their lives. To say that if they had been amputated imme- diately they would not have recovered is altogether a gratuitous assumption. Reason, on the contrary, shows that these men who had such strength to resist so many causes of death, would have been much better cured if they had been operated upon at the be- ginning, and their recovery would probably have been completed, when, by the method of Faure, they were still under the anticipa- tion of the operation. 468 NEW ELEMENTS OP OPERATIVE SURGERY. § IV. In admitting that secondary (secondares) operations succeed bet- ter than immediate, the Academy of Surgery have evidently been deceived. Against the calculations of Faure, which maintain that the success is in proportion of three to one, we may at the present time oppose the experience of a multitude of reputable persons, who have observed directly the reverse. Dubor (These, Strasb., 1803. Larrey, Clin. Chir., t. III., p. 518) affirms, that in the American war, the French surgeons, by deferring amputations, lost almost all their patients, while the Americans, by amputating im- mediately, saved almost all theirs, without scarcely an exception. In the affair at Newbourg, Percy (Gouraud, Oper. cit, p. 8) per- formed ninety-two immediate amputations, and cured eighty-six of them. M. Larrey (Ibid., p. 8) cured twelve out of fourteen. Out of sixty wounded in the naval action of Jan. 1,1794, and who were amputated immediately, two only died, (Fercoc, Lettre a M. Lar- rey, Clin. Chir., t. III., p. 515.) After the battle of Aboukir, the eleven soldiers mentioned by Masclet, (Lettre a M. Larrey, Clin. Chir., t. III., p. 517,) Avho were amputated in the first twenty-four hours, got well, while three others amputated eight days after, died. The English surgeons assert, that after the battle of Toulouse im- mediate amputation succeeded in thirty-seven cases out of forty- eight ; while in those in whom the amputation was deferred, twenty- one died out of fifty-one. At the attack upon New Orleans, the proportions were still more favorable, for out of forty-five amputa- tions of the first kind, seven only perished, while out of seven of the second, two only Avere cured. We learn also that after the bat- tle of Navarino, out of thirty-one immediate amputations, M. del Signore (Archiv. Gen. de Med., t. XXL, p. 298) lost but one ; while out of the thirty-eight that he amputated in the twelve following days, he saved but twenty-five. § V. Finally, the events of 1830 enabled us to corroborate the same facts at Paris. One hundred amputations Avere performed, thirty- four at the Hotel Dieu, fifteen at La Charite, twenty at Gros Cail- lou, thirteen at Beaujon, six or seven at St. Louis, four or five at the Maison de Sante, three at the Necker, one at the Hospital of the School of Medicine, one at St. Mery, and five at La Pitie, and in all these places it Avas observed that immediate was more suc- cessful than consecutive amputation. Almost all of the first kind succeeded, while a great majority of the other kind had a fatal issue. The service of M. Roux, the wards of M. Larrey, of M. Richerand, M. Marjolin, and Dupuytren, gave proof of this asser- tion, though with the last the difference Avas less marked. The two cases also at La Pitie, in whom I deferred the amputation, died. Nevertheless Somme, who after the battle of Antwerp, performed AMPUTATION OP THE LIMBS. 469 five immediate and three consecutive amputations, lost two of the first and saved the three last; but what a difference was there also in the gravity of the wounds ! In Holland, M. Kerst, who has de- cided for consecutive amputation, because of sixteen amputated in the first twenty-four hours, eight died, while of twenty amputated after fifteen to tAventy days, four alone perished—and who admits no other cause of the difference of result in these tAvo series than that of the period at which the amputation Avas performed—finds a sturdy antagonist in M. V. Onsenort, who, though a countryman of M. Kerst, gives the preference to immediate amputation. Though secondary amputation should even succeed as often as it fails, it would be no reason for giving it the preference ; it would be required, moreover, (and which is not the fact,) that immediate amputation, in itself, should offer fewer chances of success. The fundamental argument of the partisans of temporization, to wit, that a multitude of mutilated persons would have been enabled to save their limbs, if the surgeon had delayed, is, as I have already said, more specious than solid; for Ave can reply to them, that a goodly number of the other cases would be living with three limbs, if, in delaying the operation, they had not suffered them to die with four. §VI. Though experience had not spoken, Avho could be made to be- lieve that a simple, regular, and smooth (unique) wound, could be more dangerous than those wounds from fire-arms which, accom- panied with fracture of the bones and crushing of the soft parts, require amputation ? The pain, too, of the operation, can that be weighed in the balance along with those that patients, not ampu- tated, every day suffer, and which are reproduced upon the slightest movements, or from examinations of the Avound, dilatations, and the numerous incisions we are obliged to make to extract the splin- ters, moderate the inflammation, or give egress to the morbid dis- charges ? In fine, who would have the temerity to maintain that, in this last condition, the Avounded patient is not a thousand times more exposed to phlebitis, purulent infection, tetanus, and all the different kinds of visceral inflammation, than if an amputating wound had been substituted for the serious lesions he Avas suffering under ? And, after all, it is not at the present day that the doctrine of im- mediate amputation has been promulgated. Surgeons like Le- comte, Thompson, Hennen, MM. Larrey, Gouraud, and Guthrie, in opposing the ideas of Bilguer, Faure, Hunter, Percy, Lombard, and Leveille, have done nothing more than to confirm or to estab- lish, beyond the possibility of dispute, the justice of the assertions of Duchesne, Avho wrote at Paris in 1625, and also those of Wise- man, Le Dran, &c. The advantages of this practice being now undoubted, the only question is to know at the very first whether an amputation is or is not necessary; which excludes it then from the category of 470 NEW ELEMENTS OF OPERATIVE SURGERY. the diagnosis or indications ? It is from having been constantly wandering from this point, that the question has remained so long undecided, and that it so frequently becomes the subject of contro- versy. §VII. Upon the whole, therefore, amputation should be performed immediately; that is, in the first 24 hours, and before symptoms of reaction have commenced; in a word, as soon as possible, so long as there is no other chance of curing the patient. The stupor and insensibility (engourdissement) which are observable in some cases of Avounds, is not by any means a positive counter-indication. A Swiss, whom I saw at the Hospice de Perfectionnement, July 27, 1830, Avith the thigh shattered (broyee) from a ball, and who I advised should not be operated upon, was amputated by M. P. Guersent, and did exceedingly well. We are not to abandon any cases but those that seem to be without any resource. It is for the skilful surgeon to decide what are the accidents which require de- lay. In doubtful cases, Ave defer; but if afterwards amputation becomes indispensable, Ave should be aware of the fact that it scarcely ever succeeds if performed during the severity of the symp- toms, when the affection is not completely localized, and signs of phlebitis or infection have made their appearance. It is then especially that the viscera and all the functions should be tho- roughly examined, seeing that the reaction which Ave had hoped to have had it in our power to subdue, often leaves in the system purulent depositions (foyers) which Avould be certain to endanger the success of the operation. These various remarks are as much applicable also to amputations rendered necessary by causes other than those of fire-arms,as to those of which we have been speaking. [When to Amputate.—Sir George Ballingall (Outlines of Military Surgery, Edinburgh, 1844, p. 337) makes a remark of great value, which, though it appertains more exclusively to military surgery, has noAv (in the present frequent and dangerous use of fire-anns in our own country, on all occasions, civil as well as military, as in street-fights, broils, &c.) become of every day practical value, though apparently hitherto overlooked. It is the well-established fact that, in gun-shot Avounds from balls, there is generally an extensive com- minution and splintering of the bone, which is split and shivered, cracked and fractured, in all directions—chiefly, however, longitu- dinally, and not unfrequently to the distance of six inches, as in the tibia, &c. Numerous specimens of these are in possession of Sir George Ballingall, and he deduces from it the rule in practice, that full allowance should always be made, in cases of this kind, for the extent of this comminution, when about to amputate or exsect, or where the joints are laid open. The comminution, and also the calibre of the aperture, as is well known, are always greatest at the place where the ball makes its exit, (lb.) This Surgeon, also, presents some rather new, and certainly im- AMPUTATION OF THE LIMBS. 471 portant, rules, as gathered from his great experience, both in mili- tary and civil hospitals, in relation to the time when amputa- tions should be performed. He is satisfied that, in civil hospitals, primary amputations, i. e., those that are performed at once and be- fore reaction has commenced, do not do so well as in military hos- pitals ; and the distinction he makes, founded on the different ac- tion of the moral causes in these two different states of circum- stances, seems to us perfectly just. Thus, the soldier is ordinarily of far more robust health, and not only comes perhaps out of a filthy barrack-room into a clean, airy, Avell-regulated and uncrowd- ed hospital, Avhich thus improves his tone of health and increases his chances of cure, but has his mind at rest also as to his situation after amputation, as he knows a pension is then provided for him. Different is the condition of the laborer, for example, from the country, who, from a perfectly pure air, immediately experiences the deteriorating influence upon his health, on entering a civil hos- pital in a city, (as is remarked also by our author, M. Velpeau, see vol. I., supra,) and as is familiarly known, however clean and well- regulated the hospital may be, is almost aJways attacked under this change of his customary food, air, &c, with a species of febricula or, perchance, fever, which Sir G. Ballingall appropriately denomi- nates a seasoning, and which he says, notwithstanding the reaction which is superadded to this by the amputation itself, should not deter us, in most cases, from proceeding at once to the operation, and thus take our chances for a favorable result from this combi- nation of the symptomatic and house fever together. But few sur- geons, however, would venture to go so far. Dr. Cormack (Lond. 4* Edinb. Month. Journ., Dec. 1844, p. 1046) thinks the patient should be allowed first to go through his seasoning fever, especially if there has been a rigor. As to what are called intermediary amputations, in contra-distinc- tion to primary and secondary, i. e., those during the existence of the constitutional reaction, they are compulsory, and not the time of choice which any surgeon would prefer. Secondary amputations, hoAvever, or those performed after the inflammatory and febrile action have subsided, and when suppura- tion has commenced, are, as is well known and as has been fully discussed in the text of our author, (M. Velpeau,) always preferred, by some surgeons, to those that are called primary. Sir G. Ballingall thinks the relative proportion of deaths and suc- cesses, from both primary and secondary amputations, and an ac- curate statistic also of the co-operating influences, such as those of the air, climate, constitution, the moral effect of victory or defeat upon an army, &c., would throw valuable light upon this sub- ject. T.] Article III.—Of the Place where the Amputation should BE PERFORMED. All amputations have been divided into two great classes : those 472 new elements op operative surgery. that are performed on the body of the limbs, take the name of am- putations in the continuity, (dans la continuite ;) the others are no- thing more than disarticulations, and are distinguished by the title of amputations in the contiguity. Amputations, moreover, are per- formed in a place of election, or one of necessity, according as the practitioner is free or forced by the disease to act on one point rather than on another. Upon this subject Ave can scarcely lay down other than extremely uncertain rules, for there are none of them that are not liable to numerous exceptions. Thus, it is not always correct to maintain that Ave ought to perform as far from the trunk, and remove as little of the parts, as possible; or that we should make choice of the place that is smallest, and is the least bulky. §1. It is the same with the rule Avhich prescribes that we should always amputate above the diseased tissues. Fatty degeneration by no means exacts the removal of the parts involved in it, since it may be of some advantage to preserve them; being the usual result of an alteration in hard parts, this as well as the fistulous pas- sages and the purulent tracks, disappear as soon as the cause has been removed. It is sufficient, in such cases, to make the section of the bone above the part where this itself has undergone an al- teration, without being at all disquieted by the state of the soft parts, especially if the case under treatment be the thigh or the upper extremity. §11. On this subject, the nature of the disease is to be considered as well as its seat. If the question be that of immediate amputation in consequence of shattering or extensive damage to the limbs, or wounds from fire-arms, or gangrene, inflammation, and suppura- tion still advancing, or cancerous tumors, the instrument should be carried as high up above the apparent seat of the evil as the im- portance of the organ will alloAV. If, on the contrary, the disease which requires amputation is a gangrene defined, a necrosis, caries, suppuration, fracture, compound dislocation, wound of an artery, a division from a cutting instrument, or a strangulation, and that the morbid process which has resulted from it, is purely local, and has no disposition to extend higher up, we may, without any im- propriety, take away that part only which has been actually dis- organized. § III. After traumatic lesions, it is generally advised to amputate at the articulation, or in the continuity of the bone above it; the acci- dents which, under such circumstances, supervene after amputation, being most usually imputable to the cracks (or splits—felures) which AMPUTATION OP THE LIMBS. 473 extend sometimes to the spongy texture of the upper articular ex- tremity of the bone which has been broken. M. Kerst remarks that the fissure is always made in the direction taken by the projec- tile. Following this indication, he has also, in cases Avhere the wound has been made from above downward, been enabled to amputate successfully at the distance of some few inches only above it. Article IV.—Preparations. § I. The attentions, physical or moral, which we should give to the patient, the preparations to which it is proper he should submit be- fore an amputation, are the same as for every important operation, and vary, moreover, according to an infinity of circumstances. Any time, season, hour of the day or night, may be selected for the per- formance of amputations, as well as for every other operation of urgent necessity. Generally, hoAvever, the morning is preferred if Ave are alloAved to delay, and this because it is more easy to watch the patient during the remainder of the day, than if he had been operated upon at nightfall. § II.—Dressings, (appareil, vid. Vol. I.) The instruments required to perform amputations that are the / most complicated, are a tourniquet, a garrote, a pelote provided with ' ahandle, (pelote a manche,) or other articles suitable to arrest tempo- rarily the current of blood in the limb ; knives of different lengths, a straight bistoury, a convex bistoury, a saAV with spare blades, (de rechange,) a dissecting forceps, curved and straight scissors, , cutting pincers, (tenaiUes incisives,) erjgnes, suture needles, and a '/v tenaculum. For the immediate dressing, (le pansement,) we re- quire single, double, triple, and quadruple waxed threads, of which the ligatures of different length and thickness are to be formed; strips of adhesive plaster, lint in the rough, (charpie brute,) in small balls (boulettes) and plumasseaux, (see Vol. I.,) long, square, / and also other shaped compresses ; bandages of linen, and some- times, those also of flannel. We must also have agaric, [or spunk or punk. T.] sponges, and warm and cold water in different ves- sels ; a small quantity of wine, vinegar, and cologne water; a ta- per, with coals, in a chafing-dish, and a few cauteries, upon the supposition that they may be required. A. Among these objects there are some which demand every attention from the surgeon. Thus the length of the knives should be in proportion to the size of the limb which is to be removed. Those of Wiseman and many of the ancient surgeons had the form of a sickle, for the purpose of dividing at once as much of the soft parts as possible. These curved knives, in general use for many centuries, and which are still employed by M. Onsenort for 474 NEW ELEMENTS OP OPERATIVE SURGERY. disarticulating the shoulder, have been entirely laid aside since the time of Louis, who clearly pointed out their inutility and disad- vantages. At the present day they are made perfectly straight, terminating in a blunt, wide point. Others, on the contrary, are rounded at their extremity. There are some, also, that are made very sharp at the point, having at the same time but little breadth. (*M. Weinhold, (Bull, de Fer., t. I., p. 140,) Avho, in order to com- plete the whole amputation Avith one instrument, invented a knife- /vy saw, (couteau-scie,) has just been surpassed by M. Cazenaud, (Rev. Med., 1838, t. II., p. 442,) who possesses a citexciseur by which limbs are amputated at a single stroke, as Avas already done at the time of Botal ! ) The best amputating knives, hoAvever, are those whose cutting edge is slightly convex, as recommended by Lassus, and whose width is a medium between the knives adopted by the members or pupils of the ancient Academy of Surgery, and those of some modern surgeons. Their point is neither too acute, nor is it rounded off square, (carrement,) so that it does not become ne- cessary to give to their heel a salient angle in front of the handle which sustains them. B. The saw is an instrument which has undergone still greater variations than the knife. It is important that it should have so much weight, as to require only to be drawn upon the bone, at the time it is in action. Its blade should be properly made tense (ten- due) immediately before the operation, have a slight degree more of thickness at the teeth than near its back, and a range suffi- ciently prominent (un chemin assez marque) to enable it in pene- trating to have a free and easy movement. This range (chemin) is given to it by the manufacturer in disposing of (en dejetant) the teeth alternately to the right and left. M. Guthrie recommends arranging these teeth upon two parallel ranks, so that in one their points incline forward, and in the other backward, in order, he says, that they may penetrate as well in advancing as in receding. This modification is not adopted with us. The saw used in England since the time of Pott and Hey, being very light, is more easy of management, (a conduire ;) but to be well-handled, it exacts more practice than the French saw. f The one that Brunninghausen (Operat. cit.) claims to be the inventor of before Heine, unites ac- cording to the author, the qualities of the ordinary saw with the advantages of that of Pott. The turning saw (la scie tournante) of VX X M. Thall (Archiv. Gen. de Med., t. I., p. 268,) is still of less import^ ance. This, however, is not an essential matter in an amputation. In cases of necessity, there is no kind of saw that may not serve our purpose. Victor Moreau performed his first exsection of the tibia, in 1788, with a joiner's saw, and M. Neve Avas compelled, M. Champion writes me, to make use of the same tool for an ex- section upon the body of this bone. Be that as it may, it is Avell in the order of regular surgery, that the saw should always have one or two spare blades; this is a rule which Fabricius of Hilden was induced to adopt, from hav- ing been forced to leave an amputation unfinished, until a second AMPUTATION OP THE LIMBS. 475 ' saw could be procured for him, to replace the one he had broken. As to the other articles of the dressings, I shall return to them in speaking of their special applications, or of amputations in par- I ticular. ^-—-J § HI.—Position of the Patient. In hospitals, we generally carry the patient to the amphitheatre, or to a ward specially appropriated for operations, (See Vol. I.) We there place him upon a table more or less elevated, and provid- ed with mattresses and folded sheets, (alezes ;) in certain cases, he is simply seated upon a chair properly arranged. Out of public establishments, we may also select a particular locale, but in gene- ral, we operate upon a bed or a chair in the sleeping apartment. §IV. The assistants (Vid. Vol. I.) should each of them have a particu- lar duty assigned to them, and that properly understood before- hand. One of them is charged with compressing the artery. For this purpose we generally select the strongest and tallest, or the one who has the most coolness and intelligence. A second embraces the limb near its upper part, in order to draw up the flesh. The third supports and fixes the part that is to be removed. A fourth is charged with handing the instruments, as they are required. Others seize hold of those various parts of the body, whose move- ments might interfere with the operator. § V.—To suspend the Course of the Blood, (See Vol. I.) Amputation of the limbs is the operation in which there is the most imperious necessity of provisional hemostatic means. All that I have said of these means, and of the mode of using them, (vid. the preced- ing and present vol.,) must be borne in mind here. Compression with the fingers or hands does not prevent our having recourse to the garrote or tourniquet. " The garrote, (says M. Champion,) is my favorite means of suspending the course of the blood, because it succeeds better than any other, and because it benumbs the limb." In a feeble subject it becomes a matter of consequence to pre- vent even the loss of a small quantity of blood; in the country, and Avhere assistants cannot be had, it becomes indispensable ; and is also a preventive precaution against consecutive hemorrhage when we are separated some leagues from our patient. " I have seen," says the same practitioner, " the only assistant who was ca- pable of compressing the femoral artery with a pelote, in a case of amputation of the thigh, faint away during the operation, so that the patient would have been exposed to the greatest dangers, if I had not taken his place." The perforated plate of the garrote ex- poses the ligature to be cut by its edges and I prefer a piece of strong leather. Loder says a single tourniquet is insufficient when 476 NEW ELEMENTS OP OPERATIVE SURGERY. the extremities are thin; otherwise we should have to make too violent a pressure. The garrote, properly applied, in no way in- terferes with our preserving a sufficient quantity of skin to unite the wound. CHAPTER III. OPERATIVE METHODS. Article I.—Amputations in Continuity. Amputations in the continuity of the limbs, which were over- looked in the time of Hippocrates, and almost the only kind since in use, during a long succession of ages, are still, at the present time, the most common ; they are performed in three different ways, but principally by the circular, or flap operations. § I.—The Circular Method. When we amputate by the circular mode, we have to look suc- cessively to the division of the skin, the section of the muscles, that of the bones, the hemostatic means, and the dressing of the wound. A. Division of the Skin.—Celsus, (De Re Med., lib. VII, cap. 33,) Archigenes, (Collect, de Nicetas, p. 156,) Gersdorf, (Sprengel, Hist. de la Med., t. VII., p. 314,) Pare and Wiseman, (Chirurg., etc., Vol. IL, p. 220,) as Louis, (Mem. de I'Acad. de Chir., t. IL, p. 248,) Dupuytren, (Leqons Orales, t. IV., p 298,) and many others have done since, divided the skin and certain muscles at the same stroke. It appears on the contrary, that Maggi (De Vuln. Bomb, et Slop., etc., 1552) drew it up at first to sufficient extent to be enabled af- terwards to cover the surface of the stump Avith it. This precept, nevertheless, was rarely followed in ancient times, and it is to J. L. Petit, (Malad. Chir., t. III., p. 136,) to whom the credit is due of having caused it to be adopted. I. After having circularly divided the cutaneous envelope of the limb, Petit caused it to be drawn up (faisait relever) by an assist- ant, or did it himself, to the extent of almost two fingers' breadth. Cheselden adopted the same mode, and nearly about the same time. It was Alanson, (Practical Observations, etc., 1779,) as it seems to me, rather than Brunninghausen, who was the first that advised to dissect it, and turn it back from below upwards, after the manner of a kind of ruff, as M. Richerand, (Nosogr. Chir., etc.,) and many AMPUTATION OP THE LIMBS. 477 other French surgeons have done, at a later period. MM. Guthrie, (On Gun-Shot Wounds, &c, 1815,) Graefe, (Normen fur die Ablos- ung grosserer Glieder, etc., 1812,) &c, are of opinion that we may, without any impropriety, divide the aponeurosis and some of the muscular fibres at the same stroke ; that we are thus more sure of thoroughly dividing the skin, and that this membrane then retracts with more facility. Hey (Observ. de Chir., edit, 1814) and Langen- beck (Biblioth. Chir., et Nosol und Ther.) are of a contrary opinion. II.—But what advantage is there in avoiding with so much care, the periphery of the aponeurosis and muscles ? Whether the knife penetrates a little more or a little less, so long as the teguments are divided through their whole thickness, the remainder of the opera- tion is rendered thereby neither more nor less difficult. Surgeons who, like Hey and M. Brunninghausen, (Nouv. Biblioth. German., t. II., 1821,) prefer to have the stump completely covered by the skin, have laid it down as a principle that we must first measure the circumference of the limb, in order to preserve two inches of the integuments, as, for example, when we are to have a wound of four inches in width. Lassus (Med. Oper., t. II.) says he has fol- lowed this practice Avith success. III.—In my opinion, precautions so minute are utterly useless. The best plan, when it is not our intention to cut down at once to the bone, is to divide with the amputating knife the different cellulo- fibrous bridles which attach the external envelope to the subjacent parts, while at the same time an assistant, or the operator, draws it back with considerable force towards the upper part of the limb. The pain is less acute, and the skin preserves a thicker lining than when turned up like a ruff, and nothing is easier than to raise it in this manner to the extent of two or three inches. To effect this division the hand of the operator is passed under the parts, and in describing an arc he brings the knife upon the anterior surface of the limb. It is unnecessary to follow here the advice of Mynors, (Practical Observations on Amputat.,&.c, 1788,) that we should incline its cutting edge from beloAV upwards in order to divide the integuments by a sloping edge, (en biseau.) They are to be divided perpendicularly, Avhile Ave draAV the knife from its heel to its point, making thus as complete and regular a circle as possible. The hand is first turned in pronation, and gradually comes into supination, as it passes from the inner side of and then underneath the limb. If we prefer making this incision at one stroke, the hand turns insensibly upon the handle of the instrument so as to become gradually placed into forced pronation in termi- nating the operation. By this means we avoid that disagreeable and fatiguing twisting backAvards (renversement) of the wrist that most surgeons make who do not wish to repeat their incision. With practice it is very easy to cut in the manner I mention; but I cannot see what great inconvenience there Avould be after having divided the skin upon the inside, outside and underneath, to with- draw the instrument, as a great number of French surgeons do, in order to re-apply it in front (en dessus) to unite by means of a 478 NEW ELEMENTS OF OPERATIVE SURGERY. second cut the two extremities of the first wound. However, this ;is clearly a matter of option and not of necessity. B. Division of the Muscles..—The section of the muscles more particularly is the point which seems to have occupied the atten- tion of operators for a century past. At the time of Celsus the knife was carried a little higher up than the dead parts (des parties mortes ;) the integuments and the whole thickness of the muscles were divided by the first cut; then the deeper muscles were de- tached and raised up in such manner that the bone might be sawed a little higher up, (un peu plus loin,) and these muscles afterwards be brought back upon the Avound. This precept of Celsus, which Pare ((Euvr. Complet.,hv. XIL, ch. 30, p. 339) and Pigray (Epito- me, p. 128-129) seem also to have adopted, was for a longtime ne- glected ; and Wiseman, J. L. Petit, and Cheselden, in making the division of the soft parts at two separate incisions, appear to have also themselves forgotten it. I. It was Louis who clearly pointed out that the conicity (coni- cite) [cone-like shape. T.] of the stump, an almost constant result of the ancient methods was owing much more to the retraction of the muscles than to that of the skin. He therefore advised that the muscular layers should be divided by two successive cuts. With the first incision Louis divided the integuments and superfi- cial muscles, causing them at the same time to be drawn back with as much force as possible, so as to favor their retraction by every means in his power. The deep layers were divided by a seconcj cut; after which he made the section of the bone in the ordinary manner. II. Le Dran (Operations, etc., p. 556) says: " With one stroke I divide the integuments and one half the thickness of the muscles; I then immediately cause the skin and flesh to be drawn back as much as possible, and make a second incision in a circular direc- tion and upon a line with the skin (de la peau) where it is drawn hack and divided. By this last I cut none of the skin, but only the muscles down to the periosteum." This process has much resemblance to that of Pigray (Epitome, p. 128, in 12mo, 1615) or Celsus, and differs also as we see but very little from that of Louis. But it is this last author to whom the credit is due of having made its importance appreciated. Jf! III. Valentin (Recherches Critiques sur la Chir., p. 135) in his Critical Researches on Surgery, conceived that in order to divide the muscles it was necessary to put them successively in a state of extension at the moment when the knife was about to be applied to them; so that in the thigh for example, while the instrument was making its circuit, the limb, in adopting rigorously the rule of Valentin, would have to be thrown first backwards, then outwardly, then forwards, and finally inwards. This whimsical recommenda- tion has not had and ought not to have any partisans. ■* IV. That of Portal (Acad, des Scienc, t. CXXXVUL, p. 693, in l2mo,Ann. 1777) who reversingthe precept of Valentin, recommend* that in dividing the flexor muscles the limb, should he held ia the AMPUTATION OP THE LIMBS. 479 utmost degree of flexion possible, and in a state of extension for the division of the extensor muscleSj has not met with any greater suc- cess, though according to the author, Marechal made use of it at the hospital of Strasbourg. V. Desault ((Euvres Chir., t. IL, p. 547) combined the methods of Petit and Louis, that is to say, he recommended with the first of these authors first to divide and draw back the skin, and with the second to divide afterwards the superficial muscular layer on a line with the skin as drawn back, and to begin the section of the deep muscles at the line Avhere the first had been retracted. VI. After having dissected and turned back the skin, Alanson divided the whole of the muscles with a single stroke of the knife, taking care to direct the cutting edge of his instrument obliquely upAvards, and to carry the point of it still more obliquely around the bone, with the view of obtaining a hollow cone whose base should be at the periphery of the womid. M. Langenbeck opposes this mode of proceeding, and Wardenburg, in maintaining the im- possibility of forming a hollow cone, by following implicitly the pro- cess of Alanson, says that the knife held obliquely will of necessity take a spiral instead of a circular direction. Loefler and Loder on the other hand endeavored to show that it was an easy matter to correct this tendency of making a spinal incision. It Avould ap- pear that MM. Langenbeck and Graefe upon this point have mis- conceived the process of the English surgeon. In fact Dupuytren constantly employed this process at the Hotel-Dieu Avith the greatest success. In order that the knife when carried obliquely may not deviate from the circular direction, it suffices to hold the handle properly, in proportion as the blade penetrates. Alanson moreover , had observed that it was principally by means of its point that we hollow out (creuser) a cone through the muscles. VII. In the process of Dupuytren an assistant forcibly draws back the soft parts ; the operator holding the knife by the mode of Alanson then divides the skin and the whole thickness of the mus- cles with a single stroke; he then immediately (sans desemparer) brings back the instrument held in the same manner, upon the base of the fleshy cone which is left upon the bone by the retraction of the superficial muscles. This is done with extreme rapidity, and the result of the process is the formation of a perfect hollow cone, which apparently is exceedingly favorable to the union of the wound. VIII. Bell (Cours de Chirurg., trad, par Bosquillon,) after having divided the skin in the manner of J. L. Petit, and the muscles accord- ing to the method of Wiseman, passed his amputating knife between these latter and the bone, in order to divide their adhesions to the extent of about two inches, and in this manner to raise them with greater facility. IX. All these processes have undergone other modifications which it is unnecessary to enumerate. The brevity of the text of Cel- sus has not prevented us from discovering ia this author the origin 480 NEW ELEMENTS OP OPERATIVE SURGERY. of the process of Petit, Louis and Bell, and even that of Dupuytren ■ hut if it be questionable that any surgeon at that epoch followed a method at all comparable with those which are adopted in our days, it is not so with that which Pigray describes in the following manner :—" After having drawn the skin back (avoir retire la peau) with the two hands, we must cut all the muscles around the limb above the disease; we then, with a split compress, (compressefendue,) raise up the divided muscle in order to saw the bone as high up (le plus haut) and as near the flesh as possible. The hemorrhage being arrested by caustics, astringents or the ligature, we bring back the skin in order to adjust it (la fixer) in front of the wound by two stitches of suture placed across it, (passes en croix.") X. What is remarkable in all these processes, in appearance so different, is this, that when closely examined the most of them lead to the' same results. Whether the skin and superficial muscles are divided with the first cut and the deep-seated muscles with a second incision after the manner of Louis; or we adopt, on the contrary, the rules laid down by Dupuytren ; or whether the section of the soft parts be made in three stages, as Desault recommends, or in the manner Alanson made this division, or as Bell advises ; so long as we take care to favor the retraction of the muscles, the bone is laid bare at two, three and four inches above the point Avhere the incis- ion commenced. The division of the muscles in amputations, in conformity with either this or that mode, is therefore a matter of much less importance than some people suppose. XL The process of Bell found, in 1829, a new champion in M. Hello, (These No. 258, Paris, 1829,) formerly a naval surgeon, who recommends that it should in every case be substituted for the process of hollowing out the muscles (de l'evidement, i. e., the pro-, cess of the hollow cone. T.) and it is the one M. Champion usually adopts. In the trials I have made of it, it has in reality appeared to me that the muscles thus detached re-adhere with greater facility upon the front part of the bone, and that they could be more rea- dily put in contact and kept approximated face to face, from the bottom to the borders of the wound, than by any other method. The only difficulty is that the operative process is a little longer and not so easy. XII. With the view of preventing too great a shock upon the system, Faure (Encycloped. Method. Med., t. II., p. 210) seriously proposes to take off the limb by a succession of operations (en plu- sieurs tems) in three, four or five times for example, at 4 to 5 days apart; the first section to comprise a fourth of the circumference of the part, 1 suppose ; some days after another fourth to be divided and so on to the conclusion. Faure even asks the question whether it would not be advisable to allow the first wound to cicatrize before proceeding to the second ! XIII. The author. The most rational, surest, and the most gene- rally applicable method is as follows:—The skin is divided Avith the first cut without endeavoring too scrupulously to avoid the subja- AMPUTATION OF THE LIMBS. 481 cent parts. An assistant raises it up while the surgeon divides the bridles which attach it to the aponeurosis or muscles, to the extent of two to three fingers' breadth. The knife iioav applied on a line with the retracted skin, passes circularly and perpendicularly through all the muscles down to the bone, or at least sufficiently near the bone for the superficial layer to be completely divided. The assistant again forcibly draws back the parts, and the surgeon, with a second cut, divides all the fleshy fibres of the deep-seated layer, at the point Avhere this layer passes under the retracted ex- tremities of the muscles that Avere first divided. Whether the knife be held obliquely or perpendicularly makes no difference in the final result; Avhether Ave go immediately doAvn to the bone or merely to the deep-seated muscular layer is all the same. In both cases, however, we have to make a second division of those fleshy fibres most adherent to the bone and at two or three inches above the place of the first division. I divide the tissues perpendicularly, in order to obtain a cleaner (plus nette) section and a less extended traumatic surface. C. The section of the muscles being completed, we raise them upwards by means of a retractor. Formerly they used for this purpose bags (bourses) of wool or linen, or pieces of leather, and even of metal. Fabricius of Hilden, Gooch, Bell, and Percy have severally extolled these objects ; but at the present time we require only a simple split compress, with two tails for the thigh and arm, and three for the leg and fore-arm. The undivided por- tion of this compress is drawn back upon the posterior in preference to the anterior portion of the muscles, as M. Graefe recommends; while its tAvo free extremities are crossed and turned back in front; the assistant Avho embraces the Avhole with the two hands thus draws the soft parts backwards, to protect them from the action of the saAV. It is requisite, moreover, that this split compress, to which some surgeons, smartly reproved for it by Petit, have objected on the pretext that it interferes with the action of the saw, should be made of strong linen and wide enough to extend beyond the sides of the wound. I. Before proceeding farther, most surgeons recommend dividing and carefully scraping the periosteum. It Avas with the back of their great sickle that Pare and Wiseman effected this denudation. Since that time the bistoury or the edge of an ordinary knife has been preferred for that purpose. Some with Graefe perform this from above downwards; others with Brunninghausen detach the periosteum in this manner from beloAV upwards, or like M. V. On- senort, form a flap with it in order to bring it down afterwards upon the section made by the saw. II. All those precautions are useless as Alanson, MM. Guthrie and Cooper, and before them J. L. Petit and Ledran, had already pointed out. The motive in recommending them Avas to obviate the increase of pain, or to prevent tetanus, exfoliation and inflammation of the bone as well as the suppuration of the surrounding parts j as if the periosteum could have the least to do Avith the production of 31 482 NEW ELEMENTS OF OPERATIVE SURGERY. such phenomena ! When it has been carefully separated, one of two things must happen:—1, The saw is applied a little higher up" than the surgeon is aware of, and then it is the same as if no regard Avas paid to it; 2, the saw is in reality applied to the de- nuded portion of bone, and in this case it Avould rbe strange if there should not remain higher up a small portion which has been deprived of its envelope. In fine, if the surgeon attains the object he has in view the precaution is injurious, and if he fails, it is, to say the least, useless. He must confine himself, therefore, to de- taching carefully the fleshy fibres with the knife or the bistoury. D. Section of the Bone.—Having done this, he embraces the limb Avith his left hand, placing the thumb immediately above or below the point Avhich is to sustain the action of the instrument. The saAV, held in his .right hand, is applied perpendicularly; we first move it rapidly Avith short cuts until it has Avorked itself a passage ; afterwards, we draAV it through the whole extent of its blade, pressing only moderately upon it. So long as it has not yet made its Avay through the thickness of the bone, we may move it with rapidity ; but as soon as it has nearly completed the section, we must proceed with the utmost degree of caution. It is at this moment that the two assistants Avho are holding the two opposite portions of the limb, must redouble their attention in order to keep these in their natural direction. If the assistant who holds the dis- eased portion, lowers it, the bone almost unavoidably breaks before being entirely cut through ; if he raises it, on the contrary, the pro- gress of the saw will soon be arrested, and the operation thus rendered more difficult. It is necessary that the operator should make himself familiar with handling this instrument, and when he uses it he should take care not to incline it either in one direction or the other. By attending to all these precautions, the bone is usually sawed off neatly. Nevertheless, if any points or rough- nesses remain upon the extremity, they should be immediately re- moved with the cutting forceps, (pinces incisives,) as is usually done, or what appears to me preferable, by means of a small saw, or when they are of considerable length, by using the same saw which has served for the amputation. % The edges of the sawed bone are usually quite pointed and sharp. Some practitioners, in- deed, as MM. Graefe and Hutchinson, have advised that these should be smoothed doAvn Avith a file, or with the cutting edge of a strong, short scalpel, but this practice has rarely been imitated by other operators. Theory and observation unite, in fact, in show- ing its inutility. . § II.—The Flap Operation. The flap operation which Sprengel (Histoirs de la Med., t. VII., p. 316) and Gagnier (These de Holler, 1734, t. V.) seem disposed to ascribe to Celsus, to Maggi and other ancient surgeons, such as Par«§ and de Hilden, Avas not, as it is generally believed, proposed for the first time by Lowdham, in his letter to Young, in 1679. We AMPUTATION OF THE LIMBS. 483 shall see farther on, that Leonidas and Heliodorus describe it with sufficient clearness. It consists in cutting at the expense of the soft parts one or two flaps, (plaques,) Avhich enable us to close the wound immediately and completely. After LoAvdham, this method was extolled and variously modified, by Verduin of Amsterdam, in 1696 ; by Sabourin, of Geneva, in 1702 ; and by Morand, De la Faye, (Acad. Roy. de Chir., t. IL, p. 243,) and Garengeot, (Ibid., t. IL, p. 261,) before the middle of the last century. At first op- posed by Koenerding, (Sprengel, Oper. cit., t. VII, p. 318,) coun- tryman of Verduin, and by Heister and many others, it was soon defended again by P. Massuet, (Amput a Lamb. Paris, 1751,) Le Dran, Ravaton, and Vermale. Since then, O'Halloran, Dupuytren, Roux, Guthrie, Klein, Kern, Langenbeck, Larrey, and a multitude of other surgeons, have frequently had recourse to it. Its history presents two epochs that are quite distinct; one that comprises all that Avas said of it in the last century; the other, that Avhich be- longs more especially to the present time. A. Appreciation.—Lowdham (Young, Currus Triomph. e tereb., 1679 ; Mem. de I'Acad. Roy. de Chir., t. II., p. 244,) maintains that the flap operation is more prompt and less painful, and that it ex- poses less to tetanus and hemorrhage than circular amputation, that it renders the ligature upon the vessels useless, prevents exfoliation, obtains a rapid cure, and allows of an extremely easy adaptation of an artificial limb. There is a considerable number of these advantages that expe- rience has not corroborated. In the first place we cannot see how the flap amputation can be less painful or be more certain to pre- vent tetanus than the circular method. Exfoliation is a rare occur- rence, instead of being constant, as it was then believed to be. As the artificial limbs (moyens prothetiques) are not to be applied upon the apex of the stump, it is a matter of indifference in this respect, whether the amputation has been performed by one method or the other. In fine, it is easy to perceive that we cannot dispense with tying the vessels, and that the wound scarcely ever cicatrizes without suppurating for a greater or less length of time. Its immediate re- union, however, is an incontestible advantage ; and did not the im- provements of the circular method allow of our accomplishing in most cases the same result, there is no doubt that the flap opera- tion at the present day Avould have been generally preferred. We must alloAV, also, that it generally enables us to avoid Avith facility the projection of the bones and the conicity of the stump, and to preserve as much of the soft parts as are necessary to uniting with- out traction the widest and deepest kind of wounds. B. Processes.—The flap amputation is performed by two general methods, the one from without imvards, the other from within out- wards. In one we divide from the skin to the bones, while in the other, we commence by thrusting the knife through the limb,-so as to cut the flap from the root to its free border. If the first mode is more regular and sure, the second is more rapid and brilliant. From without inwards, it is well to begin by dividing the integu- 484 NEW ELEMENTS OF OPERATIVE SURGERY. ments with a single stroke; we then cause the assistant to draw them back, in order that Avith a second cut we may effect the divi- sion of the muscles a little higher up. In proceeding in this man- ner, it is easy to give to the flaps the form and dimensions desired, but the operation requires several stages, and is not as rapid. If we plunge through the flesh, at first the point of the instrument, in dan- ger of striking against the bones, often wounds parts that we should have preferred to avoid, divides irregularly certain tissues whose exact (nette) section is a matter of some importance, and does not always alloAV of our cutting flaps as thick as they should be for the object we have in view. Nevertheless, this mode of operating has found in our times, especially in dissecting rooms, and among those who practise upon the dead body, numerous and intelligent partisans ; but it is scarcely ever employed, any more than the pre- ceding mode for amputation in the continuity. In conclusion, too much importance, as I think, has been gene- rally accorded to the flap operation. The wound which it causes has necessarily a much greater extent of surface than if it was cir- cular. The muscles which this mode deems it so important to pre- serve, are exposed to various accidents. If they should be attacked with inflammation, they suppurate most abundantly, absorb the fluid like a sponge, and favor to a remarkable degree purulent in- fection and phlebitis. On the other hand, they scarcely ever be- come adherent (se fixent) to the apex of the stump in the centre of the cicatrix. By whatever mode we may proceed, it is the skin which finally becomes united to the cut surface of the bone, and the side of the flaps through means of the retraction of the angles of the Avound, favors to a greater degree than any other method the protrusion of the bone. C. The flap method moreover presents a number of distinct mo- difications. Lowdham, Verduin, Labourin, M. Guthrie, and M. Graefe, confine themselves to a single loAver flap, which they bring up in contact with the bleeding surface. Vermale recommends cutting one on each side, and to make them by plunging the knife down to the spot where the bone is to be sawed. That we may not be deceived in regard to the length, he proposes, before we commence, that we should mark out with a red thread the point of departure and the point where we are to terminate. Ravaton and Bell, with one stroke of the knife, divide circularly the skin and the entire thickness of the muscles; another incision, which strikes upon the bone in front and behind, in a direction parallel to its axis, then allows of the separation of the two flaps, which are dissected off and raised up immediately after. The process of Vermale is at present the only one, or almost the only one, employed, even for the formation of a single flap. The mode of Ravaton ought not, in fact, to be followed. The circular incision which it first makes is altogether so much loss. The flaps cut out in this manner, square, have too much thickness at their apex, and interfere to a considerable extent with their immediate union. When, on the contrary, they are cut with slanting or bevilled edges, (en bee de AMPUTATION OF THE LIMBS. 485 flute,) they adapt themselves to each other accurately, even though we neglect the rule laid doAvn by Mynors, that the skin should al- so be divided in a very oblique direction at the expense of its deep- seated layers. D. Two flaps should be preferred when we have it in our power to give them nearly the same degree of width and thickness, where- as, if we are unable to give to either one of them the proper di- mensions, it is better to cut one only. If the wound or the disease which compels us to amputate should leave considerably more sound tissue on one side than on the other, and has thus in some degree indicated the character of the flaps in adArance, we should avail ourselves of it. After having completed the section of the bone, Ave then equalise the fleshy parts in order to cover the stump with them. Nevertheless, it becomes necessary in this last case, in order to close the wound, that the flap, if there be but one of them, should have considerable length, and that it should be bent almost to a right angle and submitted to compression and tractions, which nevertheless endanger the success of the operation. With two flaps, on the contrary, one in front and one behind, as M. Walther (Rust's Handbuch der Chir., t. I., p. 609) advises, the bleeding surfaces are adjusted to each other without the least diffi- culty. E. Kirckland, who excises the two angles of the wound, and M. Larrey, who confines himself to slitting them afterwards (apres coup) to the extent of half an inch, make in this manner a sort of flap operation out of the circular method. M. Sedillot has remarked that in most of the methods of disarticulations in which a flap is cut in terminating the operation, the knife almost always encoun- ters a difficulty in getting below (a s'engager) the bones that are to be removed; the angles of the wound moreover being stretched and bridled, are thus jagged (denteles) and cut to a greater or less depth by means of the instrument. To avoid this inconvenience, M. Sedillot incises at first about a third of the extent of the flap with the heel of the knife or bistoury, and afterwards experiences no difficulty in finishing the operation Avithout injuring (leser) the angles of the wound. In the continuity of the limbs, at the thigh, the upper part of the leg, and at the arm or fore-arm, M. Sedillot cuts tAvo small, short, rounded flaps, which are then raised up to complete the operation by the ordinary processes for circular ampu- tation. We thus unite the advantages of wounds with double flaps to those of circular amputation, the bones being covered over in a proper manner, and prevented from projecting at the angles of the wound. I have recently, says the author, applied this me- thod to the fore-arm, and obtained the most satisfactory results. We shall see, in describing amputations in particular, what are the cases which do not admit of this mode of operating. M. J. Cloquet has suggested that in certain cases, after having cut through the skin circularly, it would be better, instead of dividing the other soft parts in the same manner, to plunge the knife between them aad the bones, in order to cut from within outwards as in the flap method. 486 NEW ELEMENTS OP OPERATIVE SURGERY. Finally, Dupuytren, M. Larrey, and others have frequently endea- vored to combine the ovalar Avith the ordinary flap operation, by commencing with the division of the skin from without inAvards, and terminating with the division of the muscles from Avithin out- wards. § III.—The Ovalar Method, (methode ovalaire.) The ovalar method, though more recent than the two others, and already described in the commencement of this century by Chasley (Rust's Handbuck der Chir., t. I., p. 593) and M. Langenbeck, (Theses de Paris, 1803,) and by Lebas, (Bull de la Fac de Med. de Paris, t. V., p. 417-420,) who explains it in a memoir, upon which Beclard reported to the Society of the Faculty of Medicine, and afterAvards by MM. Guthrie and Richerand, for certain kinds of amputation only, was not in reality introduced into practice un- til in the year 1827, by M. Scoutetten, (De la Meth. Oval, ou Nouv. Meth., etc., Paris, 18.27.) According to this last surgeon, its great advantage consists in ahvays alloAving us to cut from without in- wards, that is, from the superficial to the deep-seated parts, as in the circular method, and of preserving also a sufficiency of the flesh and soft parts to enable us Avith ease to bring the lips of the Avound into coaptation, as in the flap operation ; so that it occupies, as he says, the middle ground between the two other methods, and is the link Avhich either separates or unites them. It is certain, that by the ovalar method, we obtain a neat and regular division; that for the most part, we may preserve a sufficiency of tissues to undertake immediate reunion; and that there are but feAV points upon the limbs to which it is not applicable, unless it be in the continuity of such as present length enough to make the circular or flap method easy and sure. Its distinctive characteristic is to form a Avound of an ovoid shape, as already pointed out by Lassus, in 1793, M. Chasley, in 1803, or 1804, and M. Langenbeck, in 1809, and on Avhich ac- count M. Scoutetten has given it the name which I have retained. It consists of tAvo processes which differ but little from each other. In the one case, which is the most ancient, the operator begins by circumscribing a triangular flap in the form of an inverted V, a little under the place Avhere he proposes to use the saw or to disar- ticulate the bone. After having depressed the summit of this tri- angle, and separated the tAvo lips of the wound, he passes from above downwards, or from one side to the other, using the saw in amputations at the continuity, and the knife in cases of disarticula- tion, grazing the posterior and deep-seated surface of the bone, and terminating by uniting the tAvo first incisions at the base of the V, where the vessels had been preserved. M. Scoutetten prefers giving at the very first a perfectly oval form to his incision; ex- cept that he takes care in passing under the plexus of vessels and nerves and near the point which is to form the larger extremity of the oval, to go no deeper at first than the tegumentary tissues. This is no farther important than that it gives a little more regularity AMPUTATION OP THE LIMBS. 487 to the incision. The oval method has the advantage of uniting all that is most approved of, both in the circular and flap processes. I have frequently used it, but shall examine it more in detail in the chapter on Amputations of the Joints. Article II.—Amputation in the Contiguity. The perusal of the works of Hippocrates teaches us that there was a species of amputation at the joints, sometimes practised among the ancients. Galen and Heliodorus also speak of it in suf- ficiently clear language. The Arabs themselves were not ignorant of it, and Sprengel is evidently in an error Avhen he says that, from the time of the Greek Avriters doAvn to Munnicks, nobody makes any mention of it. Guy de Chauliac states positively that, " if the disease (la corruption) invades the immediate neighborhood of the joint, (jusque pres de la jointure,) the limb should be taken off at the joint itself, by means of a razor or other instruments, and without sawing, (sans scier.") Nor has Pare passed it over in silence. Fabricius of Hilden, speaks of it as a common process ; and Pigray thus expresses himself upon this subject: " Some start objections to cutting in the joint itself, or near it, because of the nervous parts, (parties nerveuses;) nevertheless, the dangers from these are not so very great: / have seen many such (amputations) which have done well" The labors of Ledran, Morand, Heister, Brasdor, and Hoin, therefore, have done no more than to revive this operation, by dis- pelling the prejudices Avith Avhich the physiology of the middle ages had invested it. It is performed like amputation in the conti- nuity in three principal ways, but more especially by the flat or the ovalar method. We shall see, farther on, hoAvever, that the circu- lar method is perfectly applicable to it, and that this ought, in a large number of cases, to have the preference. The advantages of disarticulation are, that it is more prompt and easy than amputation in the body of the limbs; that it does not re- quire the section of the bones, is more favorable to immediate union, and enables us to preserve a longer stump. Its disadvan- tages, at least in a large number of cases, are : that it lays bare ex- tensive osseous or cartilaginous surfaces ; that it obliges us to carry the instrument upon the thickest parts of the bones, which are least abundantly supplied with soft parts, and to make use frequently of tendinous or synovial tissues for closing the wound; and that it also makes a solution of continuity, someAvhat irregular : but it is not true, other things being equal, that it endangers, more than am- putation in the continuity, as had been for a long period thought, nervous symptoms, tetanus, abscesses, purulent collections, and symptoms of general reaction. It requires but feAV instruments, and no necessity of such complicated dressings as are demanded in am- putation in the continuity. A knife or simple bistoury are generally all that are needed to perform every step of the operation. So also have we less to fear from the conicity of the stump, the projection of the bones, or the retraction of the muscles. As the soft parts are 488 NEW ELEMENTS OP OPERATIVE SURGERY. but slightly displaced, the adhesion of the flaps is obtained with facility, and the inflammation proceeds no farther than is requisite to secure immediate union. The division acting only on the skin, the cellular and fibrous tissues and some of the attachments of the muscles; inflammation, abscesses, and constitutional reaction, are in general but little to be apprehended. Though very large in ap- pearance, the wound has in reality but very little extent; because the cartilaginous surfaces at the bottom of it, being deprived of all sensibility and wholly inert, take no part in the process of suppu- ration or inflammation. M. Kerst, professor in the military hospi- tal of instruction at Utrecht, prefers, as a general rule, disarticula- tion to amputation in the continuity, because from the last Ave have to apprehend traumatic fever of a pernicious (pernicieuse) and in- termittent character, together with inflammation of the veins in the sawed bone. The dread Avhich prevailed among surgeons of the last century, of Avounding the inter-articular (diarthrodiaux) cartilages, exposing them to the air, and touching them Avith the instrument, is at the present day entirely dispelled. In place of all those precautions formerly recommended in order to avoid the articular surface, which constitutes the bottom of the stump, some modern surgeons go to the extent of advising that it should be wounded expressly. For example, M. Gensoul (These No. 109, Paris, 1824) is of the opinion of Richter and Bromfield, that, in scarifying it (la de- coupant) Avith the point of the knife, we have a better prospect of cicatrization by the first intention. This practice, adopted also by some surgeons of Paris, and Avhich is attended with no inconve- nience, seems, nevertheless, to be sustained upon a position Avhich is far from being demonstrated. In fact, it is incorrect to say, with Beclard and many others, that after amputation in the contiguity, [i. e., in the joint, vid. supra. T.] the smooth face of the cartilage does not unite with the flaps, but remains free even after the final cure, unless by some means or another, inflammation has been ex- cited. This can only take place by exception. Whether the in- strument comes in contact with it or not, it nevertheless contracts, and that speedily, firm adhesions with the tissues that cover it; and it is as useless to scrape it with a scalpel as to cauterize it, in the manner practised in the time of Heliodorus. If the agglutina- tion is not immediate, the cartilaginous surface, acted upon by the cellular granulations which are formed upon the bone, soon de- taches itself, sometimes in fragments, sometimes in large pieces, (plaques,) at other times in the form of a shell, (coque,) and soon completely exfoliates, leaving exposed a vermilion-colored wound, which afterwards cicatrizes with great facility. In the contrary case it does not perceptibly change its appearance ; it only loses its polish and becomes rugose, (rugueuse;) but a molecular action soon developes itself, erodes, (miner,) and insensibly dissolves it, untiJ it has totally disappeared. Constituting the true epiderm of the bones, and consisting of a simple anhiste (anhiste) tissue, it cannot, with the attributes that belong to it, exist any longer than AMPUTATION OP THE LIMBS. 489 while the articular movements are preserved. As soon as the liv- ing tissues rest permanently upon it, (la touchent a demeure,) the vitality of the bones, properly so called, begins to act upon it and to destroy it, by creating the cellulo-fibrous deposition, (couche,) which is the base of every sound cicatrix ; unless in its actual state of cartilage, (veritable epichondre,) it becomes agglutinated to the soft tissues, by becoming, as M. Champion thinks, organized and blended Avith them. By one mode or the other, the tendons, apon- euroses, nerves, and vessels, ultimately become firmly adherent upon the extremity of the stump, so much so, that the patient is enabled to move it with as much facility after the cure as before the operation. When the articulation is surrounded with a large capsule, it is well to remove as much of it as possible with the bone, without however giving ourselves any great uneasiness about such part of it as may remain. In place of leaving the tendons hanging out of the wound, they should on the contrary be cut off as low down as possible, that their presence may not interfere Avith the immediate union. The incision into the fibrous and synovial sheaths, as recommended by Garengeot and Bertrandi, with the view of pre- venting their inflammation and the formation of purulent collec- tions, is useless, and should not be practised unless there are par- ticular indications for it. The fistulas Avhich sometimes follow amputations at the joints, are owing either to some point of the cartilaginous surface which has not exfoliated or become adherent to the flap of the soft parts, continuing to exude synovia ; or to one or more of the tendinous sheaths which have not closed, furnishing fluids of the same nature in quantities sufficient to become an impediment to the agglutina- tion of the tissues. These difficulties are in general very easily overcome, and almost always without any serious consequences, by means of compression, stimulating injections, cauterization, &c. Moreover, amputations in the continuity are by no means abso- lutely exempt from such accidents. If, therefore, in amputating below the articulation we can remove all the disease, and at the same time preserve a sufficiency of tissues to close the wound, am- putation in the continuity ought to have the preference ; on the contrary it is better to amputate at the joint than to go above it. On the other hand, if in amputating at the articulation we should incur the risk of not removing all the disease, we should renounce it and carry the instrument higher up. When in amputating in the continuity Ave are obliged to make the section of the bones too near the great synovial cavities, disarticulation is the preferable course. The danger of purulent arthritis is then too imminent not to justify the immediate sacrifice of the joint. All these questions, moreover, have been judiciously examined by M. Sedillot, (Thise de Con- cours, 1836.) In conclusion, the extirpation of the limbs is not more dangerous than their amputation, properly so called, and it is the extent of the disease and the functions of the organ to be re- moved, which are to influence the surgeon in his preference for 490 NEW ELEMENTS OF OPERATIVE SURGERY. one of these methods over the other, in the particular cases that present. Article III.—The Dressing. § I.—Hemostatic Means, (hemostasie.) To prevent the Aoav of blood after amputations, is one of those indications Avhich has most engaged the attention of surgeons at every epoch ; and Avhat I have said of hemostatic means in treat- ing of operations in general (vid. Vol. I.) are especially applicable to amputations. A. At the present day we are no longer under the necessity of recommending to surgeons the remedy eulogized by Galen, of one part incense and a half of aloes with the white of an egg; nor the mushroom nor puff-ball (vesse de loup) vaunted by Van Horn, and revived by Vurtz, (La Chirurgie, p. 36 ;) nor Fowler's powder, nor hog-excrement, nor the powder of burnt agaric mentioned by Char- metton, nor the thrusting the arm into the bowels of a cock opened alive, after having cut off the Avrist, as did that brute mentioned by F. Platter, (Bonet, t. III., p. 145, liv. 4, obs. 25 ;) nor the animal oil of Dippel given internally by Schulze, (Rondelai, Hemorrh. Internes, p. 90.—These de Paris, in 8vo.) The hemostatic bladder, used by Gersdorf, (Chirurgien d'Armee in German, p. 63, 1527,) reintro- duced by Wiseman and afterAvards by Fabre, (Essais sur divers Points de Physiologie, p. 160,1770.—Recherches des VraisPrincipes de I'Art de Guerir, p. 531, 1790,) and on one occasion made trial of on the fore-arm with success by Frescarode (Fabre, Recherches, &c.,p. 278, 1783) are equally useless. Nor has the reunion of the womid by Aaps (lambeaux) and compression, which ansAvered the purpose with Verduin and Sabourin, and which Kock has so much eulogized, and Smith employed, any longer to be dismssed, even though we should combine Avith it like Garengeot (Mem. de I'Acad. de Chir., t. IL, p. 180; and torn. V., p. 263) a ligature on the principal artery. It is effectually the ligature or torsion that we must have recourse to after amputations, unless in cases alto- gether of an exceptional nature. B. It was for a long time thought advisable to include a certain portion of tissue in the ligature upon each artery. If Fabre is to be believed, Oper. cit, p. 278, 17S3,) it Avas Ferrand who first resorted in amputations to direct ligature upon the artery, (a la ligature de l'artere immediate.) The author of a thesis upon sur- gery at that time also made the same remark. Desault (Journ. de Chir., t. IV., p. 203) according to Bichat (Eloge de Desault, par Bichat, p. 43) had recourse to this means, Louis being present, at the Bicetre in 1779, and before any other modern. Pouteau (An- cien Journ. de Med., t. XLVIIL, p. 440, 1777) recommended also that the artery should be isolated on each side the ligature, in order to prevent accidents. Nothing analogous to this is in practice at AMPUTATION OF THE LIMBS. 491 the present day. The tenaculum of Bromfield under this point of vieAV has naturally carried us back without any disadvantage to the time of Avicenna ; the artery is to be denuded, (ecorche,) that is, stripped of the fiesh that invests it, says the celebrated Arab, (Guy de Chauliac, trad.de Mingelouseaulx, t. I., p. 112; Des Plaies, ch. IV., Quatrieme Faqon d'arreter le Sang;) we then seize hold of it Avith a small hook, draw it gently outAvard, pass under it a thread of silk, and then tie it with a firm knot. In order not to entrust to an inexperienced assistant the direction of the ligature, Brunninghausen (Exper. et Obs. sur I'Amput.—Gaz. Med. Chir. d'Ehrhart, 1818, et Nouv. Bibl. Germanique, t. IL, 1821, p. 51) makes use of a small fork (fourchette) with blunt points, by means of Avhich he passes the thread above the artery, until the assistant has tightened the knot outside of the wound, and in a horizontal direction. As large as well as small arteries are to be tied, the author has had constructed a double instrument, the branches of which separate farther apart on one side than on the other, so that by means of the narrower extremity (sa plus etroite extremite) we may also bring up to a level with the wound the arteries that have retracted too deeply, and likewise separate them from the nerves and other parts with which they may be united; but the spring forceps (pinces a ressort) described in the article on torsion, (vid. Vol. I.,) and the pinces-porte-naeuds, as contrived by MM. J. Cloquet and Colombat, would be much preferable, if under such circumstances there should be any necessity of a particular in- strument. The ligatures required, also sometimes amount to a considerable number. Loder (Bibl Germ. Med. Chir., trad. Franc., t. II., p. 94) relates that he was obliged in a case of amputation of the leg in an infant, to use sixteen before he could effectually arrest the hemor- rhage. In another case he used nineteen, and several smaller arte- ries Avere included in the same ligature. The first case recovered in twenty-five days; but in the other the fiap, on removing the dressing on the fifth day, was found to have become detached. In other cases there is no hemorrhage, and the ligature is inapplicable, for we find no arteries, (Taxil Saint-Vincent, Jour. Univ. des Scienc. Med., t. —, p. 324.) I have elsewhere detailed (Jour. Hebd. Univ., t. I. et II.) numerous examples of this kind. Zinc (Chalmail, Recherches sur les Metastases, p. 265) has seen this in the fore-arm, Chalmail (Chalmail, Op. cit, p. 265) in the arm; Leveille, Briot, and all army surgeons have frequently made the same remark, (Gaultier de Claubry, Jour. Gen. de Med., t. XLVIL, p. 238.) It is necessary that the ligatures should be very firm. Morand (Opusc. de Chir., t. IL, p. 26S) on one occasion found that all the ligatures handed to him snapped, the threads, according to the author, hav- ing wasted aAvay from their being so old. After this nothing is more embarrassing than ligatures that are too long; fifteen inches is enough for each. The blood arrested at first may afterAvards reappear. Tetu (Re- cueil de M€d. et Chir. Milit., t. XXII., 3 Nov., 1827) amputated 402 NEW ELEMENTS OF OPERATIVE SURGERY. the fore and middle fingers with the corresponding metacarpal bones; in spite of the ligatures the hemorrhage was renewed an hour after, and a ligature upon the deep palmar arch (crosse palmaire profonde) became indispensable. Sometimes hemorrhage takes place from the end of the bone. In a case of this kind A. Petit (Acad, des Se, Paris, 1732, Mem., p. 39) succeeded with lint in the mouth of the vessel. Hevin (Pathol et Therapeut., t. IL, p. 40) used Avith advantage a plug of wax. In Loder's case of 19 ligatures, (Obs. Med. Chir., Jena, 1794, dans Bibliot. Germ., t. II., p. 94,) the blood issued copiously from the medullary canal (la moelle d'os) of the bone of the leg. To arrest it he was obliged to use eau d'arquebusade. We may be obliged to tie the veins. I have, says M. Champion, had to tie the femoral (crurale) vein which was throwing out blood in jets, (par saccades,) in a case of amputation of the thigh, per- formed upon a man who had become excessively nervous from fear of the operation, and who, after it was performed, experienc- ed prolonged paroxysms of suffocation, (des suffocations prolon- gees.) The same thing has occurred to me on three occasions; the ligature of the veins therefore after amputation, as I have already said, does not appear to me so dangerous as has been as- serted. [On the method of tying arteries, &c, see Dr. Mott's re- marks at the conclusion of this section of M. Velpeau's work, supra. T.] § II.—Disposition of the Wound. Being now secure against hemorrhage, (vid. Vol. I.,) the surgeon has to attend to the dressing. It is now that the great question of immediate or secondary union presents itself. From the time that Lyon (Alanson, Manuel Prat, de VAmput, 1765) suggested to Park the idea of bringing the parts in contact (affronter) upon the centre of the stump, to obtain union by the first intention, and that Alan- son brought the practice into vogue ; from the time Avhen, in ac- cordance with the English surgeons and the fiap method, M. Mau- noir made himself the champion of it, immediate reunion has be- come so generally adopted that it is had recourse to after almost every kind of amputation. But I have elsewhere (see Vol. I.) treated of this subject too much at length, and its advantages and inconveniences, as well as of the different sorts of dressings appli- cable to amputations, (see same volume,) to make it necessary to recur to it in this place. I shall not, therefore, speak of it again except when treating of each amputation in particular. Surgeons, however, have not confined themselves to the adoption of these different methods separately ; it has been proposed by some per- sons to blend them and to combine many of their stages, (d'en r«3- unir plusieurs temps,) with the view of profiting of the advantages of some and protecting ourselves from the inconveniences of others. It is in this manner that O'Halloran (New Method of Amput, 1765,) adopts the following modification, which, in his opinion, AMPUTATION OF THE LIMBS. 493 ought to conciliate the suffrages of all in favor of Lowdham's mode of amputating. Instead of depending upon compression to suspend the hemorrhage, he advises, like Garengeot, that we should tie the arteries with care, and in order to be sure of having no serious difficulty at the stump, he proposes that the dressings should be flat, (a plat;) that the flap should be left to suppurate for eight or ten days; and that Ave should then, as soon as it covered with cellular granulations, raise it up and adjust it properly to the rest of the wound. White (Cases in Surgery,etc., 1770)and Paroisse (Opuscules de Chir., 1806) assert that they have practised this mode in a great number of cases and Avith the most perfect success. For my own part I am convinced, from the trials I have made of it for the purpose of secondary immediate union, (reunion immediate secondaire,) that with us it has not been properly appreciated, and that in a great number of cases it possesses incontestible advantages, (see Vol. I.) What O'Halloran added to the process of LoAvdham, Beclard proposed for that of Vermale, when the flaps are formed of tendinous parts, fibrous troughs, (coulisses or sheaths) and syno- vial sheaths. Article IV.—Consecutive Treatment.—(Soins cons6cutifs.) The patient being carried to his bed must be placed there in a comfortable position; a hoop (cerceau) is made use of to sustain the weight of the bed clothes, and to hinder them from pressing upon the stump, which latter is to be placed gently upon a cushion or upon a sheet folded in the manner of afanon (vid. Vol. I.) § I.—Position of the Stump. It is the practice invariably to have this part slightly raised, in order that the muscles may be relaxed, and also according to some persons for the purpose of counteracting the tendency of the fluids to gravitate (a se porter) towards the wound. There are in fact some advantages from it in this point of view so long as there is no suppuration. But in the contrary case we evidently thereby favor inflammation along the inter-muscular cellulaT passages, (trainees,) the denudation of the bones, phlebitis, the formation of abscesses and purulent infection. The wisest course therefore is to follow the advice of Hippocrates and Alanson, that is, to leave the stump, should the form of the limb admit of it, upon a horizontal plane, and even to place it upon an inclined one, as soon as the suppuration is about to be established. § II.—Immediate Medication. A spoonful or two of pure wine might be proper to relieve the torpor or sinking temporarily produced by the operation; during the remainder of the day we give a few spoonfuls of some anodyne and mild anti-spasmodic potion; and for a drink, infusion 494 NEW ELEMENTS OP OPERATIVE SURGERY. of linden, (tilleul,) violet, poppy, &c, sAveetened Avith syrup. Ex- cept in patients who have been debilitated by long suffering, absti- nence at first, in the opinion of most surgeons of Paris, should be rigidly adhered to. According to them, the most that is admissible is a little diluted broth, (bouillons coupe) until the general reaction has taken place. This is a practice which I have renounced for many years past. If the patient has an appetite, and the consti- tutional reaction is moderate, I give him broths the first day, a po- tage on the day after, and put him on the fourth part of his usual food (je le mets au quart d'aliments) on the fourth or fifth day. Unless it be the thigh or leg that has been operated upon, I change the patient as little as possible from his ordinary diet, and treat him as a convalescent. §111. Furthermore, the regimen after amputations ought to be the same as after acute diseases, and all the greater operations, (see Vol. I.) If the patient is robust and sanguine, and the operation has been performed for a recent injury, and there has not been much hemor- rhage, congestion (le refoulement) of the fluids is to be feared, and we may resort to bleeding and depletives. In France, the import- ance at this time of diminishing the volume of the blood to pre- vent internal inflammation, and the dangers of general reaction, has been greatly insisted upon. In Germany, England, and America, hoAvever, many operators follow an opposite course. Kock, on the very first days, allowed his patients coffee, wine, and even meats. M. Benedict affirms that the bleeding, instead of preventing acci- dents, favors their development. It is those Avho are the strongest and are the most sanguine, who best resist, he says, morbific causes, and in whom inflammations are most easily cured. Therefore, the more we debilitate persons amputated upon, and the more they are bled, the more are they disposed to become sick, and the more dan- gerous and difficult to treat are the inflammations with which they are attacked. The severe dieting and the copious bleedings, pre- scribed by some persons, and immediately after amputations, only become really serviceable at the moment when incidental (inter- current) diseases and local inflammations make their appearance, (see Vol. I.) §IV. In ordinary cases, the first dressing should not take place until at the expiration of seventy-tAVO hours, or of four days, or even sometimes five or six, as recommended by C. Magati and Monro, and as still practised in Spain. In general, patients have much dread of it. Once, in fact, it Avas to them a formidable affair. No precaution was taken to prevent the adhesions of the lint and com- presses to the bottom or sides of the wound. Being performed upon the next or the second day after the operation, and consequently, AMPUTATION OP THE LIMBS. 495 before suppuration was established, it Avas calculated to produce Buch severe pain as to leave an impression upon the minds of the patients as fearful almost as that of the amputation itself. In this respect, patients of the present day are agreeably disap- pointed. The pieces of linen besmeared with grease, (les linges graisses) Avhich Bromfield (Alanson, Man., etc.,]). 33) was the first to introduce into practice, or the strips spread with cerate always render easy the separation of the other portions of the dressing. At the end of three or four days, the natural moisture and exuda- tions from the Avound have destroyed the adhesions which would have necessarily produced some traction, so that the first dressing causes no more pain than the subsequent ones. We should be on our guard, therefore, against imitating those busy-bodies (commeres) who are found even in hospitals, and who, under the idle pretext of seeing what is going on in the stump, wish to have the dressings removed on the first day. We should not, however, hesitate in re- moving them if any accidents supervene, such as violent pains in the wound, erysipelas, swelling or hemorrhage. In summer, or when the bandage becomes saturated, and emits much smell, it may also be proper on the first or second days, to remove all the pieces which do not bear directly upon the Avound, (see Vol. I.) In dressing, an assistant takes charge of the stump, Avhich he supports gently with his two hands, taking care not to give it the least sudden movement. The bandage and compresses, impreg- nated with blood and other fluids, are for the most part, glued to- gether and hardened by drying, to such degree, that their removal sometimes becomes a matter of considerable difficulty. In such cases, if by saturating them with warm water we do not suc- ceed in softening them, we must cut off the turns with a scissors. These first pieces being detached, we Avet the lint freely with water, and remove only the outer pieces, should they still adhere too firmly. As soon as the wound is uncovered, it should be washed; we do this by squeezing gently warm water upon it, and afterwards cleans- ing it with fine linen or small balls of lint; after which, the dress- ing is reapplied as at first, to be repeated every day in the same manner. If immediate union has been attempted, and no special accident has supervened, we defer to a still longer period this first dressing. Nevertheless, as it is rare that the agglutination at the first is com- plete at every point, it is likewise a rule to cleanse the stump on the third, fourth or fifth day. If no suppuration makes its appearance, and there should be no reason to believe that there are sinuses forming or appearing, (qu'il se forme ou se prepare des clapiers,) we should avoid meddling with the lips of the wound; at most, it is allowable to remove one of the strips of adhesive plaster to re- place it immediately by another. In the contrary case, and when the plasters have become loose, they should be removed in suc- cession, and the purulent and other matters, by means of gentle pressure, be encouraged to make their way outwardly. To detach these strips, they are to be raised successively from their extremi- 496 NEW ELEMENTS OP OPERATTVE SURGERY. ties towards the apex of the stump, on which point they are not to be separated until at the end of the dressing; otherAvise, were we to take them off from one side to the other without stopping, we should run the risk of destroying the adhesions which at this time are too feeble to sustain the least degree of traction. § V. The ligatures ordinarily do not come away before the eighth or tenth day, and after they have, by means of ulceration, completely cut through the artery they embraced. It would, therefore, be im- proper to endeavor to force them aAvay at an earlier period. But as soon as they delay coming away beyond that time, there Avill be some advantage in pulling upon them a little as often as the dress- ing is removed. Their retention is OAving to their having been caught in some sinuosities, or from the knot having imprisoned some fibrous lamellae as well as the artery. Their separation, more- over, is the more speedy in proportion as their application has been more directly made upon the vessels, (plus completement imme- diates.) Everything induces to the supposition that their presence ceases to be useful after the second or third day, and that there would be no impropriety at this time in disembarrassing the wound of them, provided the thing was easy of execution. I have seen them after amputations of the arm or leg, come away on the third or fourth day without any inconvenience. Bonfils, (These de Stras- bourg,) who maintains that after the sixth day we should hasten their separation, proposes even that we should subject them to a sort of permanent extension ; to carry out this object, which MM. Kluge (Bull, de Fer., t. X.) and Law (Ibid., t. XII., p. 234) have proposed to lay down as an axiom, they recommend that the knot should be tied outside and upon pieces of sponge. That we may not have to resort to what J. L. Petit (Malad. Chir., t. III., p. 196) did, who was obliged to divide at the bottom of the wound a liga- ture that did not come away, and in order to avoid, also, drawing forcibly upon them at every dressing, as soon as the inflammation has subsided, as is recommended by Alanson, (Oper. cit, p. 76,) M. Pierron (Thise No. XII, Paris, 1824) proposes that Ave should sub- ject them to a permanent torsion, which is to be increased daily; but it is not often that surgeons of the present day require any such means. Article V.—Accidents. The accidents which may succeed to amputations of the limbs are important and numerous. Some of them occur at the moment of the operation, and the others at a greater or less distance of time afterwards. § I.—During the Operation. A. Hemorrhage.—In feeble subjects the loss of blood during the AMPUTATION OF THE LIMBS. 497 operation is a thing calculated to give rise to serious consequences. It takes place sometimes before we have had an opportunity to tie the vessels, either because the tourniquet has been loosened or dis- placed, or from the assistant not making the compression properly, or because unexpected difficulties present themselves in seizing hold of the arteries. It is to avoid these difficulties that a sug- gestion has been made to place a ligature upon the principal artery of the limb before commencing the incision of the soft parts. M. Blandin gives an example of this practice, which is still follow- ed at the Hospital of Beaujon, by M. Marjolin. M. Guthrie and some others have thought it more advisable to tie the arteries in proportion as they are cut. When the ligature is impracticable, our art possesses no other resources than mediate or immediate, and lateral or perpendicular pressure. But there is another kind of hemorrhage, to which these means are not applicable : I mean hemorrhage from the veins, and which, nevertheless, is in some persons exceedingly abundant and some- times alarming, being produced by the temporary compression pre- venting the blood from returning to the upper part of the trunk, or caused by some obstruction in the respiration. To arrest it, some persons have proposed to apply a ligature on the principal vein. Monro, Bromfield, Hey, and M. Guthrie are of this opinion. With us, we generally proceed in a different manner. We remove im- mediately everything Avhich can produce any obstruction in the course of the blood through the limb. The patient is directed to make long inspirations, and the difficulty subsides almost immedi- ately. I have already remarked, that a ligature upon the veins has nothing in it alarming, and that, in persons who have been am- putated and who are already too much enfeebled, we must have recourse to it, if the other means do not promptly succeed. B. The syncopes and swoonings which result from the hemor- rhage, or the pain, or from the fright which the operation sometimes causes to the patient, require scarcely other than moral means, a spoonful of wine when they are anticipated, cold water, vinegar, or Cologne-water, thrown in the face or held to the nose, and all the other means generally resorted to under such circumstances, and which require no further detail. C. Spasms.—It is not uncommon, immediately after the opera- tion, to see the stump take on a trembling which it is difficult to re- strain—a sort of convulsive or spasmodic movement, which also requires some attention. Under such circumstances Ave endeavor, suddenly and as strongly as possible, to divert the attention of the patient, and to inspire him with courage ; we make him seize hold of his leg himself at its upper part, or, should it be thought more advisable, cause this to be done by an assistant, with both hands until the dressing is finished. In general, this symptom continues but a short time, and disappears in a few minutes. It is generally relieved by compressing the muscles with force upon two different circles of the stump. Nevertheless, if it should seem disposed to continue, the stump, as soon as the patient is in bed, should be se- 32 498 NEW ELEMENTS OP OPERATIVE SURGERY. cured by a sheet or by a napkin, folded in the manner of a cravat. It is then also that some of the preparations of opium are particu- larly indicated. D. After being placed in bed, some patients complain of acute pain. This pain, which in some is nothing more than the smart- ing of the wound, which subsides in a few hours, is increased in others so as to cause them to cry out, and to be under strong ner- vous excitement. We should then saturate the dressings with nar- cotic liquids ; for example, decoction of marsh-mallows with lauda- num, giving at the same time powerful doses of opium internally. When patients refer their pain, as is very common, to the limb they have lost, Ave must recur to the same treatment; but we must ex- pect to see this symptom return for a long time, and even after the entire cure of the wound. § II.—After the Operation. A. The accident, which still engages our attention the most after an operation, is hemorrhage, which is sometimes caused by our not having tied some of the more important arteries, or by some of the ligatures having become loose, or, more frequently than is thought, by a kind of irritative exudation going on from the surfaces of the Avound. After the third or fourth day is passed, it is rare to have any other hemorrhage than this, unless the threads have too rapidly cut through the arteries by ulceration, or that there exists that remarkable condition of the system Avhich Otto, Buel, Krimer, (Malle, These de Cone, 1836, p. 36,) Lobstein, (Anat. Pathol, t. I., p. 211,) and so many others, have related examples of, and the peculiarity of which is, that the most trifling incision is folioAved by an incessant hemorrhage. Why hemorrhage should occur after the eighth or tenth day, it is difficult to say. Petit, Bromfield, Guthrie, and other practitioners, however, have seen it occur at the expiration of three Avecks, a month, or even later. In one of my patients, after amputation of the thigh, it came on after the tAventy-third day. The case is related of a patient ope- rated upon by M. Roux, (Diet, de Med. ct Chir. Prat, t. II., p. 213,) in Avhich it did not appear until at the end of two months. The inflammation, Avhich may seize upon the coats of the vessels in the deep-seated tissues of the stump, and the suppuration Avhich sur- rounds them at the bottom of fistulous passages, can alone ac- count for this species of perforation. Hey and Hennen maintain that consecutive hemorrhage frequently proceeds from the retracted skin strangulating circularly the subjacent tissues, and especially the venous canals; and that it is from this last mentioned class of vessels that the blood comes. This opinion, in my view, appears to be far from being Avell-founded. When the blood esrapes from the veins, it is to be much more frequently imputed, as Pouteau remarks, to too unequal or powerful a compression made by the bandage upon the stump, than to the retraction of the skin ; in that case, it is only necessary to remove the dressing and re-apply it more methodically, and the hemorrhage ceases immediately An- AMPUTATION OP THE LIMBS. 499 other species of hemorrhage, Avhich appears to have been first indicated by M. Gouraud, is that Avhich comes from I he bones in consequence of their being in a state of necrosis ; at every moment the blood is observed rising up between the living and dead tissue; compression, plugging, (tamponnement,) nothing stops it—nothing but the exsection of the altered part can subdue it. The swelling of the stump, attended with a considerable degree of inflammation, causes a hemorrhage, Avhich may be suppressed in various Avays: 1st, By saturating all the dressings Avith cold Avater, Avhich is to be frequently reneAved; 2d, By applying the tourniquet or garrote permanently upon the principal artery of the limb. After having found all these means fail, Avhatever may be the cause of the hemorrhage, we may undress the Avound and proceed in search of the bleeding vessel. As it is rare, in consequence of the changes Avhich have been effected throughout the whole extent of the Avound, after the first twenty-four hours are passed, that this last-mentioned means Avould succeed, Ave have then no other resource than to apply the agaric or sponge, as recommended by White and Brossard, upon the point from Avhence the blood issues, to tampone (tamponner, i. e., to plug) the Avound, in Avhatever way it may be done, till the hemorrhage is arrested, to make use of the apparatus invented by Petit, or to have recourse to direct compression upon the gaping vessel, by means of small plugs of linen or lint, sprinkled Avith rosin, (colophane,) and held on by the fingers of assistants, who are to be relieved successively for several days; or Ave shall have to establish a sufficient degree of compression upon the track of the artery above the stump, by one of the means Avhich I have elseAvhere described, (see vol. I. and the present volume.) In a case Avhere the arteries Avere ossified, (Acad, des Sc, 1732, p. 536,) it Avas found necessary to make compression in this manner for the space of four days. In a patient, hoAvever, who, after amputation of the leg, Avas attacked Avith repeated hemorrhages after the thir- teenth day, I succeeded, by means of the tourniquet of Petit, applied to the thigh for the space of three days. A last resource, should it be practicable, consists in laying bare the principal artery and tying it above the Avound. M. Roux, Du- puytren, Delpech, Somme and Gliidella have done this success- fully. M. Arnal has given a recent instance of this kind, and I have in citing these cases also related others, (see this present volume.) J. L. Petit Avould have made trial of it, had not the de- bility of his noble patient deterred him, (Malad. Chirurg., t. III., p. 164.) Pelletan (Clin. Chir., t. II., p. 275) moreover formally recommends it, and I cannot perceive how Dupuytren, M. Roux, Delpech or M. Guthrie can claim this suggestion for others. It is after all a means Avhich may fail like the others. In a case related by M. Blandin, and in some others mentioned by M. Guthrie this ligature applied as it is after the manner of Anel, did not pre- vent the flow of blood or ultimately save the patients from death. If the vessel Avhich bleeds should be surrounded Avith soft parts Ave could also circumscribe it Avith a stroke of the bistoury at 500 NEW ELEMENTS OP OPERATIVE SURGERY. the bottom of the Avound, and by passing a ligature upon this groove immediately close the vessel, as was once practised with success by M. Sanson, (These de Cone, etc., 1836.) We should do wrong, however, to rank among hemorrhages that oozing (suinte- ment) Avhich, upon the first or second day, rarely fails to wet and soil the dressings and linens, and sometimes to go through the whole thickness of the cushions. Though it should be pure blood and not bloody serum, we have no reason to be at all under any apprehensions unless the patient has become thereby enfeebled. As a general rule, while the force of the pulse is sustained and the paleness of the face does not increase, cold ablutions and the tour- niquet, if any thing at all be required, will be found quite sufficient. B. Conicity of the Stump.—Since the labors of J. L. Petit and Louis, the cone-shaped form of the stump, an almost inevitable result of the mode of amputating formerly, has become a rare oc- currence. By immediate reunion, when that does not fail, we almost constantly prevent it. It rarely occurs noAV except some- times after the union by suppuration. Imputable entirely to the retraction of the muscles, it is in the poAver of the operator to pre- vent it, unless the cure should be complicated with some unexpected difficulty. The processes of Petit and Brunninghausen, Avhich con- sist in bringing the skin only upon the stump, are deemed less effi- cacious than those of Louis, Alanson, Desault and Dupuytren, or than all those in fact Avhich consist in cutting the muscles adherent to the bone much higher up (beaucoup plus loin) than the free muscles, (fibres,) but this is a question for future consideration. On this subject we must not forget that the muscles retract in some persons much more than in others, and much more so in propor- tion as their fibres are longer, or have been farther divided from their point of origin, or are more irritated, or slower in uniting and incor- porating Avith the cicatrix ; nor must we moreover confound their primitive with their secondary retraction. The shortening which im- mediately succeeds their section, is not in fact the only one that takes place; we often see the muscles, especially in patients possessing much strength and embonpoint at the time of the operation, but who become debilitated soon after; Ave often, I repeat, see the muscles draw themselves to a great distance within their sheaths, abandon the bones which they at first completely covered, thus rendering conical a stump which at the first dressing had the very largest kind of excavation. One of the means which contributes most to prevent this accident, is the care Avhich the surgeon takes at each dressing to adjust the bone accurately to the centre of the stump. In this respect the flap operation has the objectionable in- convenience of favoring the slipping of the parts tOAvards one of the angles of the wound. It is therefore then a matter of much import- ance to preserve a sufficiency of tissues in that part towards Avhich the bone has a natural tendency to incline, either by means of the action of the muscles or the habitual direction of the stump. After the operation we counteract the retraction of the muscles, by applying to the stump the moderately compressing bandage of the AMPUTATION OF THE LIMBS. 501 ancients, as modified by Aitken, (Essays on several important Sub- jects in Surgery, 111 I,) Alanson, Louis, and M. Richerand; arrang- ing it in such manner, that instead of pushing the flesh backwards, like the capeline censured by Decourcelles, (Man. des Oper at., p. 372,) all the portions of the dressing on the contrary concur in bringing it forward; Ave are also to dress the wound as lightly as possible, avoiding every thing Avhich can irritate it, or cause it to suppurate or retard its union ; adjusting the stump in such manner that it may constantly repose between flexion and extension, and all its muscles remain in a state of relaxation. The projection of the bone, hoAvever, is to be apprehended notAvithstanding all this, should the periosteum proceed to suppuration, and the pus detach the muscles of the stump, or if any serious affection should in the first eight days after the operation take such hold of the system as materially to interfere with the healing process going on in the wound. C. Protrusion of the Bone, (sortie de l'os.)— The protrusion of the bone after amputations, Avhatever may be the cause, is ahvays a grievous inconvenience. When it is slight and simple and Avithout denudation Ave should not, M. Gouraud says, meddle Avith it. Na- ture will elaborate her work in ultimately removing the cicatrix by bringing the skin over the apex of the stump. If the patient is corpulent he will often find that this conicity will partially dis- appear, and present no obstacle to the employment of an artificial limb, (des moyens prothetiques.) When it exists to a greater de- gree, there is nothing but the natural exfoliation or exsection which can give relief. I. Spontaneous Separation.—-If the bone is not denuded, necro- sis Avill not take place ; and Ave should be in an error to wait for its exfoliation, as advised by Lassus, (Trad, des Fract. de Pott, p. 181, 2e edit.) Pare, therefore, Avho made use of excision, was right, (Lib. XII., chap. 35.) Unless this Avere done, the osseous cone Avould, in the thigh especially, be in the way in applying an artificial leg, as in the cases mentioned by Veyret and Alanson, (Oper. cit., p. 49, 50,192, obs. 20,) and as I have also myself seen. This projection of the bone, moreover, is the cause of incurable ul- cerations. The soldier mentioned by Salmon, (De Art Amp. rar. adm., §9, sect. 2,) and Avho had both his arms amputated, is an ex- ample of this, to Avhich I could myself add a multitude of others. The articular extremities take a longer time to exfoliate than the body of the bones ; thus Smucker (Bibl Chir. du Nord, p. 57) was obliged to exsect them in a patient Avhom he had amputated at the Avrist. In a similar case, Reisenbach (Trad, par Masuyer, t. I., p. 218 ; Bibl. du Nord, p. 82) felt himself obliged to remove the lower extremity of the radius because it did not seem disposed to exfoliate. The heads of the bones of the metacarpus in a man who had had all the fingers disarticulated, having remained for ten months without exfoliating, I deemed it my duty, in order to secure the closure of the wound, to perform the operation of exsec- tion. 502 NEW ELEMENTS OF OPERATIVE SURGERY. II. Exfoliation, Avhich Avas formerly considered unavoidable af- ter an amputation, is at the present time deemed only an inciden- tal result. As it is extremely tardy in being brought about, re- quiring thirty, forty, and sixty days, and even three and four months, to be completed, Ave should not, except in a very small number of cases leave this process to nature. The red hot iron, chemical caustics, as the nitrate of mercury for example, and Avhich was frequently employed, doAvn to the present times, and even as late as by Sabatier, do not in any degree accelerate it. It is much better to confine ourselves to gentle movements Avith the forceps, to be repeated at each dressing, and directed upon the pieces of dead bone (escarre osseuse) as soon as they become moveable. It is Avell to recollect, however, that this eschar sometimes disappears without any apparent exfoliation. An adult Avhose leg Avas am- putated at the hospital of St. Antoine by Beauchene, had a necrosis at the angle of the tibia, Avhich Ave could feel Avith the probe, the wound closed over (par dessus) it, and at the expiration of a month a small abscess made its appearance ; I laid it open, and a limpid, reddish pus floAved out, but there was no more necrosis, and the cavity soon cicatrised permanently. In another case Avhere the whole stump had become involved in suppuration, I had for a long time before my eyes the extremities of the fibula and tibia, of a chalky and slightly yelloAvish color, rough and sonorous, in fact, completely necrosed ; gradually they disappeared under the flesh, the cicatrization took place, and in .four months the cure Avas com- plete. Bones, then, that have been laid bare by pus, are not abso- lutely doomed to exfoliation. I have now seen more than fifty cases, in Avhich the bones of the cranium, nose, jaws, fingers, and toes, the fore-arm and leg, and the humerus and thigh, Avere bathed in pus and divested of their periosteum, and Avhich, nevertheless, recovered Avithout any perceptible exfoliation. [This is a valuable remark of the author, Avhich is fully borne out by the experience of Dr. Mott and most practitioners Avho have been familiar Avith syphilitic and mercurio-syphilitic cases, more especially Avith the latter. We fuave noticed this fact in an especial manner at the Sea- men's Retreat Hospital, in deplorable cases from those murderous, drenching salivations for syphilis, to Avhich sailors are exposed in the hands of advertising empirics, as AA^ell as of empyrical physicians. In such cases, Avhere the energies of the system have not been too much prostrated, Ave shall find, by Avholesome, generous diet, good air, and the mild alterative treatment Avith sarsaparilla, and iodine internally, and lotions of chlorine externally, Avith strict attention to draAving as forcibly together as possible the lips of the Avound, by adhesive plaster, Avhenever dressed, and Avhich should be as at long intervals as possible,—that the granulations, even on the fron- tal parts of the cranium where the teguments are so thin, and on the sharp edge of the tibia or ulna, Avhere they are yet thinner, will, as our author has well described it, shoot out gradually over the white, dry, rough, denuded surface of the bone, and finally close the Avound perfectly without the slightest perceptible exfoliation, AMPUTATION OP THE LIMB8. 503 unless the constitution be greatly vitiated and prostrated, or the loss of substance in the soft parts be over the size of an inch in di- ameter. The Avord necrosis, however, as used by the author, to express this condition of the bone, expresses, as it seems to us, too much; for an actual death of the bone cannot, as we conceive, have taken place in these denudations. In fact, the natural, healthy, organic state of the parts, notwithstanding the loss of the periosteum, cannot have been sensibly changed, but the normal action only suspended, and not destroyed. No doubt, in former, as well as in modern times, this curious phenomenon of tenacity in the vi- tal principle, had been noticed, but (though often observed by others) not, as we are aAvare, correctly described by any one before Prof. Velpeau. T.] HI.—The exsection of the bones and of the stump, which caused so warm a debate in the ancient academy of surgery, is described by Sabatier as a simple, easy, and but slightly painful operation ; by others as a second amputation, often more dangerous than the first. When it is to be done, we should perform it so high up as not to be obliged to do it again, or endanger another conicity. We may conceive, moreover, that Avhere the integuments and super- ficial muscles are far removed from the apex of the stump, it cannot fail to be otherAvise than painful; Avhile on the other hand, if the saw is to be used only at some lines above the dead parts or portion to be removed, it becomes an operation of the least im- portance. After immediate (primitive) union especially, purulent inflamma- tion, should it supervene, will sometimes attack the periosteum, Avhich will then suppurate and become detached; the bone is then denuded, and soon mortifies, either throughout its whole substance, or only in a more or less considerable portion of it. At other times, the disease begins in the internal texture of the bone, Avhich ren- ders the accident so much the more serious. M. Moulinie has shoAvn me a sequestrum of this kind, of more than six inches in length, and Avhich comprised the entire circumference of the femur. One of those Avhich I took from the humerus Avas over three inches. The first indication to be attended to in such cases is to dilate and divide, by means of the bistoury, everything Avhich appears to in- terfere in the least degree with the free egress and discharge of the pus and other morbid matters ; after Avhich Ave should endeavor to limit the extension of the mischief, by applying expulsive compres- sion from the upper part of the limb doAvn to near the wound. We may then Avait for the exfoliation. In other cases, after the evil has ceased to extend itself, Ave have recourse to exsection, or repeat the amputation a little higher up, as in operating for coni- city. If all the tissues should be sound, perhaps there Avould be some advantage in imitating Wiegand, who, in such cases, makes tAvo semilunar, lateral incisions with the convexity downwards, at a certain distance from the borders of the Avound, and of greater or less length, according to the size and the greater or less degree of conicity in the amputated limb. These incisions Avhich com- 504 NEW ELEMENTS OP OPERATIVE SURGERY. prise the skin only, or the skin and superficial muscles, are made in such a manner as to avoid the vessels upon which a ligature might be rendered necessary. The teguments being thus detached, are then brought up and united in front of the bone by means of ad- hesive plasters or the suture. C. Hospital Gangrene, frequently among the sequelae of ampu- tations, is one of the Avorst complications that can happen. As soon as it has seized upon the stump, or involved the integuments and muscles to a certain extent, and thai the bone has become denud- ed, and topical applications and caustics have been tried in vain, amputation above the neighboring articulation, and if that be not possible, immediately above the limits of the disease, is one of the last resources we have to oppose to it. M. Gouraud obtained many unexpected cures from it, both in the army and at the hospital of Tours, Avhere I myself Avas an eye-witness to them. Percy, MM. Willaume, and Desruelles, also adopted this practice, and I do not think we should hesitate in folio Aving it under the conditions which I have pointed out, that is to say, when, in spite of the cau- terization with the nitric acid of mercury, and even with the red- hot iron, the gangrene continues to advance. [Gangrene. Hospital Gangrene.—The vitiated condition of the atmosphere in croAvded hospitals, barracks, on shipboard in trans- ports, camps, &c, depends upon the abstraction of oxygen or rather its displacement by carbonic acid and nitrogen, and the exhalation of various other deleterious gases, &c, from the skin and alvine and urinary excretions, &c. This will not only predispose to, but gene- rate a new and malignant principle, or morbific virus which will manifest itself in fevers of a putrid and ataxic and adynamic type, in the degeneration of ulcers and Avounds into hospitalpourriture or gangrene, and in such degradation or diminution of all the vital forces as to diminish the chances of success in, or give a fatal termi- nation to, diseases or operations of every kind. Thus Sir George Ballingall (Remarks on Schools of Instruction for Military and Naval Surgeons, also his Treatise on Schools of Naval and Military Surgery, 3ded., Edinb., 1844) remarks that when military hospitals are over-crowded, too long occupied, or filled with a relay of fresh cases immediately after the removal of the old, results the most fatal are the consequence. In March, 1837, after an action, the surgical hospital at San Telmo afforded a striking example of this. " There were thus," says Mr. Allcock, (London Lancet, 1840-41,) " 1041 patients in the hospital of the legion, calculated to accommodate, Avith due regard to health, 800; the chief press of the extra num- bers fell upon the surgical hospital of San Telmo." The following gives the melancholy result:—Of 17 primary amputations there were only two recoveries; of 4 intermediary all died ; of 3 secon- dary only one recovered, making a total of 24 cases of amputation and only three recoveries. M. Ollivier, of Paris, has satisfactorily established by personal inoculation on himself (See his late Avork on Traumatic Gangrene) what Avas in our opinion long since familiarly known, that the AMPUTATION OP THE LIMBS. 505 matter of hospital gangrene is contagions and will reproduce itself. Sponge has been, according to Sir Geo. Ballingall, (Op. cit.,) ascer- tained to be a direct vehicle of this contagion, by the careless and culpable use of the same sponge to cleanse the ulcers among the sick of a regiment stationed at Feversham, England, as related by Deputy Inspector Marshall, (lb., and Cormack's London Sp Edin. Monthly Jour., Dec, 1844, p. 1040.) Some persons have on this account gone so far as to propose to discard sponge altogether as a detergent, from the difficulty of clean ing it, and this has been actually done in some English hospitals, (Cormack, ib., p. 1041,) and surgeon's lint substituted. We cannot agree Avith Sir G. Ballingall that venesection can ever scarcely be admissible in cases of hospital gangrene; unless it be in very rare instances in young robust subjects in Avhom the purulent infection has produced such violent perturbation in the cerebral and circulating functions as to have caused for the time being in the early stage a violent inflammatory febrile reaction, spasms, convul- sions, local engorgement, &c. T.] Amputation during non-limited Traumatic Gangrene.—The edi- tors of the Journal des Conn. Medico-Chirurg., (Paris, June, 1842, p. 257-8,) remarking upon a case of amputation Avhich Avas per- formed near the head of the humerus on a young man by Mr. Too- good at Bridgewater, (Eng.,) during the height of a non-limited traumatic gangrene which had rapidly spread from a shot wound a short distance above the wrist, nearly as high up as the shoulder, observe that Mr. Toogood Avould not have deemed this remarkable if he had been aware of the fact that MM. Larrey, Gouraud, pere, &c, had long been in the habit of this practice in the army, espe- cially in Avounds from fire-arms, Avhere nature is powerless in arrest- ing the progress of the evil and limiting the gangrene except by a violent general reaction. Bleeding in Mortification.—There are cases, says Sir B. Brodie, (Medical Times, March 1, 1845,) Avhere bleeding and purging will arrest the mortification and cure the patient as in robust habits— not so in persons whose constitutions are broken doAvn by mercury, intemperance, &c., Avith small, weak, frequent pulse, anxious coun- tenance, &c. Thus you find these tAvo classes of patients Avhere a neglected chancre has resulted in mortification of the penis. In the one Avhere bleeding, not stimulation, is required, an artery perhaps Avhile the physician is hesitating Avill spontaneously inflame, and after the discharge of a pint of blood an immediate amendment takes place by nature's unaided efforts. T.] D. The inflammatory enlargement (gonflement) of the stump, sometimes shoAvs itself in the form of simple erysipelas, at other times under the characters of an erysipelatous phlegmon. In the first case, if the skin only is affected, the adhesive plasters are fre- quently the cause of it, either because they have been drawn too tightly over the wound, or because they contain too great a pro- portion of matters of an irritating quality; we have then nothing more to do than to remove them, and to dress the inflamed surfaces 506 NEW ELEMENTS OP OPERATIVE SURGERY. for a few days Avith emollient cataplasms. In the second case the accident is of a much graver character and merits the most serious attention. The phlegmasia rapidly extends itself; the muscles and skin are soon dissected by the pus; the sub-cutaneous tissues and the cellular prolongations (trainees) sometimes go on to mortify and slough off in large masses, (se detacher par lainbeaux,) an ataxic or adynamic fever supervenes and the patient's life is placed in peril. Union by second intention is not often folloAved by such accidents; Avhich is one of the strongest objections urged against the rigid partisans of union by the first intention. As soon as these symptoms become manifested they must be vigorously combated ; they are mitigated sometimes by uncover- ing the Avhole wound so as to dress it flat, and by applying leeches to the stump and then cataplasms ; but Avhen such means are un- successful, or when they are too late, I knoAV of nothing more effi- cacious than deep and numerous incisions. In 1828 I had occasion to use the flap operation for an amputation of the leg. The Avhole thickness of the stump soon became the seat of an extensive phleg- masia; erysipelas and purulent collections already occupied the lower third of the thigh. The stupor and other adynamic symptoms went on Avith a frightful rapidity. I considered the patient lost beyond all hope. Beauchene, Avho thought otherwise, made from eight to ten deep cuts upon different inflamed portions of the skin. From that time the symptoms began to subside and the patient re- covered. It is against this erysipelas also with a greyish tint, and which so often terminates in gangrene in persons who have been amputated, that M. Larrey advantageously employs the actual cautery. The hot iron applied Avith a certain degree of force upon the inflamed surfaces, so as to imitate the branches of the fern or the nerves upon the laurel leaf for example, or other figures, cer- tainly did Avonders at the Hospital of the Guard where I have witnessed the most extraordinary results from it. Suppose the disease should, after having given rise to numerous general phenomena, again become circumscribed to the part, there often results from it that denudation of the bone, and those fis- tulous burrowings Avith that conicity of the stump, which can only be cured by a second amputation. " Experience has taught me, says M. Gouraud, that Avounded persons sustain amputation of the stump better than that of the limb, and that the success of the former is more probable than that of the latter. Of ten persons upon Avhom I performed it in 1814 and 1815, nine Avere cured." Instead of attacking the whole stump, the phlegmasia is limited sometimes to the cellular tissue surrounding the vessels, and espe- cially the sub-cutaneous veins; there will then soon be found along the track of these canals, small purulent collections and abscesses, which are to be opened in good season, should not antiphlogistic means or compression have prevented their development. E. Purulent Infection. Phlebitis.—The veins often become in- flamed, either in themselves alone, or concurrently with the sur- rounding parts. Here as elsewhere Phlebitis is exceedingly dan- AMPUTATION OP THE LIMBS. 507 gerous. The symptoms of adynamy, putridity and ataxy that are soon developed, are almost always folloAved by death ; so that this becomes one of the most formidable of the accidents that can pre- sent themselves after amputations. The dangers Avhich it involves, imputed even down to our OAvn times to inflammation propagated up to the heart, depend as 1 have shoAvn (see Vol. I.) upon a to- tally different cause. Purulent infection Avhich is so often compli cated with phlebitis, is another accident Avhose dangers are pre- cisely similar. It is true that the researches of M. Monod and M. Reynaud, tend to prove, that the inflammation of the medullary tissue of the bones participates also in the production of those symp- toms Avhich are generally ascribed to phlebitis and infection from pus; but this is a question which requires neAV investigations, and I am of opinion that on this subject persons have had their minds warped by preconceived theories. F. Cystitis.—We are often, says M. Gouraud, obliged to apply the catheter to persons Avho have been operated upon, and many observers have made the same remark. Whatever may be the pri- mary cause of it, it is no less certain that cystitis is by no means an unfrequent consequence of amputations, and especially of am- putation of the abdominal extremities; Ave must be prepared for this inflammation upon the least appearance of trouble in the uri- nary passages. It is useless to say that Avhen this affection menaces blisters ought to be proscribed; but M. Blandin is evidently de- ceived in imputing it to this therapeutic agent, for it is observed where no preparation of cantharides has been made use of; as I saw in the case of a Avoman Avhose thigh Avas amputated by M. Roux, in 1S26. For more ample details on the accidents Ave have just enumerated, and upon tetanus and every other disease that can be complicated Avith the results of amputation, I can refer only to treatises upon pathology properly so called, and to the arti- cle (see Vol. I.) upon operations in general. Article VI.—Organic Changes produced by Ampu- tation. As has been noticed by all surgeons, very remarkable changes after the removal of a limb, sometimes take place in the person who has been operated upon, changes Avhich relate either to the stump itself or to the constitution in general. § I.—In the Stump. The muscles, vessels, cellular tissue, aponeuroses, tendons and bones themselves, undergo at the place of their section, a transfor- mation of such character, that all their parts are blended together in their union with the cicatrix, and consist at that place only of layers or fibrous cords, more or less dense and more or less dis- tinct ; the stump Avhich had wasted at first, afterwards becomes the seat of a more active nutrition, increases in size, and finally at 508 NEW elements op operative surgery. the expiration of an indefinite period of time, attains in this respect the volume nearly of the root of the other limb. § II.—In the rest of the System. Persons amputated upon, acquire a remarkable embonpoint, and an augmentation of energy in the organs of digestion, circulation and reproduction; the vital fluids compelled to circulate within narrower limits, increase the activity of all the functions, in the same Avay as the intensity of a light becomes more and more vivid in proportion as Ave concentrate its rays. The tendency is to the formation of the sanguine temperament. The salutary efforts of nature to remedy this too great plethora of the system, are mani- fested according to the age and sex in epistaxies, hemorrhoids, more abundant menstruations, a greater frequency of stools, and more copious perspiration and secretions. Garengeot therefore advises in order to prevent this plethora and croAvding of the blood, that patients Avho have had a limb amputated, should from time to time be bled, that they should reduce their nourishment one quar- ter part during the first year, and abstain from violent exercises. A soldier in the army of the Eastern Pyrenees had his two thighs amputated and recovered perfectly. The activity of all the viscera, particularly the stomach, increased to a singular degree. In a short time this man acquired a corpulency the end of which it Avas im- possible to foresee. The stools in fact were nearer together Avithout hoAvever any perturbation of the belly. But the immobility to which this double mutilation subjected him made his plethora itself a disease. A species of carriage was procured. This passive move- ment did more harm than good, because it favored digestion more than transpiration and the other excretions. This unfortunate per- son finally sank under the burden of sanguineous plethora. " I have seen hundreds of such cases, says M. Gouraud, and they ap- pear to me every way worthy the attention of physicians." I have myself seen a young soldier in Avhom it became necessary to ampu- tate in succession a leg and both arms, also an employe in a bureau who had had his thigh taken off, both of whom by the plethora which ensued, fully confirm the observations of this practitioner. Article VII.—Prognosis of Amputations. Amputations have ahvays been considered very da ngerous, and they are so in reality. Nor can anything be more uncertain than the consequences Avhich may result from them. Welschius (Bonet, Corps de Med., t. IV., p. 312) says, that out of five persons ampu- tated Avhom he saAV at the Hotel Dieu, four terminated fatally. Out of tAventy-nine operated upon by M. Baudens (Gaz. Med. de Paris, 1838, p. 346, 347,) or his assistants at the expedition to Constan- tina, twenty-four died, while out of twenty others amputated by M. Pointis (Ibid., p. 448) at Bougie, during the space of four years, not one perished ! M. Warren has lost eight out of forty at the amputation op the limbs. swy Hospital at Boston, while M. Chelius, (Arch. Gen. de Med., 2e serie, t. IX., p. 229,) at Heidelberg, has saved twenty-seven out of twenty-nine. The English surgeons, who maintain that a greater proportion of persons amputated die in France than among them, attribute it to our mode of dressing; but in examining the fact in itself, M. B. Philipps has recently read a paper (1838) at the Med.- Chirurgical Society of London, by which it appears that the mor- tality in persons amputated is at least as great in England as in France. At La Charite, I have in the course of one year lost but two out of tAventy-six. In the preceding year I had lost six out of twenty-one, and in following year I lost four out of nine- teen. A young surgeon of Philadelphia maintained that in his country persons do not die from amputations as they do with us. Upon returning to America, he ascertained that six died out of twenty-four. A pupil of the Hospital of Lyons considered himself fortunate in saving twelve out of seventeen, and M. Laborie (Bull. de Therapeut, t. XV., p. 165) eulogizes a kind of dressing by which only four are lost out of every eleven. An opinion has gained ground among physicians, that in the hospitals of Paris Ave lose one in every tAvo or three patients; but this is not generally true. As to myself, I have lost but one in every five or six. It is, besides, impossible in this loose Avay to form a correct opinion of the mortality of amputations. Success or failure in these cases depends more than anything else, upon the nature of the lesion Avhich requires the operation, the accuracy of the diagnosis as to the condition of the viscera, the importance of the limb to be amputated, the circumstances and the precautions con- nected with the patient, and the hygienic means and consecutive treatment employed; therefore, Avhen patients die, is it from the amputation, or in spite of the amputation ? Other things, moreover, being equal, amputations are more dangerous in hospitals than in private practice, under an extreme than in a mild temperature, during epidemics than in an ordinary healthy condition of the at- mosphere, in men than in women, in old men more than in adults, in adults more than in children, in the lower rather than in the up- per extremities, and near the trunk more than at a distance from it. I ought also to remark that amputation of the fingers has to me appeared more dangerous than that of the toes, and that the for- mer, in itself, is not less hazardous to life than amputation of the arm. 510 NEW elements op operative surgery. SECOND PART. AMPUTATIONS IN PARTICULAR. CHAPTER I. THE UPPER EXTREMITIES, (Membres Thoraciques.) The upper extremities, exposed by their uses and their relations with external agents to every kind of injury, frequently require am- putation. The principle in regard to them, is to take aAvay from them as little as possible. The small portion which is preserved rarely fails to be still of some service. We thus amputate sepa- rately the fingers, the several bones of the metacarpus, the hand alone, the Avrist, the fore-arm in its continuity, and at its articulation, the arm at different points of its length, or at its union with the shoulder, or the shoulder itself. Article I.—Partial Amputation op the Fingers. The amputation of the fingers, though but slightly mentioned by, the ancients, must have been had recourse to by them in a great number of cases, and at the present day is very frequently perform- ed, and in a great variety of modes, Avhether we limit ourselves to the removal of one of the phalanges only, or take aAvay the Avhole, Avhether Ave amputate in the continuity of the bones, of Avhich they are made up, or prefer doing it at the articulations. § I.—Anatomy. The fingers, composed of three pieces of bone, articulated in the tAA^o anterior phalanges in the manner of a hinge, (en ginglyme,) and at the metacarpal phalanx by enarlhrosis, (enarthroses,) are, moreover, composed of tendons, fibrous grooves, (coulisses,) syno- vial sheaths, arteries, and nerves of considerable size, and also of a cutaneous covering, distinguished on its anterior surface by re- markable characters. It is upon their palmar face that arc found the tAvo flexor tendons and the fibro-synovial groove, in which they glide. One of these tendons is attached at one extremity to the articular projection (renflement) of the third phalanx, (phalange ungueale,) and at the other to the metacarpal phalanx by means of a simple fibrous bridle. The tAvo layers of the other flexor, on the contrary, are attached to the sides of the middle phalanx. As amputation of the upper extremities. 511 all the flexor tendons are gathered together in the hollow of the hand before they reach the Avrist and the fore-arm, nothing can be more dangerous after amputation of the fingers, than inflammation of their sheaths. From their synovial sheath, terminating in a cul- de-sac only, on the anterior surface of the metacarpo-phalangeal articulations of the tAvo or three median fingers, operations performed on the thumb or little finger are thereby rendered yet more dan- gerous. From the cellular tissue being accumulated in front in form of a cushion, this part is generally selected from Avhence to obtain soft parts to cover the stump after an operation. From their dorsal surface being more convex, it would be rendered more difficult to cut out in that part a flap of sufficient Avidth and thickness. From the two arteries that run along their sides, (les cotoient,) lying so close to the bones, compression upon them may, without any diffi- culty, be substituted for the ligature. The tAvo phalangeal articu- lations have this about them remarkable, that being supported on their sides by tAvo very strong ligaments, and in front and behind by tendons of considerable strength, they cannot be divided but by means of certain precautions. The pulley which their head ter- minates in, and the small cavities separated by a crest Avhich are found upon the posterior extremities of these phalanges, are also important, to be noted in enabling us to guide the action of the bis- toury Avith security. The skin in these parts possesses peculiarities which are of so much the more importance, that these are not ordinarily effaced by its morbid condition. In the midst of a considerable number of folds and Avrinkles which are found upon its dorsal surface, there are three Avhich must be particularly recollected. One Avhich is perfectly transverse, corresponds almost always av it h the line (intcr- iigue) of the articulation ; the second, convex behind, lies over the union of the head of the posterior phalanx Avith its body; Avhile the third, convex forAvards, has the same relation to the anterior phalanx. The palmar surface of the articulation of the third (pha- lange tienne) phalanx, is directly underneath, or at farthest, at the distance of a line in advance of the transverse groove Avhich is alone found upon the skin at this part. The same may be said of the middle articulation, in respect to the deepest and most clearly defined (la plus tranchee) line in the integuments which surround it. The metacarpo-phalangeal articulation, surrounded like the preceding, by tAvo lateral ligaments, and flexor and extensor ten- dons, has, moreover, in front of it, or upon its sides, the termina- tion of the lumbricales and inter-ossei muscles, and the trunk of the collateral arteries Avhich bifurcates only a short distance further in advance. As it is upon the head of the metacarpus that the phalanx turns, this latter, during flexion, is almost entirely con- cealed under the former, Avhich alone forms the projection Avhich is seen in the knuckles. These articulations are not upon the same line. The transverse groove on the palm of the hand Avhich cor- responds to the articulation of the fore and little finger, is situated many lines farther back than that of the two intermediate fingers. 512 NEW ELEMENTS op operative surgerv. The best mode of striking upon them is to look for them at ten to twelve lines farther back (au dela) than each inter-digital commis- sure ; by which arrangement, also, the cushion of their palmar (an- terieure) surface serves for an excellent flap to cover completely the head of each matacarpal bone when Ave remove all the fingers. § II.—Amputation. In former times, the fingers were always amputated in the con- tinuity of their phalanges. In the time of Fabricius of Hilden, they were removed by a cutting forceps, gouge, chizel, or some other similar instrument, operated upon by strokes of a mallet. At a later period, the saw was substituted for these, Avhich, in addition to their clumsiness, had, says Fabricius of Hilden, (Bonet, Corps de Med., p. 516,) the inconvenience of splitting the bones and giving rise usually to very serious consequences. Verduc, Petit, Ga- rengeot, Sharp, and most modern surgeons, opposed this manner of proceeding; so that, for a long time past, amputation of the fingers in the continuity was abandoned. The operation, it is averred, is more difficult, and that the portion of the phalanx Avhich is left can be of no use. Upon this subject, it would seem to me, they have gone too far, and that it is better, as Le Dran (Operat, 1.1., p. 308) and MM. Guthrie and S. Cooper think, to saw through the phalanx where it is practicable, than to extirpate it entire : in the fingers there is no part which has not its uses and importance. M. Graefe occasionally has no hesitation in still employing the chizel and ham- mer, (Rust's Handb. der Chir., t. I., p. 620.) A young military surgeon, M. Moreau (Gaz. Med. de Paris, 1836, p. 93) has specially pointed out the advantages of amputation in the continuity of the phalanges, and I have often had occasion to confirm in practice the opinion which I first expressed upon this subject. A. Amputation in the Continuity.—We will suppose the disease to be confined to one of the two last articulations. It is clear that we cannot remove it entirely, without dividing the posterior pha- lanx at a certain distance from the diseased articulation, and that the remainder of the bone cannot fail to prove serviceable to the patient. We may moreover perform this operation, either by the circular or flap method. I. Circular Method.—In the first mode, the integuments are to be divided as near as possible to the part affected; we then push them backwards, in order to divide the tendons and effect the sec- tion of the bones by means of a small saw, or, what is better, by a good cutting forceps, (tenaille incisive,) at three or four lines far- ther back than the point Avhere Ave commenced the incision. II. The Flap Method.—In the second process, we may confine ourselves to a single flap, which it is better to cut in front, or, doing as Heliodorus formerly did, (Nicet, de Lus quce Digit, accidunt, p. 159,) Ave may, should the soft parts not make it objectionable, make two flaps, giving then a little less length to each, Reunion, also, by the first intention, should be attempted in both cases. AMPUTATION OF THE UPPER EXTREMITIES. 513 B. Amputation in the Contiguity.—I. Circular Method.—The skin is divided circularly at three lines in front of the articulation. The assistant pulls it back, in order that we may be enabled to divide the extensor tendon higher up, and enter betAveen the pha- langes on their dorsal surface, after having divided the lateral liga- ments. It is not until the bistoury comes out on the palmar sur- face, that the section of the flexor tendons is accomplished. This process Avhich Avas followed a long time ago, described by Garengeot, and recommended by Sharp, Bertrandi, (Operat. de Chir., p. 504,) Leblanc, (Operat, t. I., p. 308,) and Lassus, (Med. Oper., p. 545,) and which has been generally adopted in England, is quite as good as any other, and alloAvs of a ready facility of union by the first intention. II. Flap Method.—A Process of Garengeot,—Flaps of the same length, one dorsal, the other palmar. Garengeot (Oper. de Chir., t. III., p. 436) recommends that we should adopt for amputation of the fingers the method of Ravaton, or Avhat is better that of Heli- odorus ; that is to say, that Ave should make two lateral incisions united in front by a circular incision; that we should dissect off the two flaps thus made and raise them up to a level Avith the articula- tion before dividing that, and that we should then unite them by first intention. b. Process of Ledran, (Operat., p. 576,)—Two flaps, one to the right, the other to the left.—In the place of making two flaps, one in front and the other behind, Le Dran makes them on the side, and gives them a semi-lunar form; this is the process lately described anew by M. Maingault, and very properly condemned by M. Blandin. c Process of Laroche (Encyclop. Meth.,part Chir.,t. I., p. 108,) or of Loder, (Rust's Handbuch der Chir., t. I., p. 635,) attributed to M. Lisfranc—A Palmar Flap only.—The skin is divided at about the distance of a line in front of the transverse fold on the dorsum of the finger in order to be enabled to penetrate the articulation at the first stroke. The lateral ligaments are also immediately divided by inclining the bistoury first to one side then to the other. The articulation being completely separated, we have nothing more to do than to cut out a palmar flap of sufficient length to close the wound perfectly. The operation by this mode is performed in an instant. The cicatrix being turned towards" the dorsal surface of the finger is, it is said, more favorably situated than when in front; a very questionable advantage certainly, and one that is more than counterbalanced by the risk of having the phalanx denuded poste- riorly. Besides the disease does not by any means always permit us to obtain a flap of sufficient length. d. Process of M. Lisfranc.—The diseased finger is placed in supination; the bistoury is inserted transversely and flatwise in front of the palmar line, between the soft parts and the phalanx, the palmar (anterieure) surface of Avhich is grazed in order to obtain a flap similar to the preceding, and which is then raised up; the joint is then divided from before backwards, without leaving any posterior flap. This process is not as good as the preceding one. 514 NEW ELEMENTS OF OPERATIVE SURGERY. e. Process described by Laroche, (Encyclop. Meth. part. Chir., t. I., p. 108,) and adopted by M. Walther, (Rust's Handb., t. I., p. 625.) A dorsal flap only. When the disease does not admit of our forming a flap in front, (i. e, a palmar flap,) Ave may divide the skin at one line in advance of the palmar furroAv, and thus arriving at the fibrous groove, tendons, articulation and lateral ligaments, finish by forming a flap from the dorsal surface of the finger Avhich has been amputated. The cicatrix being less exposed to view and to the ac- tion of external agents, offers, it is seen, some advantage, as La- roche says, (Encyclop., p. 108,) to people of condition ; but in per- sons who work in the fields, it exposes to painful contact with hard bodies, which an infinity of laborers are obliged to seize with the hand. It is therefore from necessity and not from preference when we are obliged to operate in this Avay. /. The Usual Process.—Two Flaps. MM. Richerand, Gou- raud, (Handb. der Chir.,t. I., p. 625,) &c, recommend making two semilunar flaps, one dorsal and the other palmar, and each from three to four lines in length. This process, modified in the follow- ing manner, appears to me to be of a more general application, and fully as secure and as prompt in its execution as any other; I pro- ceed to describe it more particularly :— g. Process of M. Rust, (Prineip. Oper., etc., p. 84.) The Palmar Flap longer than the other. The operator seizes the diseased fin- ger and gently flexes it as he draws it towards him, Avhile an as- sistant supports the upper part of it, flexes the other fingers or se- parates them from the first, and fixes the entire hand in pronation. He then with a narrow bistoury, held in the first position, passes it from one side to the other through the entire track of the ante- rior fold of the skin, and cuts out a small semilunar flap, with its convexity towards the nail; the divided teguments are drawn back by an assistant; the bistoury ascending with them, traverses the joint as it divides the extensor tendon, and cutting the lateral ligaments to the right and left, passes betAveen the articulating sur- faces, and arrives at the anterior ligament. The surgeon then di- rects the cutting edge of his instrument forAvards to make it glide upon the palmar surface of the phalanx, which he has just disar- ticulated, and to form a flap of from four to six or eight lines in length. h. The anterior (i. e., the palmar) flap is the one to be principally depended upon, though the other is not without its use. That it may not be too short, and in order that we may at the same time give it the necessary length, I think with Delpech, that it is more prudent before terminating its section, to take the measure of it, so to speak, by raising it upon the articular surface (facette) which it is destined to cover. All these processes, however, enable us to obtain our object. The trials I have made of them have convinced me that we may to a certain extent adopt any of them indifferently; that the preference to be given in such cases, depends much more upon the pathological condition of the parts or the fancy of the surgeon, than upon the absolute value of the operative process. AMPUTATION OF THE UPPER EXTREMITIES. 515 At all events, the amputation of the phalanges is an easy operation. It is certain, however, when we can control the choice, that the mode I have just described, and that which comes under the cir- cular method, are to be preferred. The others will not be neces- sary, except where we are obliged from the condition of the soft parts to cut the flap entirely from one only of the tAvo phalangeal surfaces. C. Dressing and subsequent Treatment, (suites.) The operation having been completed by one process or another, it rarely becomes necessary either to tie or twist the arteries. The blood, after the ampu- tation of the phalanges stops of itself, or by means of gentle pressure. If, hoAvever, we should prefer using the ligature, each thread should be afterwards arranged at the corresponding angle of the wound. The tAvo flaps, carefully brought together, are kept in contact by one or two strips of adhesive plaster, Avhich embrace the stump in the form of a noose, and are carried back to the wrist upon its dorsal and palmar surfaces. A perforated linen besmeared with cerate, a little dry lint, a soft compress and a narrow bandage to adjust the whole, complete the dressing. In respect to regimen, a light diet for two or three days, and afterwards nourishment some- what diminished in quantity and less succulent than usual, are the only restrictions to which the patient is to be subjected. D. Accidents. Provided the patient keeps his hand in a sling, (echarpe) it is not necessary to confine him to his bed, unless ac- cidents should supervene. The best method, however, in these cases, of preventing any complications, or remedying them when they do occur, is to establish a uniform, (exacte) and regular com- pression, from the fore-arm to the Avound, including therein the hand, which is to be well protected (garnie) on its two surfaces. If unfortunately, purulent infiammation should seize the stump, we must hasten to remove the bandages, and to substitute emol- lient cataplasms in their place, and endeavour to check the disease by leeches, mercurial unctions, or even deep incisions. This in- flammation, from its propagation along the synovial membranes (toiles) becomes one of extreme danger, and together with phlebi- tis renders amputation of the phalanges as formidable almost as that of the arm, especially amputation of the thumb, forefinger, and little finger. As we are 'not obliged in the last (ungueale) [i. e., the third] phalanx, to open so completely into the tendinous groove, the operation here is attended Avith much less danger than in the others. I will add that I have in three cases of amputation of the phalanges, obtained^complete and immediate union, without any suppuration. § II.—Amputation of a whole Finger, (amputation de chaque doit en totalite.) Some surgeons, and among others, Lassus, (Med. Oper., p. 543,) have laid it down as a precept, that Avhen the middle phalanx is diseased, the first should also be removed at the same time; since 516 NEW ELEMENTS OF OPERATIVE SURGERY. say they, this last, when preserved alone, remains immovable, and becomes much more embarrassing than useful. To remedy this inconvenience, which he explains by saying that, after the remo- val of the second phalanx, the flexor tendons are deprived of every kind of point d'appui, and are incapable of acting on the first pha- lanx, M. Lisfranc (Coster, Manuel de Med. Oper., 1823) has con- ceived the singular idea of making at first one or two incisions in front of the metacarpal phalanx, to traverse in this manner the whole thickness of the soft parts, in order to promote inflammation of the tendons and their previous adhesion to the surrounding tis- sues ; but this would be making two operations instead of one, and as I have said elsewhere, (Anatom. des Regions, t. I., 1825, first edition,) and as has been well remarked by M. Scoutetten since, (Arch. Gen. de Med., t. XIII., p. 54,) the object which M. Lisfranc has in vieAV is naturally accomplished by the fibrous bridle which attaches one of the flexor tendons to the first phalanx of the fin- gers. Even though this anatomical arrangement should not exist, we should not have to fear the immobility mentioned by Lassus. After the cure, the tendons invariably become fixed to the neigh- borhood of the cicatrix, if they do not to the bone itself, so that no- thing hinders them from flexing or extending the root of the am- putated finger. On the other hand, observation proves that these fears are purely theoretical. All the patients I have seen, who have had the two last phalanges removed, have used the first perfectly well, and Avould have been lothe to have had it sacrificed. It is not proper, therefore, to amputate the whole of the first phalanx, un- less the disease has extended so far as to make it absolutely neces- sary. [A great deal of new and valuable anatomical surgery, and the settlement of many curious, nice, and exceedingly important points of controversy, have come before the public on this difficult subject of the division of the flexor tendons of the fingers, (in tenoto- my especially,) since the author penned the text in this part of his work. By referring to the interesting discussion which took place recently in the Paris Academy, and Avhich we have embodied in our first volume, it will be seen that Prof. Velpeau himself, as well as others, have contributed many new and interesting facts upon this subject. T.] Considering that after the operation the two collateral fingers are found widely separated by the head of the intervening metacarpal bone, Dupuytren preferred amputation of this last bone in its conti- nuity to simple disarticulation of the finger. If the patient incurred no more risk by one mode than the other, or if the head of the me- tacarpal bone did not ultimately become narrower, (s'aplatir,) so as to permit a nearer approach of the tAvo neighboring fingers, we might adopt this process which M. Champion and many other modern practitioners have sanctioned, and which the English, M. Larrey says, (Clin. Chir., t. III., p. 609,) employ to prevent inflam- mation in the fibrous structure of the hand ; but this is entirely the reverse, and the surgeon ought not to go beyond the metacarpo- phalangeal articulation, unless he is compelled to do so. AMPUTATION OF THE UPPER EXTREMITIES. 517 A. Circular Method.—The disarticulation of the fingers is per- formed only by the flap or oval method. The circular, carelessly described and adopted by some authors, by Leblanc (Precis des Operat, etc., t. I., p. 328,) among others, and recommended also by M. Cornuau. (These No. 71, Paris, 1830,) is attended only with in- conveniences, and ought to be rejected. B. Flap Method.—I. Process of Sharp.—After having made a circular incision upon the root of the finger in front of the commis- sure, Sharp (Operat. de Chir.,o. 390) proposes that we should make another upon each side in order to form a dorsal, and afterwards a palmar flap, before proceeding to the articulation. This is a mode which is inherently defective, and which no one ought to follow, notwithstanding the modification which Rust (Handb. der Chir., t. I., p. 621) has given to it. II. Process of Garengeot, (Operat, t. III., p. 431.)—The root of the finger, at first isolated down to the articulation by tAvo lateral or parallel incisions, is afterwards laid bare upon its dorsal surface by a semilunar or transverse incision. There is then nothing left but to divide the extensor tendon and the sides of the capsule, in order to separate the joint and remove the finger, while terminat- ing by the section of the flexor tendons and the skin which covers them. This is the process described by Bertrandi, (Traite des Oper., p. 504,) Leblanc, &c. The one that many moderns have substituted for it differs only in this, that the extremities of the two lateral divisions are made to join upon the dorsal and palmar sur- faces of the articulation, in place of being united by a transverse incision. III. Process of J. L. Petit—(Malad. Chir., t. III., p. 208.) The root of the finger, circumscribed by two semicircular incisions which include its commissures and are prolonged obliquely in con- verging to become united behind on the dorsum and in front of the hand, is first laid bare down to the articulation, which is opened and then separated from one side to the other or from before back- Avards. IV. By Puncture. In place of dividing from the skin to the bones, as in the preceding mode, Ave may, as Rossi (Med. Operat., t. II., p. 235) proposes, plunge in the bistoury from the dorsal to the palmar surface, in order to cut out successively the tAvo flaps from Avithin outwards and from behind forAvards, that is, from their base to their apex; but this is a process Avhich has no advantage over the others, and which makes a less regular wound than that of Petit, of which in fact it is only a repetition reversed. M. Plantade (These de Montpellier, 1805) proposes, after ha\~ing formed in this manner the first flap, that Ave should divide the joint and finish as in the following method, Avhich is somewhat less objec- tionable. V. Process of Ledran, (Operat. de Chir., p. 577,) or of M. Gou- raud, (Prineip. Optr., p. 83,) improved by M. Walther, (Rust's Handbuch, t. 1., p. 622,) and attributed to M. Lisfranc, (Malgaigne, Man., etc., p. 304.) The assistants seize the hand turned in pro- 518 NEW ELEMENTS OP OPERATIVE SURGERY. nation, and also the sound fingers, holding them apart from the median line while they keep them extended. The operator seizes the diseased finger with his left hand and exerts some movements upon it in order to be the better enabled to identify the articulation. Holding the bistoury in his right hand in the first position he directs its heel upon the dorsum of the articulation, or commences even at four or five lines beyond that, and dividing the skin reaches the middle of the commissure upon one side; depressing the wrist he prolongs the incision in the same direction nearly up to the groove which transversely crosses the palm of the hand in front of the joint. The cutting edge of the instrument is brought back upon the convexity of this semicircular Avound, to divide from before backwards the remainder of the soft parts doAvn to the articulation, which is laid open upon the side by turning the edge of the instru- ment transversely into it as soon as it reaches behind the head of the phalanx; while Ave are dividing the joint and the aid is draw- ing the skin gently back towards the wrist to the right or to the left, we reverse the finger as though Ave Avere in the act of luxating it. Dividing the extensor and flexor tendons at the moment the assistant is drawing upon the teguments in an opposite direction in order to protect them from the action of the bistoury, the surgeon finishes the operation with a second flap, similar to the first, but cut in the direction from Avithout imvards, and from the metacarpus to the interdigital commissure on the opposite side. VI. To give greater length to the flaps, Garengeot and some others recommend to commence the first and terminate the se- cond flap at some lines in front (au-devant) of the commissures. Others propose that their apex should be cut off square, and not made pointed as they generally are. It has appeared to me that by approximating the root of the fingers with some degree of care, we may very easily bring the two sides of the Avound in contact, without having recourse to the above precautions, Avhich hoAvever have no other inconvenience than that of exposing the skin to be- come turned back upon itself and to render the operation some- what more difficult. When the first incision is made, it is Avell, in order to run no risk of going beyond the head of the bone and to avoid all kind of grop- ing in the dark, to search with the fore-finger for the internal tuber- cle of the phalanx Avhich is to be removed ; which is moreover an easy matter, as it is the first projection we meet with behind. I would recommend that the first incision should be prolonged nearly a half an inch beyond the articulation, because Ave can then divide Avith much greater ease all the fibrous tissues Avhich surround it without interfering with the other lip of the Avound, and because we shall be more easily enabled by this means to cut out the other flap in a regular manner. When we have adopted the precaution of grazing the sides of the phalanx and of not passing beyond the head of the metacarpal bone, the trunk of the collateral arteries will generally be foimd to AMPUTATION OP THE UPPER EXTREMITIES. 519 have escaped; there are but two vessels Avhich bleed, and Avhich can be tied or twisted if they do not stop of themselves. The process of Ledran is the most rapid of all, and has no other disadvantage than that of not always allowing us to give the same regularity nor exactly the same form to the last flap as to the first; in this respect the method of Petit is preferable to it, and does not merit the censures Avhich some persons have bestowed upon it. C. The Oval Method.—The hand of the patient, the assistants and the operator are arranged as in the preceding process: we commence also in the same manner. I. Process of M. Scoutetten.—The surgeon seizes the affected finger with his left hand, and gently flexes it Avhile holding it slightly apart from the others, and then commences the incision upon the dorsal surface behind the articulation, with the heel of the bistoury Avhich he gently brings forAvard to the border of the commissure, and comes round with it upon the palmar surface of the finger, by cutting exactly upon the semicircular line which separates it from the hand, properly so called; arrived at the opposite border, he re- conducts (reporte) the bistoury to the anterior or phalangeal extre- mity of the Avound, and brings it back obliquely to the metacar- pus to unite the two extremities of the incision. Without leav- ing the part to be severed he Avidens the lips of the wound as much as- possible, divides the extensor tendon, then the lateral ligaments, increases the flexion of the finger in draAving upon it as if in order to dislocate it, reaches its palmar surface by passing the bistoury through the articulation, and finishes by dividing the flex- or tendons as Avell as the soft parts which connect the phalanx to the cellular cushion of the hand. II. In the place of folloAving the palmar groove of the finger, on arriving at its commissure, it is more convenient to make the se- cond incision immediately in the same manner as the first. We then disarticulate, and proceed for the rest of the operation in the mode just described. We have thus circumscribed a V incision, and the wound does not present the form of an oval until after the operation is finished. III. In the ovalar method we rarely divide the common trunk of the collateral arteries. Provided we have not given too much width to the point of the flap which is to be removed with the fin- ger, [i. e., the point or angle on the dorsal surface of the hand im- mediately behind the articulation where the two incisions meet, or where they commence, if Ave adopt the modification of M. Velpeau above. T.] the tAvo lips of the Avound may be brought together with ease and reunion effected Avith more facility and certainty by this than by any other method. It is therefore the process Avhich ought to be generally adopted ; and it possesses so much the greater advantage that it does not require the skin to be sound to so great an extent as in the others. The Avound Avhich results from it, leav- ing the palmar cushion untouched, offers in fact a surface one half less in extent than by the flap method, and its regularity always renders coaptation easy; but to perform it well, it is necessary to be 520 NEW ELEMENTS OF OPERATIVE SURGERY. intimately conversant with the anatomy of the parts, and to have had much practice with the operation, and its repetition on the dead body. § III. Amputation of the four last Fingers at one Operation, (ensemble.) Some ancient authors, Avith various Avorks on military surgery, and many theses written at the commencement of the present cen- tury, shoAV that the amputation of all the fingers at one operation had been already practised. In a case Avhere the fingers of both hands had been mutilated by the bat of a cotton dresser, I had an opportunity of putting in practice at the same time all the known methods, and of obtaining flaps from all the sides of the fingers, either to give length to the stumps, or take advantage of the facili- ties offered by the soft parts intended for covering the bones. In 1804, I Avas so fortunate as to have it in my poAver to prevent am- putation at the Avrist in a young lady Avho had all the fingers burnt except the thumb, Avhich remained sound. The cure Avas pro- tracted, but the results Avere of immense importance to the patient, (Champion, Private Communication.) The cases, hoAvever, which demand this kind of operation may be readily conceived Avithout the necessity of pointing them out in detail. The crushiftg of the parts, (un ecrasement,) a projectile from a cannon, congelation, or any thing which Avould at once disorganize the four appendages of the hand are of this nature. Nevertheless as the cases are rare, where all the fingers are destroyed up to their metacarpal articula- tion, and no farther than that point, there must be but few occasions where the operation is called for. A. The hand and the fore-arm being held in the same manner as for amputating a single finger, the operator having seized hold of the fingers which he is about to remove by placing his left thumb transversely upon their dorsal surface, and his left fingers upon their palmar surface, gently flexes them and directs the assistant to stretch the skin by drawing it backwards ; he then Avith a straight bistoury makes a transverse incision slightly convex in front, and from six to eight lines below the extremities of the metacarpal bones, taking care to commence at the fore-finger if he is operating on the left hand, and at the little finger if on the right hand. This first incision exposes the extensor tendons in front of the articula- tions. As soon as the integuments are properly drawn back the surgeon opens into the articulations, and divides their anterior ligament. Nothing more remains for him to do than to pass in front of the head of all the disarticulated phalanges a narrow knife, Avith Avhich he cuts from behind forward a large semi- elliptical flap, whose limits are naturally marked out by the groove which connects the palmar surface of the fingers with that of the hand. The same knife might serve also for the dorsal incis- ion ; but as it is necessary to pass successively over projections and depressions, the bistoury is much more convenient. AMPUTATION OP THE UPPER EXTREMITIES. 521 B. In order to prevent the [subsequent] protrusion of the flexor tendons we must divide them upon a line with the articulation be- fore finishing the flap. For this purpose it would be better, perhaps, after the dorsal incision has been completed, to cut out the palmar flap as M. Caillard (These No. 307, Paris, 1833) proposes, before proceeding to the disarticulation. In order to make the circular incision, M. Cornuau (These No. 71, Paris, 1830) first incises the entire palmar groove, then proceeds to the dorsal incision and finishes with the disarticulation. This process is as good as any other, no doubt; but in an amputation of this kind the surgeon ought to hold himself in reserve to regulate his conduct by the con- dition of the parts rather than by Avhat he learns in books. C. There are eight arteries divided by this operation. As they are bent at an angle upon themselves, (les coude,) in raising the tissues to close the Avound, it is not generally necessary to apply the ligature. The palmar flap, usually the only one, and always the longest, has no need of sutures to unite it to the dorsal. Strips of adhesive plaster suffice to keep it firmly attached to the head of the metacarpal bones. Over these we apply a perforated linen, spread with cerate. The Avhole is then covered Avith a thin layer of lint, then a soft compress, and some long ones Avhich embrace the stump from before backAvards, or obliquely, and in the same direction as the adhesive straps. After having properly padded (matelasse) the palm of the hand, nothing more remains than to support all these pieces by means of a bandage, the turns of which, brought more or less into proximity with each other and drawn tolerably tight, should be extended above the Avrist and passed once or twice between the root of the thumb, the remainder of the hand and the free extremity of the stump. D. The same or nearly the same kind of bandage also will an- swer after the extirpation of a single finger. Nevertheless we pro- ceed somewhat differently, according as Ave have preserved flaps or confined ourselves to simple oblique incisions. In the first case, in fact, there is required a narrow strip of adhesive plaster to fasten the two portions of preserved tegument upon the head of the meta- carpal bone; Avhile in the other case it is sufficient to pass one crosswise and to approximate the roots of the tAvo collateral fingers, as much as possible by drawing gently upon the bandage as it passes round the borders of the hand. It is the same when we have adopted the oval method. E. There is no need of remarking that when Ave wish to ampu- tate tAvo or three adjoining fingers only instead of four, the opera- tion should be conducted upon the same principles, that is, in such manner as to have but one flap for the Avhole Avound instead of dis- articulating them by as many separate operations. § IV.—Accidents. However easy or trivial the disarticulation of the fingers may seem, it is nevertheless frequently followed by very serious accidents. A 522 NEW ELEMENTS OF OPERATIVE SURGERY. man and a woman, in the year 1825 and 1826, died from this cause in the hospital of Perfectionnement; and a patient upon whom I ope- rated at La Pitie, in 1831, perished in the same Avay. Among those upon whom I have operated at La Charite, two have died, and it Avould be no difficult matter to find similar examples else- where. It is sufficient to remark that the operation should not be decided upon but with caution, and Avhere absolutely required. Its dangers arise from the extreme facility and fearful rapidity with which the inflammation, through the medium of the tendinous grooves, (coulisses,) sheaths, and synovial membranes and the ex- ceedingly loose lamellar tissue upon the dorsal and palmar sur- faces both of the phalanges and hand ; is propagated in the direc- tion of the Avrist, attacking at the same time the soft parts, the ar- ticulations and the surface of the bones, Avhich in this manner soon become the seat of a suppuration which nothing can arrest. To dilate (debrider) the fibrous sheath of each finger amputated, as is recommended by Garengeot, (Operat. de Chir., t. III., p. 432,) J. L. Petit, (Malad. Chir., t. III., p. 208,) and Bertrandi, and as has been again recently advised by M. Barthelemy, (Journ. Heb. Univ., t. XII., p. 429,) would in no manner prevent the development of those formidable phlegmasias, which besides are totally disconnected with every kind of strangulation. M. Champion has on two occa- sions subdued the inflammatory accidents which supervene after amputation of the fingers, by means of caustic potash applied to the palm of the hand ; but when cataplasms or the vigorous applica- tion of leeches do not arrest their progress in the beginning, there ia nothing which can prove really efficacious but numerous and deep incisions. The remedy is painful, undoubtedly, but it is a question of life and death; and every one who has had an opportunity of witnessing their sometimes almost miraculous effects Avill not hesi- tate an instant in resorting to them. Article II.—Amputation of the Metacarpus. Like the fingers, the bones of the metacarpus may be amputated in their continuity or at their articulations, and separately or all together; they may also be exsected or even extirpated (extirpes.) § I.—In their Continuity. Though the case may be rare in which we may have occasion to amputate the first and last bone of the metacarpus in their conti- nuity, it is not so with those which support the fore, middle, and ring finger. A. Anatomy.—The bones of the metacarpus, enlarged at their two extremities, incurvated in front, convex and wider on their dorsal surface, which is covered only by the flattened tendons of the ex- tensor muscles of the fingers, and by cellular tissue, veins and skin, and separated by spaces of less width near the wrist than elseAvhere, constitute in their ensemble a sort of grille (or grating, i. e., grillage) amputation op the upper extremities. 523 protuberant (bomb 6) behind, and the concavity of which is occu- pied by the inter-ossei muscles, the tendons of the flexors, the lum- bricales muscles, the two arterial palmar arches of the hand and their branches, the distribution of the median nerve, the muscles of the thenar and hypo-thenar eminences, and the palmar aponeuro- sis and common integuments. Though scarcely moveable at their posterior articulations, they may however be approximated so as to incline towards each other in front at their digital extremities; from Avhence it folloAvs that after having sawed obliquely through their middle portion, Ave are enabled to efface in a great degree the chasm which results from it, and that the defor- mity produced by this kind of amputation is much less than from the removal of one of the fingers. As their phalangeal extremity is in a state of epiphysis to the age of six or ten years, Ave may in children, and if the disease requires it, amputate one or all the fingers, by means of the bistoury. At a later period the saw becomes indispensable. B. Operative Process.—The chisel, gouge and mallet, have, as in amputation of the fingers, been employed though more rarely for the removal of the metacarpal bones. I. Partial Amputation.—In the hand, we must sacrifice nothing unless compelled to do so. Briot (Progres de la Chirurgie Mili- taire, p. 127,) has often seen, and many times himself performed an amputation of a portion of the hand with success. " We have often," says M. Larrey, (Clin. Chir., t. III., p. 609,) "not had it in our power to save anything but the thumb alone, or the thumb and little finger, or the tAvo or three last fingers of one hand, but they constitute hooks that are extremely useful to the patient." In a case where the hand Avas crushed, M. Champion obliquely divided the four first bones of the metacarpus, after having disarticulated the thumb, and preserved the little finger. " This little finger," says the author, " performs important services as a hook." a. The Ancient Process.—The parts being arranged, and held as for amputation of a single finger, the operator traverses, at some lines beyond the disease, the Avhole thickness of the hand from its dorsum to its palmar surface, then directs the point of the bistoury, held in the third position, upon the bone itself perpendicularly; inclines it a little to one side while drawing upon the skin; then straightens it (redresse) to graze the surface of the bone ; approxi- mates it to the median line when its point reaches to the outside, and terminates by cutting towards himself with the entire edge of the instrument (a plein tranchant) as far as to the middle of the corresponding inter-digital commissure. After this first incision, one precisely similar is made upon the opposite side, but in such manner that the tAvo form but one only behind ; that is to say, that the thumb and forefinger hold the tissues apart to the left, Avhile the bistoury, carried back to the commencement of the wound, glides from the other side to fall also into the same division in front. We then divide what remains of the soft parts about the bone, by passing around its entire circumference Avith the point of the in- 524 NEW ELEMENTS OP OPERATIVE SURGERY. strument. A thin piece of light Avood, sheet-lead, or pasteboard, or a thick compress is then inserted deep in the wound, to prevent the saw which must divide the bones, from before backwards by a long bevelled section [i. e., shelving, or slanting, or sloped—en biseau tres allonge] from wounding the flesh. This bevel (ce biseau) in consequence of the kind of motion peculiar to the carpo- metacarpal articulation, must be placed upon the ulnar side for the tAvo last fingers, and on the radial side, on the contrary, for the two first. When the bistoury has not been carried too far outwardly, the collateral arteries are not usually Avounded except at the root of the finger; in the contrary case, we run the risk of wounding their common trunk to the right and left, which, nevertheless, does not generally prevent us from dispensing Avith the ligature or torsion. In dressing, it suffices to keep the lips of the wound gently ap- proximated by means of some strips of adhesive plaster applied transversely, and three or four turns of bandage. In trying to obtain a perfect coaptation, we make traction upon the posterior articula- tions, but this is calculated to give rise to the train of formidable evils pointed out above. This operation, Avhich is not appreciably more difficult than the disarticulation of a finger, makes a bleeding surface or Avound three or four times larger, and necessitates the division of soft parts that are more delicate and far more nume- rous ; so that in this respect, at least, it is certainly much more seri- ous, nor should we have recourse to it unless after ascertaining that the other will not suffice. b. New Process.—I have long substituted the following for the ancient process. An assistant separates the fingers apart, and holds the hand. Embracing the diseased finger Avith my left hand, I make an incision draAvn obliquely from the posterior to the anterior articulation of the metacarpus, so as to go around the entire root of the finger. Setting out from the point Avhere this terminates, another incision on the other side proceeds to join the former at a very acute angle on the back of the hand, as in the ovalar method. I after- wards isolate the bone on its sides and palmar surface, to beyond the diseased portion. I had at first used the rowel-saw (scie a mo- lette) to divide from the dorsum to the palm of the hand, but M. Liston's pliers enables us to perform the section Avith far greater facility. Using this instrument, all the soft parts in the palm of the hand are protected from injury, and the operation is at once easy and rapid. None of the five patients upon Avhom I have used these pliers have had any accidents folioav, and everything shows that the bone thus divided heals as well as after the use of the saAV. This process, should it be generally adopted, will rarely make it necessary to disarticulate the bones of the hand. By this process, the operation performed by M. Simonin, (Decade Chir., 1838, p. 52,) to remove the second bone of the metacarpus, would have been made very easy and very simple. It is, after all, only an improve- ment of the ovalar method, and especially of the process long since AMPUTATION OF THE UPPER EXTREMITIES. 525 employed under similar circumstances by M. Langenbeck, (Rust's Handbuch der Chir., t. I., p. 641.) II. Amputation in mass, (en masse.)—a. Louis (Mem. de I'Acad. Roy. de Chir., t. IL, p. 272) made the section of the greater part of the bones of the metacarpus, in such manner as to leave only their posterior portion, in the case of a young girl, who was quite satis- fied in having this mere vestige of the hand preserved. It would be better still should their anterior extremity (leur tete) alone be diseased, to divide them all in this manner transversely, rather than to disarticulate them. The operation could not present any great difficulties. A semi-lunar incision, with the convexity anteriorly, would lay bare their dorsal surface; a narrow knife, passed be- tween the bones and the soft parts, from one border of the hand to the other, would form a palmar flap of from twelve to eighteen lines in length ; a bistoury would then divest each bone of the tis- sues that surround it, in order to render the section with the saw more neat and easy. b. A Single Palmar Flap.—In such cases, M. Van Onsenort makes in the pa/m of the hand, placed in supination, an incision near the fingers, Avith its convexity anterior, and comprising the entire thickness of the soft parts. From each extremity of this incision, he makes another which is oblique, and Avhich are directed respectively to the radial and ulnar borders of the wrist. The upper extremi- ty of these are united by a transverse incision, which divides through the whole of the tissues on the dorsum of the metacarpus. We then, by means of a narroAV bistoury, isolate the bones from their muscles and periosteum; hold back the divided parts by means of a retractor (releveur) bandage with five tails, and then saw through the bones. c. A process much more simple, and one to which, considermg all the circumf tar.ces, I giye the preference, consists, after the dorsal flap is formed, in denuding each bone .upon its sides, and then di- viding them successively with Liston's pliers, before making the palmar flap. § II.—In the Contiguity. A. Partial Amputation.—All the bones of the metacarpus may be separately disarticulated and amputated, together with the finger which corresponds to them. This may be done with the whole toge- ther, or with the four last only, and by a single stroke. But it is almost exclusively on the first and fifth that disarticulation is perform- ed, since it is more easy to amputate the others in the continuity. I. Metacarpal Bone of the Thumb.—From the mobility of this bone, and its shortness, we rarely think of dividing it by the saw when diseased, but prefer disarticulating it. Nevertheless, if its anterior extremity was alone affected, I see no reason why we should not divide it immediately posterior to this. There can be no particular danger in this operation, which, moreover, would not be difficult, and might be performed either by the flap oi circu- lar method, and would differ from amputation of the fingers at the 526 NEW ELEMENTS OF OPERATIVE SURGERY. joint in this particular only, that it would require the intervention of a cut of the saw, or a stroke of the cutting pliers, to finish it. a. Anatomy.—The metacarpal bone of the thumb Avhich, upon its dorsum and outside, is scarcely covered except by the skin, and which is concealed in front by the whole thickness of the thenar eminence, presents, near the carpus, relations which it is important should be noted. The articulation of this bone Avith the trapezium being situated obliquely in relation to a line which would extend to the root of the little finger, and presenting, in some sort, a mixed cha- racter between the hinge (ginglyme) and enarthrosis, (enarthrose,) and surrounded with a very loose capsule, may be reached upon all the points of its circumference, but principally at its two poste- rior or dorsal thirds. The tendons of the extensor ossis metacarpi pollicis, (long abducteur,) and of the abductor pollicis manus, (court extenseur,) occupy and support its cutaneous region; while the radial artery passes around its ulnar side in going to the palm of the hand to form the deep-seated palmar arch. As to the tendons of the extensor secundi internodii pollicis, (long extenseur,) and of the flexor longus pollicis manus, (long flechisseur,) their position in front and behind is too well known to require any particular notice here. We determine the position of the articulation by gliding the forefinger from before backwards, either upon the dorsum or on its sides, as it is immediately behind the first osseous tubercle we encounter. b. Operative Process.—We may disarticulate the first metacarpal bone by a great variety of methods, and with ease in whatever way we do it, provided we possess any address or skill. I. Ancient Process.—If the surgeon is not ambidexter, the hand of the patient should be held in pronation for the left side, and su- pination for the right; in the contrary case, it is placed in pronation for both sides. While the assistant holds the wrist with one hand, and the root of the four last fingers with the other, the operator seizes hold of the thumb, which he carries into abduction; then directs upon the middle of the commissure the cutting edge of the bis- toury, held in the first position, with its point upAvard ; divides with its entire edge (en plein) the whole thickness of the soft parts, grazing from before backwards the ulnar border of the bone as high up as to the carpus; prolongs from four to six lines towards the wrist the incision of the teguments upon the dorsal and palmar surfaces; opens into the joint by inclining the bistoury outAvardly ; divides all the fibrous parts with the point rather than with the body of the instrument, in order that he may avoid wounding the skin; reverses the thumb at the same time upon its radial border, luxates it, and after having divided the articulation, cuts the flap from be- hind forward, grazing the outside of the bone until he reaches to within some lines in front of the metacarpo-phalangeal articula- tion. To preserve to the flap, especially at its base, the required width and thickness, it is advisable, while cutting through the inter-osseous space, to incline the handle of the instrument a little tOAvards the hypo-thenar eminence, and to direct its cutting edge AMPUTATION OF THE UPPER EXTREMITIES. 527 towards the pisiform bone, or the ulnar border of the carpal ex- tremity of the radius. In prolonging the wound of the skin to some lines beyond the carpo-metacarpal articulation, we obtain a means of disjointing the bones with ease, without notching (Gchancrer) or hacking (decouper) the margins of the flap which is to cover the Avound. If we have wounded the radial artery itself, we apply the liga- ture to it. The exact coaptation of the surfaces renders this re- source unnecessary, Avhen there have been no other arteries divided but the branches on the thenar eminence. After having applied the adhesive plasters, it is well to place a mass of lint or a gradu- ated compress upon the outer surface of the flap, the base of which especially must be strongly pressed against the second metacarpal bone. 2. Another Process.—An assistant holds the thumb ; the surgeon with the three first fingers of his left hand seizes hold of as much of the soft parts and draAvs them as far outwardly as possible ; plunges in the bistoury by puncture from the dorsal surface of the hand to the palmar surface of the thenar eminence, grazing the radial side of the articulation; cuts out a flap as in the preceding process, reverses it backwards, and causes it to be held up by an assistant; he then him- self takes hold of the thumb; causes the lips of the Avound to be held apart; divides the joint from without inwards, luxates the bone and brings the bistoury back to terminate the operation at the point where it should have commenced in the other process. As the final result is precisely the same in the two processes, and as it is always less easy to disarticulate by this mode, which as it appears is still followed by M. Walther, (Rust's Handb. de Chir., t. I., p. 642,) we should give the preference to the first. c Process of the Author.—In the place of making the flap by cutting from within outwards, we may proceed in the opposite direction, that is, commence with the section of the integuments, and reverse it afterAvards by dissecting it from its apex to its base; this would be a more certain means of giving it as much regularity as possible, and the proper dimensions desirable, only that it would require a little more time. In actual practice we obtain in this manner a result infinitely preferable to the processes above de- scribed. 4. New Process.—I have frequently, in amputating the thumb, adopted the following mode. A dorsal incision carried from the styloid process of the radius to the middle of the commissure be- tAveen the two first fingers, [i. e., betAveen the two first metacarpal bones. T.] and comprising the teguments, the tendon of the exten- sor secundi internodii pollicis, with a part of the first inter-osseous muscle, lays bare at first the articulation. While an assistant holds open the lips of the wound, the surgeon divides the ulnar side of the capsule,luxates the bone, and passing the bistoury underneath, sepa- rates it from the thenar eminence by cutting the soft parts from behind forAvards and from within outwards. The palm of the hand being respected by this mode enables us to give to the flap the form and 528 NEW ELEMENTS OP OPERATIVE SURGERY. extent we may require, and without any special obstacles to over- come. 5. Ovalar Method.—Lassus, Beclard, and M. Richerand, have long since described the oval method for the amputation under con- sideration. The operation is commenced as I have pointed out. The incision passes round the anterior surface of the root of the thumb, [i. e., the palmar,] to ascend upon the outside to its dorsal surface, and unite this second incision to the extremity of the first. In the second stage the point of the bistoury is directed upon the articulation which is divided from its dorsal to its palmar surface ; after which nothing remains to be done but to detach the bone from the soft parts which are adherent to it, by gliding the instru- ment in front of it from behind forwards. By this means Ave ob- tain an oval wound which is elongated to a great extent, and the lips of which may be united with the greatest degree of facility, so as to leave between them nothing but a linear cicatrix. It is the best and most simple of all the processes knoAvn, but not quite so easy as the preceding, which moreover accomplishes the same results. II. The fifth Metacarpal Bone.—The bone which supports the lit- tle finger is disarticulated and removed by the same processes as those described for the thumb. Its articulation with the unciform bone (l'os crochu) presents this remarkable peculiarity; that it inclines obliquely in the direction of a line which would strike in front of the articulation of the trapezium with the first metacarpal bone, and that it is united to the metacarpal bone which supports the ring finger by an articulation (facette) which is nearly flat (plane) and by two or three ligamentous bandelettes. This articulation is recognized upon the outside by passing the point of the fore-finger along the dorsal surface of the last metacarpal bone, since before reaching the line of the pisiform bone we meet with a slight pro- tuberance, then a small depression which is exactly upon the inter- line of the articulation. a. When we follow the ancient process we need have no fear of the bistoury catching (s'engager) as it does in amputating the thumb between the bones of the carpus. We must therefore carry it unre- servedly as far as to the unciform bone by grazing the radial surface of the fifth metacarpal, and directing the edge of the instrument towards the median line of the wrist, so as to preserve almost entire the hypp-thenar eminence. When the inter-metacarpal ligament is divided, the point of the bistoury, which is then to be inclined u> wards the ulna, readily enters into the articulation. In proportion as the other fibrous tissues are divided, the finger is to be reversed upon its ulnar border, that the instrument may escape from the articulation, to form the base of the fiap cutting out the latter from behind forward/and prolonging it beyond the metacarpo-phalangeal articulation, while the little finger in the meanwhile is brought nearly into its natural position. b. The second process in which we commence in forming a flap by plunging through the soft parts from one of the sides of the AMPUTATION OF THE UPPER EXTREMITIES. 529 hypo-thenar eminence to the other, before having separated the fifth from the fourth metacarpal bone, is in this part of more easy and advantageous application than upon the other border of the hand. The soft parts which naturally make a very considerable prominence on the outer part of the bone which we are about to remove, enable us by this means to cut out a thick flap of sufficient width ; but the disarticulation is also more difficult than by the preceding mode. c The process which I sometimes employ for the metacarpal bone of the thumb is not applicable with the same advantage to that of the little finger, Avhere the ovalar method is evidently preferable. The incision, commencing in front of the styloid process of the ulna, is carried obliquely forward to the root of the little finger, passing round its palmar surface from its ulnar to its radial border. We stop at the commissure in order to re-apply the bistoury at this point in order to prolong the incision backwards to unite it at an acute angle (en pointe) with the beginning of the first incision. We might, moreover, begin just as well by falling on the com- missure between the tAvo last fingers, and terminating Avith the inner incision. As to the disarticulation, it presents nothing peculiar, and does not require any other notice. III. The Middle Metacarpal Bones.—Without being impractica- ble, the disarticulation of these three bones is, nevertheless, it must be conceded, much more difficult than that of the two first; also amputation in their continuity is generally preferred to their dis- articulation. If, hoAvever, Ave should desire to have recourse to the last, it may be performed either by the flap or ovalar method. 5 'A. The Flap Method.—1. Metacarpal Bone of the Fore-finger. —The bistoury directed from before backwards, and from the commissure tOAvards the carpus, soon reaches the ligament which unites the metacarpal bone of the fore-finger to that of the mid- dle finger. We then raise the handle to divide the dorsal liga- ment, and then depress it to cut the palmar ; the finger is inclined towards the thumb, the articulation entered, then separated by the point of the instrument, and the operation finally terminated by forming upon the radial side of the bone a flap which is prolonged until it reaches beyond the metacarpo-phalangeal articulation. 2. Metacarpal Bone of the Middle Finger.—The bistoury is applied betAveen the tAvo middle fingers. Before proceeding to the disarticulation, the Avound must be prolonged in front and behind upon the wrist to the extent of half an inch, slightly approximating to the median line. This articulation is somewhat oblique in the direction from the ulna to the radius and from before behind, for Avhich reason the operation Avould be rendered much more difficult if Ave commenced upon the other side. When the dorsal and pal- mar ligaments are divided, and when the bone Avhich we are about to remove is separated from the metacarpal of the ring-finger, we act upon its anterior extremity as if for the purpose of luxating it backwards, and then endeavor, while an assistant draAvs the lips of the Avound towards the thumb, to disarticulate (degager) its car- pal extremity, upon Avhich, moreover, is inserted the tendon of one 34 530 NEW ELEMENTS OP OPERATIVE SURGERY. of the radial extensors of the carpus, (un des radiaux externes.) This being accomplished, the bistoury is glided with its entire cut- ting edge (a plein tranchant) along the outer surface of the bone to the commissure of the fore and middle finger. 3. For the fourth metacarpal bone, (i. e., the metacarpal bone of the ring-finger,) we must direct the bistoury upon the same space; prolong the incision in the same manner posteriorly, with this dif- ference, however, that it must be inclined towards the ulna; we then separate the two contiguous osseous articulating surfaces, and divide the ligaments as in the preceding mode, calling to mind that the articulation of the metacarpal bone of the ring-finger Avith the os magnum and the os unciforme (os crochu) is oblique from Avith- out imvards and from before backAvards, and that it is also continu- ous with that of the fifth metacarpal. In traversing the Avhole palm of the hand by two parallel incisions Avhich are united poste- riorly by means of oblique A incisions, M. Rust (Rust's Handbuck der Chir., t. I., p. 653) may perhaps render the operation more easy, but it produces a larger Avound, and one which is manifestly more difficult to heal. B. The Ovalar Method.—M. Langenbeck (Rust's Handb. der Chir., t. I., p. 654) Avas the first Avho successfully extirpated one of these bones by the ovalar method. The operator divides the integu- ments on their dorsal surfaces, by commencing at half an inch be- yond the carpal articulation ; he prolongs his incision to one of the digital commissures, brings it back upon the opposite side by pass- ing around upon the palmar surface of the root of the finger; then unites its tAvo extremities by cutting from before backAvards, or from behind forAvards, after the same rules on the outer side of the bone Avhich he is about to disarticulate. While an assistant sepa- rates as far apart as possible the tAvo lips of the wound, the surgeon, with the point of the bistoury, and Avithout using any force divides in succession the ligaments of the articulation ; and Avith his other hand makes an effort to luxate the bone. When he has finally effect- ed this last result, the bistoury is glided flatAvise and horizontally, in order to divide from the carpus to the root of the finger all the soft parts which still adhere to its anterior surface. M. Simonin, (Decade Chir., 1831, p. 51,) in disarticulating the second bone of the metacarpus, in a patient of his Avho got avcII, combined the ovalar with the ancient process. The oval incision being made, this surgeon slit up (fendit) the palm of the hand, and found more facility by this mode in disarticulating the bone, re- moving Avith it the finger at the same time. B. Simultaneous Amputation. When the Avhole hand is affected in such manner that the carpo-metacarpal articulation remains un- implicated, is it necessary to remove the wrist at the same time Avith it ? To believe in dogmatic treatises on surgery, there should not be the least doubt upon this subject, or, to speak more cor- rectly, none of them have paid any attention to this question; at the present time, however, this is no longer the practice. In confining ourselves to the disarticulation of the metacarpal AMPUTATION OP THE UPPER EXTREMITIES. 531 bones, we preserve a greater length to the fore-arm, and a move- able portion of limb, and obtain incontestible advantages for the ap- plication of an artificial limb, (des moyens prothetiques.) M. Lar- rey (Clin. Chir., t. III., p. 609) affirms that military surgeons have long employed this operation. M. Yvan (Arch. Gen. de Med., t. XIV., p. 293) also says that many of the military patients of the Hotel of the Invalids have undergone this operation, and have done well after it. On the other hand, I find in a thesis sup- ported in 1803, detailed observations upon this subject. In many soldiers of the army of the Rhine, says the author, amputation was performed at the carpo-metacarpal articulation Avith the view of saving at least the thumb. J. B. J. A. Blandin, (These, 1803,) who describes this operation, and censures it, says this kind of disar- ticulation is very difficult; that in one case purulent collections rendered it necessary at a later period to amputate the arm, and in another the fore-arm, and that both died. Paroisse (Opuscules de Chir., 1806, p. 218) also in a patient of his, was enabled, by confining himself to the extirpation of the three last bones of the metacarpus, to preserve both the thumb and fore-finger. M. Delatouche, (These, Strasbourg, 1814, p. 45-46,) who, in removing the fourth and fifth bone of the hand, was equally fortunate, says, that in fourteen or fifteen cases of this description, he has been enabled by this mode, to save a number of fingers. M. Mornay (These, Strasbourg, 1816) maintains the advantage of saving the thumb at least. Troccon, who thought himself the author of this operation, repeated it a great many times upon the dead body, and presented a careful description of it to the Institute, which obtained a somewhat favorable report from Percy and Pel- letan. At a later period, M. Maingault, (Nouv. Meth.pour Ampu- ter la Main, &lc.,) in 1822, endeavored aneAv to draw attention to it, Avithout mistrusting, as it would seem, that any person had spo- ken of it before him. Since the treatise of Troccon, M. Gensoul (Arch. Gen. de Med., t. XIV., p. 293) has performed it Avith entire success at the Hotel Dieu, of Lyons, preserving only the thumb. Before him M. Guthrie had amputated the two last fingers and their corresponding metacarpal bone. M. Walther (Ibid., t. XXIV., p. 135) has also performed this operation for the second and third finger in one case, and for the third and fourth in another, (Graefe und Walther, Journal, Vol. XII., 1S29.) Finally, Troccon advanced the idea that it Avould be practicable to remove at the same time one or more bones of the first range of the carpus, and M. Benaben (Revue Medicale, 1825, t. I., p. 377) undertook to demonstrate the correctness of this opinion by successfully performing amputation upon the scaphoid, the trapezium, and trapezoid bones, and upon the metacarpal bones of the thumb and fore-finger. Tavo English (surgeons) also have claimed priority on these different points : the one, M. Sully, avers that in 1S07, in a patient Avho is still livin* he removed the last bones of the metacarpus, and also the unci- form bone, the pisiform, (pisiforme,)and the pyramidal, (pyramidal.) The other, M. Radiore, avers, that in an infant of nine years of a»c 532 NEW ELEMENTS OF OPERATIVE SURGERY. in whom he removed the three middle metacarpal bones and the os magnum, (os grande,) he preserved only the thumb and little finger. As often as we can preserve the thumb or any of the fingers, there is no doubt that we ought to adopt the process of these prac- titioners, and follow the advice of Troccon and M. Maingault As a general rule, the carpo-metacarpal disarticulation should be preferred to amputation of the wrist. But it is an operation Avhich exacts practice and an intimate knowledge of anatomy; so that if the surgeon does not feel sufficiently confident of himself to perform it without fear, he ought not to undertake it. I. Anatomy.—We have already spoken of the arrangement of the first and fifth bone of the metacarpus, Avith the trapezium, and unciform bones. The metacarpal bone of the fore-finger, Avhich is but loosely attached on its outer border to that of the thumb, but more firmly united on its inside with the third metacarpal bone, presents posteriorly on its outer side, a tubercle which is prolonged some lines towards the Avrist, and gives attachment to the tendon of the extensor-carpi-radialis-longior, (premier radial.) [For all the muscles, see Table at the beginning of Vol. I., this American Edition. T.] Its posterior articulating surface is articulated on its outer portion Avith the trapezium, and on its two inner thirds with the anterior articulating surface of the trapezoid bone, Avhich is found incased there, as it were, in a sort of triangular cavity. The third bone of the metacarpus also presents a tubercle which projects (tend a glisser) beyond the interline of the os magnum and the trapezoid bone, upon which tubercle is inserted the tendon of the extensor-carpi-radialis-brevior, (second radial externe.) Its posterior articulating surface, oblique from without imvard, rests in almost its Avhole extent upon the corresponding surface of the os magnum ; while the articulating surface of the fourth metacarpal bone, oblique internally and posteriorly, is united with the radial half of the anterior articulating surface of the os unciforme, and then with a similar articulating surface (facette) which is presented by the os magnum anteriorly and on its inner side. All these bones, on their dorsal surface, are kept in contact by ligaments in form of longitudinal and transverse narrow bands, (ban- delettes,) and on their palmar surface by ligaments much more ir- regular in form, and also by fibrous bundles (trousseaux) which fill up the spaces which the points of the posterior extremities of these bones leave between them in front. Their synovial sheath is con- tinuous, moreover, with that of the carpus, and is extended conse- quently betAveen the tAvo ranges of bones of this part; so that in- flammation of the osseous surfaces as a consequence of the ampu- tation Ave have been treating of, must, as a matter of course, be of a very formidable character. In revieAving all these articulations upon their dorsal surface, we see that that of the first metacarpal, oblique anteriorly and internally, terminates at one or tAvo lines in front of (au devant) that of the second, the interline of Avhich latter goes at first al- most directly backAvard, becomes nearly transverse before leaving AMPUTATION OP THE UPPER EXTREMITIES. 533 the trapezium, then turns round into a semilunar direction, with its convexity backwards on reaching the trapezoid bone, (tra- pezoide,) and afterwards again passes obliquely backwards before abandoning this bone and uniting itself with the third metacarpal. The articulation of the third metacarpal bone commences at half a line nearer the wrist than the extremity of that of the second, and inclines obliquely inwards and forAvards, as if to rest (pour tomber) upon the posterior fourth of the fifth metacarpal: it terminates, moreover, at two or three lines nearer the fingers than the com- mencement of the articulation of the fourth, Avhich last at first follows such a direction, that if prolonged, it Avould become blended (irait se perdre sur) Avith the pisiform bone ; afterwards it becomes almost transverse on arriving at the os unciforme, and is continuous, but in some sort Avithout any line of demarcation, with that of the last metacarpal, Avhich is also very slightly oblique posteriorly. The manner of identifying externally the first and fifth of these articulations having been pointed out above, it is, as I conceive, unnecessary, to recur to it here. II. Operative Process.—A. Method Adopted by the Author.—An assistant supports the fore-arm, while he makes pressure at the same time upon the radial and ulnar arteries. The hand of the patient, turned in pronation, is embraced by the operator, Avho con- fines himself to holding the four last fingers, when he wishes to pre- serve the thumb ; Avith a straight bistoury, or a small knife, Ave make a semicircular incision, with its convexity fonvard, about half an inch in front of the articular line Ave have just described. The as- sistant draws the skin back tOAvards the fore-arm. With a second cut of the bistoury, the surgeon divides all the extensor tendons, and proceeds immediately to disarticulate, commencing on the ra- dial side if he operates with the left hand, and on the ulner side, on the contrary, if he operates on the right. The point of his bistoury should merely be draAvn over the Avhole extent of the dorsal sur- face of the articular interline, for there is no need of penetrating the joint in order to divide the ligaments. If we begin by the thumb, its cutting edge will be first directed from behind forAvards and from Avithout inAvards; then almost directly backwards; after- wards transversely, obliquely forward, (en devant.) obliquely back- ward, (en arriere;) then forAvard again through the whole extent of the articulation of the os magnum, Avith the third metacarpal bone, very obliquely backAvard upon arriving at the fourth, almost transversely to separate this last, and in such manner as to follow the same direction for the separation of the fifth metacarpal from the os unciforme. During this manipulation,a certain degree of force is exerted upon the anterior extremity of the hand, as if for the purpose of luxating it- All the articulations being noAV laid open, the point of the bistoury is used to complete the section of the fibrous parts which may still hold them together. When these are all completely separated, the knife is glided gradually tOAvards the palm of the hand, and being turned flatwise, cuts out a semilunar flap of an inch or an inch 534 NEW ELEMENTS OF OPERATIVE SURGERY. and a half in length, grazing, as it proceeds, the palmar surface of the metacarpal bones Avhich are to be removed. The terminating branches of the radial and ulnar arteries have necessarily been di- vided. Those of the first are found upon the dorsal surface of the wrist, and near its radial border ; the second must be sought on the inner side of the pisiform bone. Immediate reunion, Avhich is in some sort indispensably necessary, requires here the same precau- tions as after the simultaneous amputation of the four last fingers. b. Process of M. Maingault—The process Avhich I have just de- scribed after Having often made trial of it on the dead body, and which is founded upon the principles laid doAvn by Troccon, is not the same as that of'M. Maingault. This last-mentioned author pro- poses that the surgeon should commence by forming the palmar llap, with a small knife inserted between the bones and the soft parts, so as to pass a little in front of the projections of the unciform and trape- zium bones, leaving untouched everything which appertains to the thumb. He afterwards makes a semi-lunar incision upon the dor- sal surface of the metacarpus, at the distance of an inch from the articulation ; then returns in front, (revient en avant;) and while an assistant draws the flap backAvards, he directs the point of the bistoury upon the base of the first, [flap,] (du premier,) until he exposes the inter-articular line. After which he proceeds to the disarticulation from before backAvards, commencing Avith the me- tacarpal bone of the little finger, or by that of the fore-finger, ac- cording as the operation is upon the right or left hand. c. The trial Avhich I have made of this process has convinced me that it is not in reality very difficult. From not being practised in it, hoAvever, or from its inherent defects, it has appeared to me that the other was much more convenient. The definitive result, how- ever, it is seen, must be the same in both cases. d. If the tAvo last metacarpal bones, or the tAvo first, only were to be removed, the operative process would have to undergo some modifications. It would be necessary, in the first case for example, to commence by a transverse incision a little in front of the articu- lations, then to make another parallel to the axis of the metacarpal bones, upon the dorsum of that which supports the little finger, in order to cut upon that part a dorsal flap, which is to cover the whole ulnar side of the wound after the operation. This being done and the disarticulation completed, we would terminate the operation by forming only a small flap, of one or two inches in length, which we should be obliged to separate down to its base in the palm of the hand, in order to be enabled to raise it in front upon the transverse branch of the Avound. We should proceed in the same manner nearly for the removal of the thumb and fore-finger, or for the fore and middle fingers. Proceeding in this manner, M. Gairal, (Journ. Hebd., 1835, t. III., p. 64,) in the case of a man who had a musket burst in his hand, was enabled to preserve the two last fingers. Another patient, operated upon at Nancy (Gairal, Journ. Hebd., 1S35, t. III.) by the same process, lost only the three middle metarcarpal bones, while he preserved the thumb and little finger. AMPUTATION OP THE UPPER EXTREMITIES. 535 Should it be required to remove at the same time some of the bones of the carpus, there is no rule that could be laid doAvn in ad- vance ; these nice operations must in general be left to the ana- tomical skill of the surgeon. M. Van Onsenort, in amputating the inner half of the metacarpus, with unciform, pisiform, and pyra- midal bones, cut out a single flap only upon the ulnar border of the hand. The patient got Avell, and preserved the use of his thumb and fore-finger, with the middle finger in a slightly ankylosed state. Article III.—The Wrist. In our times, says Percy, it is only at Tunis, or among other bar- barians, that they cut off the wrist by means of a large hatchet, driven by a weight falling from above between two grooved uprights, (montants a coulisse,) or a heavy chisel, which is struck upon Avith a leaden hammer. Nor is there any one Avho any longer believes it necessary to amputate the fore-arm, when, in order to remove the totality of the disease, nothing more is required than to dis- articulate the hand. Among the moderns, hoAvever, there are many surgeons Avho regard this last operation as exceedingly dan- gerous. The facts related by Slotanus, (F. de Hilden, in Bonet, p. 504,) Bartholin, (Hist. Anat, cent. 5, hist. 63,) Paignon, (Mem. de I'Acad. Royale de Chir., t. V., p. 504, 1819,) Leblanc, (Precis des Operat, t. I., p. 317,) Andouillet, (Acad, de Chir., t. V., p. 505,) Hoin,(f6.,p.506,) Sabatier, (lb., p. 504,) Brasdor, (/fe„p.492,) Las- sus, (Med. Operat, p. 541,) M. Gouraud, (Prineip. Operat, p. 79,) and other surgeons, who affirm that it is almost always successful, have not dispelled the fears Avhich it formerly inspired, and which Schmucker (Rougemont, Bibl. Ch.duNord,t.I., p. 56) still entertains. § I.—Anatomy. The radio-carpal articulation, surrounded with numerous tendons and synovial grooves and membranes, offers, moreover, this re- markable peculiarity : that it is terminated at the extremities of its largest diameter, by the processes of the radius and ulna, which gives it a semilunar form, concave transversely, slightly concave also from before backwards, Avhere is lodged a kind of head formed by the scaphoid,semilunar and trapezium bones, which are kept in place by the internal, external, posterior, and anterior ligaments. As the first range of the bones of the carpus diminishes (s'amincit) at its extre- mities, especially on the ulnar side, a line drawn transversely be- tween the apices of the styloid processes, Avould naturally strike be- tAveen this range and the second. The pisiform, the point of the sca- phoid, the crest of the trapezium, and that of the unciform bone, rise sufficiently above the line of the palmar surface of the radius and ulna, to require also that they should not be overlooked at the moment of operating. The skin on the anterior surface of the Avrist presents almost constantly three wrinkles, which may be of some service in regulating the direction of the instruments. One of them, and which is the most constant, is found immediately above the 536 NEW ELEMENTS OP OPERATIVE SURGERY. thenar and hypo-thenar eminences, and corresponds to the line of division of the two ranges of the bones of the carpus ; the second, which is noticed at four to six lines behind this, is over the line of the radio-carpal articulation, and the third still higher up, cor- responds usually Avith the epiphysal (epiphysaire) line of the bones of the fore-arm. When these folds are not very obvious, it is ordi- narily sufficient to flex the hand moderately to make them distinct. § II.—Operative Process. The amputation of the Avrist is performed only by the circular and the flap method. OAving to the arrangement of the articular surfaces, and the slight degree of thickness in the soft parts, the oval method is not applicable to this operation. A. The Circular Method.—The surgeons of the last century hav- ing contented themselves with remarking that the amputation of the Avrist Avas performed like that of the fore-arm and leg, without entering into any details upon the subject, it is to be inferred that they employed the circular method, described, moreover, Avith suf- ficient clearness by J. L. Petit, the only one pointed out by Lassus and Sabatier, and the one, we must confess, which still presents the most advantages and facilities. The assistant who holds the fore-arm, draAvs the integuments forcibly backAvards. The surgeon seizes the hand of the patient, and places it in a state of flexion, while he makes his incision upon the dorsal surface tOAvards the radius on the con- trary, when he incises imvardly, and upon the ulna Avhen he reaches the outside, and in extension at the moment the instrument is passing underneath. In this manner he makes a uniformly cir- cular incision, at a large finger's width (a un grand travers de doigt) in front of the processes of the fore-arm, and confines himself at first to the section of the skin which it is easy to push back after- wards to near the joint. A second cut divides all the tendons upon a line Avith the retracted integuments. We then enter the articula- tion upon either one or the other side, taking the corresponding styloid process for our guide, and making the bistoury describe a curved line, with the convexity directed posteriorly. Though the radial and ulnar arteries are readily found, and may be either tied or tAvisted, they are often left in the Avound without this precaution, and without any hemorrhage resulting from it. As to the inter-osseous, it is too small to require the least attention. If the operation has been well performed, there will be found a suffi- ciency of integuments to enable us to bring them forward Avithout any difficulty, and to cover the articulating surfaces completely. It is in these cases that Garengeot and Louis (Leblanc, Op. cit., t. I., p. 319) advise the division of the tendinous sheaths to the extent of one or tAvo inches, in order to prevent the formation of purulent collections. The inclined (declive) position of the stump at least seems, in these cases, to be imperiously demanded. B. The Flap Method.—I. Ancient Process.—The army surgeons appear to have for a long time employed, and M. Gouraud in 1815 AMPUTATION OP THE UPPER EXTREMITIES. 537 has described, a process which consists in making, on the dorsal surface of the wrist, a semilunar incision, with its convexity to- wards the fingers, and whose tAvo extremities seem to be continu- ous with the styloid processes of the radius and ulna. An assist- ant then immediately draAvs back the cutaneous envelope, and the operator divides the bridles Avhich unite it to the subjacent tissues. A second incision, made upon the line of the articulation, serves to divide all the extensor tendons and the posterior radio-carpal liga- ment. We then divide the lateral ligament and the tendons of the radial muscles, (muscles radiaux,) [see vol. I., Table of the Mus- cles. T.] and of the extensor-carpi-ulnaris, if they have not already been divided at first. Nothing more remains than to separate the joint with a narrow knife, Avhich is glided in front of the carpus, so as to terminate by cutting out a palmar flap of about an inch in length. Some surgeons recommend giving this flap a length of two inches from its root, and consequently to obtain a portion of it from the thenar and hypo-thenar eminences. Should Ave have been enabled to preserve a sufficiency of skin in the beginning, this pre- caution would be more injurious than serviceable. To cut it with facility, and to give it all the regularity possible, the cutting edge of the instrument must be inclined in good season towards the integu- ments, in order not to strike against the osseous projections of the carpus, and that Ave may remove the pisiform bone at the same time with the hand. Should the flexor tendons, which form in that part a bundle of considerable size, make any resistance, we ought not to hesitate to direct the instrument under them, in order to divide them transversely. The approximation and reunion of the lips of the Avound will be thereby rendered more easy. This process, which is as prompt as it is simple, has the advan- tage, should the soft parts posteriorly be degenerated, of enabling us to preserve a sufficiency of them in front to cover the whole wound ; but it has the disadvantage of endangering denudation of the boney angles and their protrusion betAveen the lips of the Avound ; for the thickest and Avidest part of the cutaneous flaps is situated precisely upon the concave and least salient portion of the articulation. II. To cut the 2 flaps before opening into the articulation, as has been done by M. Walther, (Rust's Handb., t. L, p. 609,) Avould per- haps give more regularity to the wound, but would not in any way change the character of the process. M. Rust, (Ibid., p. 610,) Avho, by means of tAvo lateral and tAvo transverse incisions, gives a square or trapezoidal form to the dorsal flap, which he then raises up to divide the articulation, and to finish as in the ordinary process, has, it appears to me, rendered the operation thereby unnecessarily com- plicated. III. Process of M. Lisfranc.—The operator, provided with a narroAV knife, transfixes (transperce) the tissues on a line with the styloid processes, from the radius to the ulna or from the ulna to the radius, according as he is operating on the right or left limb ; passes in this manner between the soft parts and the anterior sur- 538 NEW ELEMENTS OP OPERATIVE SURGERY. face of the carpus ; then brings the instrument in front, and cuts out, as in the preceding case, a semi-elliptical flap of about two inches in length. This flap being raised up, or turned back, en- ables the surgeon to make, immediately after, upon the dorsal sur- face of the wrist, a semicircular incision nearly similar to that of the process Avhich I have just described, and at the same time to divide the extensor tendons nearly on a line Avith the articulation; then to disarticulate by passing under the point of one of the sty- loid processes; thus terminating the operation as in the circular method. IV. ,In describing the process Avhich M. Blandin, (Jadelot, Jour. Hebd., t. III., p. 460,) on one occasion, adopted Avith success, the editors of Sabatier have, as it Avere unconsciously, added to it a slight modification. After having formed the palmar flap, in place of carrying the knife behind the Avrist to divide the integuments there, they propose to divide the joint immediately from before backAvards, and to finish with the division of the tissues which cover the dorsum of the carpus. Whether Ave adopt one mode or the other, this process presents nearly the same advantages and the same inconveniences ; that is to say, it is infinitely less convenient than the flap method usually folioAved, and, moreover, differs from it by such slight modifications as not to require any further notice. V. The method of Rossi (Elem. de Med. Oper., t. IL, p. 233) which proposes to make two flaps, one to the right and the other to the left, in the place of forming them in front and behind, also has no claims to our notice. VI. At the Avrist as elseAvhere the surgeon is often guided by the condition of the diseased parts, much more than by the rules estab- lished upon the dead body. A man who had had the metacarpus and fingers contused by a cotton dresser (batteur de coton) exhibited upon the palm of his hand a large flap of sound tissues. After having abraded and regularized this flap, M. Champion, who has never had any occasion to regret having preferred extirpation of the wrist to amputating the fore-arm above it, raised it up to its place and effected the cure of his patient. In an army farrier, in whom a cancerous affection extended posteriorly to a line with the articulation, I was obliged to take the flaps from the outside and in front. The patient recovered. VII. The borders of the Avound should be approximated from before backAvards. A roller bandage brought doAvn from the elbow to the wrist, and long compresses for each side of the stump, pro- tect the synovial membranes from inAammation and purulent col- lections. A slightly depending position best suits the Avound. If an inAammatory engorgement should take place in the stump we must hasten to remove the bandages, and to substitute emollient topical applications, and antiphlogistic to the agglutinating means. Article IV.—The Fore-arm. The law that we should amputate as far from the trunk as pos- amputation op the upper extremities. 539 sible, and save as much and take away as little of the parts as we can, and Avhich is applicable to all amputations of the upper ex- tremity, is more especially so to that of the fore-arm. J. L. Petit, (Malad. Chir., t. III., p. 207,) Garengeot, (Operat. de Chir., t. III., p. 441, 2e edit.,) Bertrandi, (Operat. de Chi?:, p. 471,) and more recently M. Larrey, (Clin. Chir., t. III., p. 603,) influenced by false appearances or erroneously reported facts, have, notAvith- standing, taken opposite ground. According to them, the loAver third of the fore-arm is not sufficiently provided with soft parts, and has too many fibrous tissues to enable us to cover the bones conve- niently after amputation, or to secure us against the thousand dan- gers from operations in this region. Its upper half, on the con- trary, provided Avith numerous muscles, and having but few ten- dons, presents the conditions the most favorable for the success of such operations, and ought consequently to be selected by prefer- ence at the expense of sacrificing some inches of tissues that might if necessary have been saved. To this reasoning Ave may reply, that even the thinnest part of the fore-arm, and Avhich is the most completely destitute of muscular fibres, will always enable us to preserve a sufficiency of skin to unite immediately and close the wound ; that in point of fact (en derniere analyse)' it is always the integuments which form the cicatrices, and that these integuments are at the same time so much the more preferable and more supple and solid, where there is the least quantity of muscle and tendon. It is a point, moreover, Avhich experience seems to have now definitively settled, for I meet with no one who desires to make it a subject of controversy. § I.—Amputation in the Continuity. The fore-arm, besides its 20 muscles, and their tendons, the radial, ulnar and inter-osseal arteries, their corresponding nerves, and the median nerve, and the aponeurosis, and the superficial veins Avhich are distributed over its whole extent, presents also for consideration, I, Its tAvo bones moveable upon one another, and separated by a space Avhich narroAvs as their extremities approximate, and Avhich by means of a sort of [intervening] membranous diaphragm form the fioor (plancher) for the anterior and posterior inter-osseous cavi- ties and fossae ; 2, A series of decussating fibres (intersections fibreuses) and of abundant lamellar tissue betAveen the different fleshy layers, whose intimate connections allow of but very little retraction, at the same time that the ensemble of these parts is as favorable as possible to the development of phlegmonous inflam- mations and purulent collections. A. Circular Method.—All the processes of the circular method, as that of Celsus, the one by Wiseman and Pigray, those of Petit, Le Dran, Louis, Alanson or Desault, are those that have been most usually employed in amputation of the fore-arm. The most gene- rally followed, hoAvever, at the present time, and the one which I think the best, is performed in the folloAving manner :__ 540 new elements of operative surgery. I. Process adopted by the Author.—An assistant placed upon the outside of the shoulder of the patient, who is supported upon the side of his bed, or seated upon a chair if he is not too weak, compresses the brachial artery against the humerus beloAV the axilla, (See this volume, supra.) A second assistant, or the same one if Ave cannot procure another, seizes hold of the fore-arm turned in pro- nation, and holds himself prepared to draw back the skin tOAvards the elboAV. The limb Avhich is to be amputated should at the same time be enveloped in linen and supported by a third assistant. a. First Stage___The operator, seated upon the inside, seizes with his left hand the fore-arm above the point where the skin is to be divided, if he is on the left side, and under it on the contrary, unless he is ambidexter, Avhere he is to amputate the right fore-arm, and then makes a circular incision upon the integuments doAvn to the aponeurosis, and at the distance of two or three fingers' breadth below the place Avhere he intends to make the section of the bones. Should any cellulo-fibrous bridles interfere Avith the retraction of the teguments he rapidly divides them, and immediately bringing back the knife upon the outer and posterior surface of the radius, he makes a circular incision as at first, cuts through the Avhole thick- ness of the flesh as near as possible to the skin, first upon the dor- sal region, then upon the palmar, and lastly upon the radial. In order that the soft parts may not shrink or retract, (s'affaissent,) instead of submitting to the action of the knife, it is necessary to effect their division by a saw-like movement of the instrument, which should not quit the surface of the radius before resting fully against the ulna, keeping the edge close to the surface of the latter bone as the incision is brought round upon the palmar surface, if we do not wish any part to escape or recede posteriorly. I have no need of adding that the same precaution is equally necessary for the remainder of the circumference of the limb. b. Second Stage.—The divided muscles retract to a greater or less extent. The knife is noAV directed behind upon the dorsal sur- face of the ulna, and while the surgeon draAvs the instrument tOAvards himself, its point as it proceeds falls upon the posterior inter-osseous fossa which it traverses to its depth, and divides, as it returns and comes round upon the posterior surface of the radius, every thing which it meets in its progress. It is now replaced underneath to complete in front Avhat it had just effected behind, after which nothing more remains undivided around the bones. c. Third Stage.—The middle tail of the compress, slit into three tails, is then immediately passed, by means of a forceps, through the inter-osseous space from the palmar to the dorsal surface. The soft parts being thus protected and draAvn back, the surgeon pro- ceeds to the section of the bones, commencing Avith the radius; he continues the section in such manner as to act at the same time upon the radius and ulna, but so as to finish upon this last bone. d. Fourth Stage.—After the amputation of the limb, and the re- tractor compress is removed, the assistant charged Avith drawing back the soft parts, immediately relaxes them. We then attend to amputation op the upper extremities. 541 the arteries, searching for them successively in the depth of the tis- sues. The anterior inter-osseal which is accompaniedjby a nervous filament, which it is well to avoid, is usually found upon the middle of the palmar surface of the ligament of the same name. The radial situated more externally and superficially, is seen between the supinator radii longus, the flexor carpi radialis and the flexor longus pollicis manus; it is besides so remote from the nerve that its ligature does not in this respect exact any special precaution. In order to find the ulnar artery Avith its accompanying nerve on its inside, we must look for it on the inner side of the arm and be- tween the flexor carpi ulnaris, the flexor digitorum sublimis, and the flexor digitorum profundus. As to the posterior inter-osseal artery, which is distributed (s'eparpille) through the fleshy bulge (masse) of the extensor muscles, there is no need of troubling our- selves about it, unless amputation is to be performed at the upper half of the fore-arm. e. Fifth Stage.—The lips of the wound are to be brought together from before backAvards, and it is in this direction that the adhesive strips are to be applied. We thus obtain a transverse linear wound, whose angles embrace the bones, and have hanging out from them me ends of the corresponding ligatures on either side, while the end of the middle ligature is to be brought up directly in front. II. Process of Alanson.—If the skin should be lardaceous, (larda- cee) or have contracted morbid adhesions with the subjacent tissues, it would be better, after having made the circular incision through it, to dissect it up and turn it back upon its outer surface so as to form a ruff in the manner of Alanson and Brunninghausen. III. Anonymous Process.—Should any difficulty be apprehended about dividing the muscles and tendons Avhich are found at the bot- tom of the inter-osseous fossae, Ave may, after the integuments are incised and raised up, glide the knife flatwise between the bones and the soft parts, and immediately after turn up its cutting edge outwardly, so as to cut transversely from within outwards all the soft parts on a line Avith the raised-up skin, and do this in succession upon both sides of the limb. It was M. Hervez de Chegoin, (Mem. de I'Acad. Roy. de Chir., t. II, p. 273,) I believe, who in the year 1819 first published the suggestion of this modifi- cation, Avhich M. Cloquet says he has often employed with success, (Diet de Med., t. II., p. 153,) and Avhich, from inadvertence no doubt, the editors of Sabatier had appropriated to themselves. IV. All the muscles being divided, it is possible that we may desire to detach them still more, in order to be enabled to sa\v the bones higher up. In this case we detach with the point of the knife or bistoury the two borders of the inter-osseous mem- brane to the extent of some lines. Here, as in all other points of the limb, we ought to preserve so much the greater extent of in- teguments, as the operation is performed higher up, or to speak more correctly, in proportion as the volume of the part is more considerable. Nor must Ave forget that owing to the deep-seated muscles being inserted upon the bones nearly throughout their 542 NEW ELEMENTS OP OPERATIVE SURGERY. whole extent, they retract but very little towards the elbow, and that it is therefore principally on the skin that we must rely for unit- ing the wound and covering the stump. B. The Flap Method.—Circular amputation of the fore-arm gene- rally succeeds very well, and alloAVS the cure to be accomplished in the space of from three to four Aveeks. Nevertheless it has been proposed to substitute the flap method for it. In our own times it has still been employed by M. Graefe, in the manner recom- mended by Verduin and LoAvdham, and as Ruysch says he has seen it performed, that is, by cutting a flap on the palmar surface of the limb and finishing the rest of the operation in the same man- ner as in the circular method. Vermale, Ledran, (Operat, p. 565, 569,) Klein, Hennen and M. Guthrie, prefer, on the contrary, mak- ing tAvo flaps, one in front, the other behind. Under this point of vieAV it would be difficult to Avithhold the preference from the pro- cess of Vermale, Avhich is eulogized also by M. Langenbeck (Rust's Handb. der Chir., t. I., p. 693,) and Rossi, (Oper. cit,t. II., p. 233,) over that of Verduin. I have performed it and also caused it to be repeated upon the dead body by a great number of pupils. I have performed it on the living subject tAvice, and I am satisfied that it is generally less advantageous than the circular method, though the operation is easier and more quickly done. It is true that it is not then with the skin only but also Avith much of the fleshy fibres that we cover the extremities of the bones. The two flaps are suffi- ciently thick, and supplied Avith a sufficient abundance of cellular tissue to adapt themselves accurately together, and to furnish with security all that could be required for immediate union. To be enabled then to unite by first intention, each should have a length of about tAvo inches. If the disease extends more on one side than on another, Ave need not make but one flap, or Ave may give them an unequal length. So that one does not perceive at first Avhy this mode of operating may not be applied as Ioav down as the cir- cular method. Unfortunately upon examining it more attentively, it is perceived that most of these advantages are illusory. All the muscles cut with a sloping edge (en biseau) necessarily augment the traumatic surface. Being included Avithin the thickness of each flap, they serve only to increase the danger of the inflammations which may be developed. The bones also are not the less exposed to protrude (a s'echapper) at the angles of the Avound ; and the most simple reAection makes it apparent, that, by a circular incision, an inch of integuments will more accurately close up a Avound of tAvo inches Avidth from before backAvards, than Aaps one-half longer, because of the void Avhich these latter constantly tend to leave at each side of their base. The folloAving, hoAvever, is the operative process:— I. Operative Process.—The limb being turned in pronation, and properly held, the operator cuts his palmar Aap, by passing his knife from one side of the fore-arm to the other, betAveen the bones and the soft parts, which latter he divides obliquely from above doAvn- wards (de haut en bas.) To form the dorsal flap, he draws the lips AMPUTATION OP THE UPPER EXTREMITIES. 543 of the wound backwards, replaces the point of the instrument in the upper part of the first division, causes it to glide posteriorly, and finishes with the same precautions as before. Directing the assistant to turn back immediately all the soft parts, he passes round the radius and ulna as in the circular method, cuts Avhat may remain of the soft parts, inserts the retractor, (la compresse fondue,) and afterwards effects the section of the bones as in the usual mode. II. Remarks.—By cutting the palmar flap first, we are enabled to give greater thickness to the dorsal, and the palmar surface of the fore-arm being turned downAvard, the blood which escapes at first, in no Avise interferes with the remainder of the operation. Moreover this precaution is far from being indispensable. The im- portant point is to obtain two flaps of nearly equal dimensions, and not to take off too much of their angles, (de ne pas trop en degarnir les angles.) It is certainly remarkable that a military surgeon Avho, no doubt, in the movement of armies is prevented from keeping pace (au courant) Avith the progress of science, has conceived the idea of applying the ovalar method to amputation of the fore-arm, and of making the point of the oval fall upon the ulna ! The limb might be left in supination instead of placing it from the beginning in pronation; but then the sawing of the bones would produce more concussion upon the joints and Avould not be as easy. The radius and ulna are recommended to be sawed at the same time, so as to finish hoAvever on the last, because the ulna, from being more firmly connected Aviththe humerus, supports the action of the instrument better than the radius could do. In directing the operator to place himself on the inside between the limb and the trunk, I have not pretended to lay down an invariable rule. Ber- trandi (Oper. cit., p. 473) remarks, that when the patient is in bed, if Ave did not place ourselves upon the outside, Ave should be little at our ease, at least for the right limb. The English and German surgeons, and amo^g them M. Guthrie, are in an error in saying that the flap operation is only applicable to the upper part of the fore-arm. It is applicable to its entire extent. Ledran (Oper. cit., p. 563,}had already remarked that a patient operated upon by him in this manner, recovered in tAventy days, Avhile by the circular method he did not obtain cicatrization under tAvo or three months; Avhich, hoAvever, is in no respect remarkable, because at that time they Avere not yet successful after circular amputation in obtaining union by the first intention. III. Reunion and the dressing are performed here in the same way as at the Avrist, and the consequences of the operation exact the same precautions in both cases. M. Davidson performed this amputation successfully for an elephantiasis of the hand; but M. Mussey, (Gaz. Med. de Paris,) 1838, p. 394,) Avas obliged to am- putate also the arm and afterAvards the shoulder; M. Baud (These No. 142, Paris, 1S31) has performed it, though there Avas a fracture of the arm; in a patient of M. Blanche (Puchot, These No. 207, Paris, 1S35) no ligature Avas required ; and Hoeff (Gazette Salut., 11 SI, No. 7) also performed it without tying the arteries. 544 NEW ELEMENTS OP OPERATIVE SURGERY. § II.—Amputation in the Contiguity. Some surgeons of the last century, on the strength of a passage in Pare, (liv. XII., ch. 37,) who says he ventured to disarticulate the fore-arm that had become gangrenous in a soldier with a frac- ture, have supposed that by systematizing this operation, practice might derive some advantages from it, that among others of saving three or four more inches to the limb than in cases where amputa- tion was performed on the arm itself; other facts confirm this remark. In a nun, says Cattier, (Biblioth. de Planque, t. V., p. 11, in 4to.,) who would not permit herself to be amputated upon the living part, the fore-arm ultimately detached itself at the elbow, and the patient recovered. A girl, (Acad, des Sc. Hist, p. 41, art. 10,1703,) in whom the two fore-arms had separated at the elboAV, took them herself to the Academy of Sciences ! But many of the moderns have objected that this advantage is of too trivial importance to be purchased at the risk of numerous difficulties and dangers of every kind which must necessarily accompany a disarticulation of this nature. If it be possible to cut from the soft parts a fiap sufficiently long to cover the whole extremity of the articulating surface of the humerus, it must be equally practicable to do so in circular ampu- tation immediately below the joint. In the contrary case it is re- marked, that we ought not to decide upon leaving so large a carti- laginous surface exposed, and that amputation of the humerus would therefore become indispensable. ^These arguments are less conclusive than they at first sight ap- pear. Because the' soft parts may be in a condition to be saved, it does not folloAv that the bones are sufficiently sound to alloAV of the action of the saw, or to preserve the least portion of them. Ne- crosis, caries, comminuted fractures, &c, may extend up to the ar- ticulation, and without the surrounding parts having entirely lost their primitive character. The diseased bones also being once re- moved, who does not know that the soft parts ultimately often be- come restored to their natural state ? Moreover, the operation in itself less dangerous than amputation of the arm, is far from being as difficult as has been imagined. M. Rodgers, (Velpeau's Anat, American translation, etc., annot., Vol. IL, p. 520,) of New-York, and M. Chiari, (Bulletin de FCrussac, t. XII., p. 275,) have per- formed it successfully, and Dupuytren has also had every reason to be satisfied Avith it. For myself, I consider it advisable, wherever the bones are diseased to the extent of an inch or two from the joint. B. The Flap Method.—Owing to circumstances, or from neces- sity, Pare either has not, or but very obscurely, described, his method, supposing, without doubt, that any person could divine or imitate him. I. Process of Brasdor.—After various trials, Brasdor (Mem. de VAcad. de Chir., t. V.) determined upon the folloAving rules:—A semi-lunar incision, Avith its convexity doAvnwards, and comprising the posterior half of the circumference of the limb, is first made at AMPUTATION OP THE UPPER EXTREMITIES. 545 some lines beloAV the apex of the olecranon, in order to enable us to divide the lateral ligaments, and the tendon of the triceps, and to lay open largely the articulation of the radius. The knife then passed AatAvise from one side to the other, between the anterior sur- face of the bones and the soft parts, forms a large flap Avhose base corresponds to the joint, and its apex to a point three or four inches below. Finally, we terminate by disarticulating the ulna from the coronoid process to the olecranon, and by the division of the triceps muscle, if that has not already been done in the beginning. II. Process of Vacquier.—In the third Thesis in quarto, support- ed at the Faculty of Paris at the commencement of the present century, Vacquier proposes the folloAving modification to the pro- cess of Brasdor: he commences by cutting Avith a double-edged knife the anterior flap from beloAV upAvards, as high up as to a line with the articulation ; then divides the ligaments Avhich unite the radius and ulna to the humerus ; luxates the fore-arm, and termi- nates by detaching the olecranon from the large tendon which is inserted upon it, and from the integuments, so as to leave a flap of some lines in length behind. III. Process of Sabatier.—Sabatier ascribes to Dupuytren the process by Avhich it is considered more advisable to saAV through the olecranon and leave it, rather than to remove it, and to form a flap of the character of that of La Faye for amputation of the shoul- der, or of that of Verduin in amputation of the leg, rather than literally imitate the process of Vacquier. IV. Process of Dupuytren.—According to MM. Sanson and Begin, Dupuvtren performed amputation at the elboAV-joint seven or eight times successfully, by cutting a flap after the manner of Verduin, that is to say, by plunging a double-edged knife in front of the articulation, from one tuberosity of the humerus to the other, betAveen the bones Avhich he grazes and the soft parts Avhich are raised up with the left hand, in order to divide them from above doAvnwards. The disarticulation being effected, Dupuytren com- pletes the operation by saAving through the olecranon, or remov- ing it. The difference between these various processes is much less than Vacquier supposes. The final result of all of them is nearly the same, except that that of the member of the ancient academy, being a little more tedious and difficult, ought to be laid aside. V. Process of the Author.—I see no advantage in preserving the olecranon, as Sabatier advises, and as Dupuytren has frequently done. The triceps does not require it for the movement of the hu- merus, and it is evident that its preservation can in no way favor the success of the operation. For the saw to reach its anterior surface, it is necessary that the articular surfaces should be completely disjointed. No obstacle can then interpose to prevent our detaching it from the integuments Avhich cover it behind. But supposing that there posi- tively exists a wish to preserve it, the following modification has appeared to me to present some advantages. The limb is held moderately flexed, and in supination. With a knife Avith one cut- 35 546 NEW ELEMENTS OP OPERATIVE SURGERY. ting edge only, we make an incision transversely on the upper part of the fore-arm, a little beloAV the tuberosities of the humerus, in order to form a flap after the manner of Dupuytren. The assistant takes hold of this flap and raises it up. The operator then divides transversely, as in the circular method, an inch below the condyles, the teguments Avhich remain behind ; causes the skin to be raised up, re- turns in front, divides the external lateral ligament, and disarticu- lates the radius. Finally, after having carefully divided all the soft parts which surround it, he saws through the ulna, immediately beloAV the anterior border of the coronoid process, as near as possi- ble to the joint, and in a direction continuous Avith the humero-ra- dial interline, (interligne,) [i. c, the line of the inter-articulating surfaces of the humerus and bones of the fore-arm. T.] We thus avoid all the difficulties attending the disarticulation of the humerus, and the operation is as speedy as by any other mode; there is no need of making any traction or exertion upon the bones, and the wound, Avhich has considerably less width, must be less disposed to suppurate, and more easy to unite by first intention. VI. Another modification, applicable to all the flap processes, and which I should much prefer, would consist in cutting and dissecting the parts from the skin to the bones, instead of plunging the knife at first between the flesh and bones, as is the objectionable prac- tice in amphitheatres. B. Circular Method.—I have satisfied myself that circular amputa- tion, in these cases, would offer decided advantages. An inch of in- teguments, preserved below the elboAV, would be sufficient to cover the trochlea (poulie) of the humerus, Avhile, by the flap method, there would be required three or four in front. All the muscles being sacrificed, the Avound Avould in reality be less in extent, less dis- posed to an abundant suppuration, and cause less intense reaction upon the system. After having divided the skin circularly, I dis- sect it, and turn it back as high up as on a level with the joint, after which I divide the anterior muscles, then the lateral ligament? in order to disarticulate from before backwards, and terminate with the division of the triceps behind. The humeral [or brachial] ar- tery alone requires tying or tAvisting, and the cutaneous ruff (rnan- cfcette) [i. e., the turned-back fold of skin. T.] may be brought down without the least difficulty in front, so as to close up the wound. Article V.—Amputation of the Arm. Amputation of the arm, required most generally for some disease of the humero^cubitai articulation, is usually performed below the middle part of the limb. As other affections, however, such as jl£- sions of the humerus itself, may also exact this operation, we are sometimes compelled to amputate much nearer the shoulder. § I.—Anatomy. The humerus, constituting the only bone in the arm, cylindrical amputation op the upper extremities. 547 in its middle portion, tAvisted slightly (legerement contourne) upon itself, and near the elbow flattened in such manner that its borders are felt naked under the skin, is also surrounded Avith numerous muscles. The deltoid, coraco-brachialis, long head of the triceps and the bi- ceps, which are all attached to the scapula, together Avith the pec- toralis major, and the latissimus dorsi, [see Table of Muscles, Vol. I.,] form a distinct system, whose retractile powers Ave must, make alloAvance for when Ave are about to amputate above the deltoidal tuberosity. As these muscles are all inserted beloAV the head of the humerus, M. Larrey came to the conclusion that, in amputating upon a line with the surgical neck, (col chirurgical,) the fragment of bone preserved would be of no use, but, in fact, hurtful, from being kept in a state of permanent extension by the supra-spinatus and infra-spinatus muscles. Below the deltoid-muscle, the biceps which extends from the shoulder to the fore-arm without any adhe- sions, is the only one after its division Avhich can retract to any con- siderable degree ; the others, the brachialis internus, and the three divisions of the triceps, having their fibres implanted upon the hu- merus itself, cannot retract but very little from the point where the knife has divided them. § II.—Operative Process. If, like Petit, after having divided and raised up the skin, we should confine ourselves to dividing all the muscles upon the lower half of the arm at the point upon which the saw is to be directed, the biceps Avould rarely fail by its subsequent retraction to produce a denudation of the bone. A. Circular Method.—The integuments are too moveable upon the aponeurosis to require the trouble of dissecting them and turn- ing them back upon their external surface, as Alanson proposes. Among the processes then to be selected, there remains that of Cel- sus or Louis, modified by Dupuytren, and that of Desault. I. The Lower Half—The patient being seated, and the artery compressed, as in amputating the fore-arm, an assistant seizes the limb and raises it from the trunk at almost a right angle. The rule recommends that the surgeon should place himself upon the out- side ; but Avhen we operate on the left arm there is some advan- tage in placing ourselves on the inside. With the left hand we draw back the skin in proportion as the instrument proceeds. The division of the integuments is made as near the elbow as possible, In incising the muscles circularly on a line with the retracted skin, it is important to cut through the whole thickness of the biceps. We may, in fact, after the manner of M. S. Cooper, divide, at first, this muscle only, in order to make the division of those of the deep- seated layer only, at a few lines from the point Avhere we are to saAV the bone. When the humerus is laid bare, it could not be other- wise than advantageous to separate the fleshy fibres from it parallel to its length, as was recommended by Bell, and as is still practised by M. Graefe. M. Hello (These No. 258, Paris, 1829) also maintains 548 NEW ELEMENTS OP OPERATIVE SURGERY. that the deep-seated fibres thus preserved are the only ones which can be brought doAvn in front. I Avill add to this, that it is then neces- sary to dissect the skin, as recommended by Alanson; and after- wards to divide all the tissues perpendicularly and with a single stroke of the knife. In whatever manner we operate, we must take care that Ave do not wound the radial nerve. The last mus- cular layer should be divided at about three inches above the line of the division of the integuments. The retractor compress, and the section of the bone require no particular directions. The brachial artery is found betAveen the biceps and the inner portion of the triceps, close to (accolee) the median nerve, and be- tAveen its tAvo accompanying veins. The situation of the other two or three branches Avhich require some attention, Avill be indicated by their bleeding. The practice of closing the Avound from one side to the other, though there Avould, in fact, be a little less void to be overcome in closing from before backAvards, arises from the preference that exists of having a cicatrix directed from before backwards, rather than transversely. II. The Upper Third.—The biceps above the deltoid depression, being at this point nearer to its origin, cannot retract as far; but the volume of muscular tissues being much greater, it is as in- dispensable as it is lower doAvn to save a considerable portion of integuments, and to favor their retraction as much as possible be- fore making the section of the bone./De la Faye (Mem. de I'Acad. Roy ale de Chir., t. IL, p. 241) had already proposed, and Leblanc (Precis d'Oper., t. I., p. 328) combated the process advocated by M. Larrey, (Clin. Chir., t. III., p. 560,) to wit: that it is better to disarticulate the humerus than to amputate it above the muscles, which connect it with the chest. The advice of Leblanc, Percy, (Rapport a I'Institut sur la Desarticulaiion du Bras,) and Riche- rand, however, has prevailed. \ Experience has proved that after the cure, the deltoid muscle, the pectoralis major, the latissimus dorsi, the teres major, and coraco-brachialis, are not without their action upon this small extremity of bone as De la Faye called it, and that they may execute various movements upon the stump. The small portion of the arm which remains, augments at least the pro- tuberance of the shoulder, prevents the slipping of the suspenders, preserves the holloAV of the axilla, and most usually alloAVS of holding against the chest certain foreign bodies, as for example, a cane, and port-folio. " It is a constant source of satisfaction to me," says M. Champion," when I reflect upon the usefulness Avhich a stump like this has proved itself susceptible of, in three patients in Avhom I had saved it." Besides, it is not necessary then to open into the articulation, nor consequently to fill up the large cul-de-sac Avhich exists betAveen the acromion and the scapular tendon of the triceps muscle. B. Flap Method.—The arm is the limb Avhich appears to be the least favorable to the flap method; so much the more so as its rounded form and the position and small volume of its bone are AMPUTATION OF THE UPPER EXTREMITIES. 549 wonderfully adapted to the success of the circular method. Klein and M. Langenbeck, notwithstanding, have endeavored to bring the other into vogue. I have myself had recourse to it on tAvo occa- sions on living man, and have often performed it, or caused it to be performed, upon the dead body. At the first glance, Ave might suppose that a great advantage could be obtained from it, for union by the first intention. By the flap method, it is not the skin only, as in the circular, but the muscles themselves, Avhich cover the ex- tremity of the bone and shut up the Avound ; in this Ave have no- thing to fear from the retraction of the muscular fibres or the isola- tion of the cutaneous envelope ; three incisions by the knife, one for each flap, and another for the denudation of the bone, and one di- vision by the saw, complete the Avhole operation. Well! Avith all these advantages, the rapidity and facility of the manipulations are all that are real. The muscular mass to Avhich so much value is attached, is, after all, calculated only to favor phlegmonous inflam- mation of the stump, Avith a constant tendency to slip from one side to the other, and, should suppuration ensue to ever so slight an extent, to protrude the bone through one of the angles of the wound. Nowhere, in fact, are the inconveniences of the flap me- thod so conspicuous. Nevertheless, Sabatier himself advises it when we are obliged to amputate near the shoulder. I. Process of Klein.—A narrow knife, plunged through the arm, from the radial to the ulnar side, and grazing the bone, cuts out a first semilunar flap of about tAvo inches in length; after having formed another in the same manner upon the opposite side, both are raised up; Ave then divide at their base the small quantity of muscle still adherent to the bone, Avhich last is saAved with the usual precautions. It is almost a matter of indifference also whether we begin Avith one flap or the other. II. Process of M. Langenbeck.—The assistant raises up the in- teguments Avith force ; the operator, seated on the inside, supports the lower part of the limb Avith his left hand for the right arm, and vice versa for the left arm; provided Avith a good knife in the other hand, he cuts Avith a movement (en frappant) from below upAvards, and from the skin to the bone, an inner lap, Avhich should have, as in the preceding case, a length of from tAvo to three in- ches ; then, in passing the knife and his Avrist underneath, to bring them back in front of the arm, he is enabled thereby to form an outer flap similar to the first. I have seen young German physicians practise this process in our theatres, and execute it Avith the greatest celerity; but such exhibitions of power and address can possess no importance except in the eyes of those surgeons, who, like the pupils of MM. Langenbeck and Graefe, go for those only who, in amputations, operate with the greatest rapidity, and count even the seconds. III. Process of Sabatier.—Sabatier recommends the flap me- thod only in cases Avhere the operation is performed so high up that it is impossible to employ the tourniquet. His process Avhich had already been described by Leblanc, (Opir. cit., t. I., p. 327,) con- 550 NEW ELEMENTS OP OPERATIVE SURGERY. sists in forming, by means of a transverse incision and two longi- tudinal incisions, a flap, of the shape of a trapezium, at the expense of the antero-external portion of the deltoid muscle, then in raising this flap up, and by a circular incision, dividing the remainder of the soft parts before proceeding to the section of the bone. It is to be understood, moreover, in this case, as in all others, Avhen the ampu- tation is to be performed near the shoulder, that the compression of the artery should be made above the clavicle, or upon the second rib, as I shall point out farther on. [Artificial Arm.—In cases Avhere a fragment of the humerus is preserved, M. Von Peterssen, a Dutch sculptor, according to the report of M. Majendie, made to the Academy of Sciences of Paris, Feb. 17, 1845, (Gaz. Med., Feb. 22, 1845, p. 125-126,) has con- trived an ingenious piece of mechanism, Avhich, both in its form and articulations, representing the wrist, hand, and fingers, is made to execute by means of springs and the leathers, by which it is fixed to the stump and chest, a great number of the functions of a living, healthy arm, so as to become exceedingly useful in seizing bodies with the hand, lifting a tumbler, food, &c, to the mouth, in fact, performing a great number of the movements of flexion, extension, &c. The whole weight is but 500 grammes, and the cost about 500 francs or less. The examination made by the commission of the Academy (of which M. Velpeau Avas one) of persons Avho had had this apparatus substituted for one or both arms, proved highly satisfactory, and their report expresses unqualified commendation of the invention, in Avhich favorable conclusions the Academy also entirely concurred. T.] Article VI.—Amputation op the Arm at the Shoulder Joint. It is an error to suppose that disarticulation of the arm had not been ventured upon until the beginning of the last century. La- roque, (Journ. de Med., 1686, Juin, p. 3,) in the year 1686, relates a case of this operation. The limb had become gangrenous. " The surgeon took a small saw to amputate the humerus; but having perceived that the bone shook (branlait) near its articulation with the shoulder, he made a jerk upon it, (y donna quelque secousse,) when the bone readily escaped from its socket, (boite,) after Avhich the boy Avas soon restored to his former health." Though the idea must have often presented itself to the minds of surgeons, as to La Gareine, (Bibliot. de Planque, t. V., p. 9, in quarto,) the fear of opening into so large a joint, and the ignorance of the means hoAV to suspend the course of the blood in the limb during the ope- ration, together Avith the proximity of the trunk, had deterred the boldest practitioners from undertaking it. Le Dran (Garengeot, 2e 6dit., tome III., p. 454 ; le edit., tome IL, p. 382, 1720) is the first who has described it. His father had had recourse to it about the year 1715, (Obs. de Chir., 1.1., p. 315,) for a necrosis of the humerus, accompanied with copious suppuration, and completely cured his AMPUTATION OF THE UPPER EXTREMITIES. 551 patient. Since then, it has been pretended that Morand, the fa- ther, (Opuscules de Chir., p. 212, 2e partie,) or Duverney, (Mih- leew, Elements of Surgery, &c, 1746,) had performed it before Le Dran, but of this no satisfactory proof has been given. At the present time, the advantages of this amputation are no longer dis- puted by any one. It has been so often performed that it is useless to discuss its practicability. § I.—Anatomy. The articulation of the shoulder being surmounted by two pro- cesses which extend beyond its line in front, and greatly augment its vertical diameter, presents an arrangement much more favorable for immediate reunion in a transverse direction, than from above doAvnwards. In its union Avith the body of the bone the head of the humerus forms an extremely open angle, (extremement ouvert,) and the fibrous capsule is inserted a little upon the inside, (en dega.) In the amputation it is necessary that the edge of the instrument should describe a circular line exactly corresponding (semblable) to the plane (plan) of the hand, if we desire to separate the fibrous tissues from it Avith facility. Finally, the glenoid cavity, surround- ed with a tendinous border, having greater height than Avidth, seems to be still further prolonged upon its upper part by means of the vault formed by the two processes just mentioned. In proceeding from above doAvnwards, Ave find about this joint, besides the common integuments and a very thin aponeurotic layeT, the deltoid muscle, a loose cellular tissue, the tendons of the supra- spinatus, inira-spinatus, sub-scapularis and teres minor muscles, to- gether Avith the fibrous capsule and the tendon of the long division of the biceps; on the inside the coraco-brachialis and the other por- tion of the biceps ; lower down the scapular portion of the triceps; then the brachial plexus and axillary vessels, and under the skin the pectoralis major, the latissimus dorsi, and the teres major mus- cles. Many of these parts may be readily recognized upon the outer surface. Thus the apex of the acromion is easily distinguish- ed above the stump of the shoulder, and on the inside appears to be continuous with the clavicle. The coracoid process a little nearer to the thorax, and more prominent than the last mentioned bone, may also be very easily distinguished by the touch. In that part is found also a triangular space Avhich may be made of prac- tical value. Bounded on the outside and below by the head of the humerus, above by the clavicle and acromion, and on the thoracic side by the coracoid process, this space conducts directly into the articulation. The posterior border of the axilla, raised up and turned outAvardly upon the side of the scapula, also enables us to reach beloAV the acromion and to traverse the upper and outer part of the articulation. In some persons the acromion is much more prominent than in others. Sometimes also its anterior border is greatly depressed, so that its humeral side presents a very deep ca- vity. In infancy it remains a long time cartilaginous. In two 552 NEW ELEMENTS OP OPERATIVE SURGERY. subjects, considerably advanced, that is to say, adults, I was en- abled by a very slight effort, to separate it as an epiphysis of the spine of the scapula. These different anomalies being of a nature to render disarticulation of the arm either more easy or more em- barrassing, should, as Avell as the other anatomical details which I have just given, be always present in the mind of the operator. § II.—Operative Process. The amputation of the arm at the joint, is one of those that offer the greatest variety in the number of the operative processes. Every surgeon, Avho has performed it, has deemed it his duty to propose one. The circular flap and ovalar methods, and all the dif- ferent modifications that these general processes admit of, have been used for this amputation. A. The Circular Method.—The idea of applying the circular me- thod to the disarticulation of the arm, does not belong, as M. P. F. Blandin (Diet de Med. et de Chir. Prat, t. II., p. 258) supposes, to the author of the article on Amputation in the Encyclopedia. De la Roche, (Encyclop. Method. Chirurg., t. I., p. 109,) Avho prepared this article, adopts the flap, and not the circular method ; but Ga- rengeot (Oper. cit, p. 460, t. III., 2e edit.; t. IL, p. 378, le edit.) says positively that, in his time, several persons gave it the prefer- ence. Bertrandi (Oper. de Chir., p. 454) also speaks of and cen- sures it. Alanson described it in 1774, and proposes that the mus- cles should be divided obliquely, as in amputation of the thigh. It is a great error, therefore, for M. Graefe to have supposed that he was the inventor of it, and that other moderns should have claim- ed this honor ; but each one of these authors has presented it under a particular point of view. I. Ancient Process, or that of Garengeot. The passage in Ga- rengeot Avhich refers to the simple circular method, points out, but does not describe, this method. The artery being compressed by an indirect ligature, (une ligature mediate,) [see vol. I.,] and the soft parts raised up by an assistant, an incision is made successively through the integuments and muscles down to the bone, commencing at three fingers' breadth beloAV the acromion; a last cut of the knife detaches the head of the humerus from the glenoid cavity, and completes the operation. II. Bertrandi is evidently more clear. A large convex bistoury divides through the body of the deltoid upon its dorsal surface, at some distance from the acromion, arrives at the biceps muscle, opens the capsule, passes behind the head of the humerus after Ave have luxated it, and terminates the division of the soft parts Avith that of the posterior half of the limb ; " so that Avhen the arm is separated, there remains a circular incision through the soft parts, around and in front of the glenoid cavity." III. M. Cornua.u (These No. 71, Paris, 1S30) has proposed a pro- cess founded on the same principle as the preceding. The skin being divided at four fingers' breadth from the acromion, and drawn AMPUTATION OP THE UPPER EXTREMITIES. 553 back by an assistant, the operator proceeds to the section of the muscles, Avhich he accomplishes with a single stroke of the knife, carried transversely from the coraco-brachialis muscle down to the tendon of the teres major, causes them to be raised up, opens into the joint, Avhich he traverses from above doAvnwards, grazes the neck of the humerus, and terminates by a second transverse in- cision, Avhich unites the tAvo extremities of the first, includes the vessels, and makes a circular Avound. IV. Process of Alanson and M. Graefe.—Alanson's method has nothing in it peculiar. But M. Graefe, in order to form, at the ex- pense of the muscles, a holloAV cone Avith its base dowmvards, uses the broad point of a buckler-shaped (en rondache) knife. V. Process ofM. Sanson.—Adopting the pure circular method, M. Sanson (Elem. de Pathol, etc., t. III., p. 498,2e edit.) divides at the same stroke both the skin and muscles, at an inch beloAV the acro- mion and before disarticulating the humerus. VI. Process of the Author.—I have repeated all the modifica- tions of the circular method upon the dead body, and have ascer- tained that there is no other method more rapid, or forms a more regular Avound, or one more easy to unite by the first intention. The process which has seemed to me to combine the most advan- tages, consists in dissecting and raising up the skin to the extent of tAvo fingers' breadth, and without interfering Avith the vessels; then to divide the muscles as near as possible to the joint, which is to be immediately laid open; terminating the operation Avith the division of the triceps, and of the bundle of vessels whose trunk has been previously secured by an assistant. B. The Flap Method.—The different processes included under the flap method, may be divided into two classes. By one, we make a transverse wound; Avhile the others, on the contrary, pro- duce a solution of continuity whose greatest diameter is the ver- tical. I. Transverse Method.—Each one of these tAvo classes forms, to some extent, a particular method, Avhose respective advantages and disadvantages should be carefully considered. The first Avas for a long time the only one employed, and to this belong the processes of Le Dran, Garengeot, De la Faye, and Dupuytren. a. Process of Le Dran, (Operat, p. 571.)—The patient being seated upon a chair, an assistant seizes the arm and holds it at a short distance from the trunk; Avith a narroAV knife, the surgeon then makes a transverse incision through the deltoid, the tAvo por- tions of the biceps a little in front of the acromion, the tendons which are attached to the head of the humerus, and the fibrous cap- sule ; while an assistant gives a swinging (fait basculer) movement to the arm, and luxates its head from below upAvards, the surgeon, holding his knife constantly in a transverse direction, passes the in- strument behind and cuts out a flap, of from three to four inches in length, at the expense of the muscles of the posterior part of the limb, in which flap are comprised the plexus of nerves, the vessels, the borders of the axilla, and various muscles. 554 NEW ELEMENTS OP OPERATIVE SURGERY. b. Process of Garengeot.—Garengeot's mode of operating (t. III., p. 457) differs in three particulars from that of Le Dran. In order to compress the artery, he advises, instead of a straight needle, to use one that is curved, which is to be inserted from before back- wards through the muscles, and to graze the neck of the humerus. With the view of forming an upper flap at the expense of the del- toid, he recommends the first incision to be made at three fingers' breadth in front of the acromion. Finally, in terminating like Le Dran, with a flap in the axilla, he gives it less length and cuts it in a square shape, in order to adapt it better to the deltoid flap. c. Process of De la Faye.—La Faye (Mem. de I'Acad. de Chir., t. II.) does not apply any previous ligature. Differing from Ga- rengeot, and coinciding Avith Le Dran, he recommends but one flap only; but, instead of placing it beloAV, he takes it from above, and gives it the form of a trapezium. A transverse incision is first made, at about four fingers' breadth from the apex of the acro- mion ; two other incisions, one of which is begun upon the inside and the other upon the outside of this process, are continued in a line with the muscular fibres to the extremities of the first. The flap being dissected and raised up, enables us to enter the joint, luxate the humerus, lay bare the soft parts of the axilla, and to apply a ligature upon the artery before detaching the arm from the trunk immediately underneath. In place of a trapezium flap, Portal, (Precis de Chir., t. IL, p. 791,) imitating Dahl, (Amputat ex Arlicul, etc., 1760,) prefers one which is V-shaped. d. Process of Dupuytren.—In a thesis supported in 1803, Gros- bois recommends the following modification of the process of La Faye : With one hand he seizes the whole thickness of the soft parts which are to form the upper flap; with the other he plunges through these tissues at the base of the deltoid, Avith a small knife held hori- zontally, and the cutting edge of Avhich is to be directed forAvards; the flap is then cut out from behind forAvards and from Avithin out- wards, taking care to give it the suitable length. Grosbois speaks of this modification as one that belongs to him, and which he had long reflected upon. It is probable, however, that he derived the idea of it from the lectures of Dupuytren, for it is under the name of this professor that it is generally knoAvn. • c. Process of M. V. Onsenort, (Graefe und Walther, Journal, t. X., p. 469.)—In place of forming the deltoidal flap by cutting from the soft parts to the skin, it may be done in the opposite direc- tion ; that is to say, from the integuments to the articulation and from the apex to the base, giving it also a semilunar form. This mode, too, which does not differ materially from that of Garengeot, is also, by some pupils of medicine, ascribed to Dupuytren. I have seen MM. Dubled and Guersent (the younger) perform it upon the dead body with great rapidity; and M. V. Onsenort, Avho uses a knife curved on its flat side, endeavored, in 1825, to point out its great advantages. Cline, Avho commences by compressing the ar- tery upon the first rib, and who makes a flap capable of cover- ing the wound with a narrow knife at the expense of the deltoid, AMPUTATION OP THE UPPER EXTREMITIES. 555 then divides the articulation, and with a single stroke the muscles which connect the arm to the shoulder and the trunk. This process, which the surgeon of London was in the habit of employing a long time since, and which is adopted also by Chiari, (Renzi, trad. ltal. de ce Livre,o. 306,) is described by M. Smith, in the Avork by Dorsey, (Elements of Surgery, vol. II., p. 222,) in an exceedingly obscure manner ; it has, hoAvever, a good deal of resemblance to the preced- ing, and I ought to add that, in making trial of it according to the mode indicated, I found that I could perform the operation with almost inconceivable rapidity. /. Process of Grosbois, attributed to MM. Lisfranc and Cham- pesme.—Grosbois (These No. 190, Paris, 1803) had already re- marked that another advantage could be obtained from his proposed modification of the process of La Faye, by proceeding in such manner as to open at the same stroke into the upper part of the articular capsule. MM. Lisfranc and Champesme have constructed from this suggestion the basis of a neAV process, (Coster, Manuel de Med. Oper., 3e edit., p. 95.) The arm being slightly approxi- mated to the trunk is carried upAvards and outAvards. The opera- tor being placed in front of the shoulder applies the point of his knife to the coraco-acromial triangle, one of its edges being in a direction upAvards and forwards, the other backwards and down- Avards ; he then plunges it through the soft parts and the articula- tion from within outAvards, from before backAvards, and from above downwards, so that it may come out an inch behind the acromion; he then with one hand seizes the deltoid and raises it up ; divides it from behind forwards and slightly from below upwards; passes round the upper part of the head of the humerus, giving gradually to the blade of the instrument a direction almost horizontal; sepa- rates the arm from the trunk as soon as he has proceeded in his incision to the extent of about an inch, and finishes the flap as in the process of Grosbois and Dupuytren. g. Bell (Cours de Chirurg., traduit par Bosquillon, t. VI.) com- mences with a circular incision at four inches beloAV the joint; he then makes a longitudinal one upon each side in order to form two flaps in the manner of Ravaton ; dissects and raises up these flaps, and finishes by disarticulating. h. The process of Laroche (Encyclop. Method., Part. Chir., t. I., p. 109) differs from the preceding in this, that the circular and late- ral incisions being made, the author raises up the anterior flap, and proceeds to the division of the joint before completing the posterior flap. i. Appreciation.—Of all these modes the most rapid and simple is that of Cline, or of M. Onsenort; but it is difficult then to give to the upper flap all the extent desirable. That of Grosbois Avhich comes next, Avould be yet more rapid if in performing it, surgeons who are unpractised did not run the risk of striking the point of their knife against the head of the humerus or the acromion. It endangers, moreover, the formation of a flap much too thin at its base. It is evident, hoAvever, if Ave should be satisfied with an 556 NEW ELEMENTS OP OPERATIVE SURGERY. upper flap, that the process of Grosbois or of Dupuytren Avould be preferable to the three incisions of La Faye. II. The Vertical Method.—To the second class of the flap method belong all those processes Avhose object is to place the flap in front or behind, or full as well to make one on each side. a. Process of Sharp.—The first process Avhich appears to belong to this series is that of Sharp, (Operat. de Chirurg., p. 389.) This author first divides the skin, the deltoid and the pectoralis major, from the apex of the acromion to the hollow of the axilla, so as to lay bare the vessels and to be enabled to tie them; he then passes through the articulation from Avithin outwards, and terminates by dividing the soft parts on the opposite side, so as to preserve as much of the integuments as possible. 6. The Process of Bromfield is too complicated and too long to be described at present, though it belongs to the vertical method. c. Process of Poyet.—Poyet (De Method. Amput, etc., 31 Aout, 1759) in a thesis upon the disarticulation of the arm, proposes to make a longitudinal incision from the apex of the acromion to nearly as far as the deltoidal depression (empreinte) upon the hu- merus ; then to separate the lips of the Avound, in order to divide the articular capsule and the tendons Avhich surround it, and to luxate the head of the bone, terminating by passing the knife be- tween this last and the muscles Avhich are divided with a single stroke from above doAvnwards. Dorsey (Op. cit, Vol. II., p. 333) of Philadelphia, Avas successful with a process nearly the same as that of Garengeot. d. The Process which. Laroche describes in the Encyclopedia, in- stead of belonging to the circular method, is no other than that of Bell or Ravaton, modified so that one of its flaps is upon the inside and the other upon the outside. e. Process of Desault.—The limb held between extension and flexion is brought slightly forward ; the surgeon embraces with one hand the tissues of the shoulder, and Avith a narroAV knife divides them from above downwards and from before backAvards, while grazing the head of the humerus; he forms a first and inner flap from three to four inches in length, Avhich includes the anterior border of the axilla and the vessels and nerves, and which the assist- ant raises immediately up in order that the operator may divide the joint from before backwards or from within outAvards,and terminate by forming a postero-external flap similar to the first. e. (bis) Hasselberg (Nouv. Procedepour desarticuler I'Hum., 1788) in describing the process of Desault, says that the artery is com- pressed betAveen the scaleni muscles, and the arm raised to a right angle, and that the knife ought at the very first to divide the articula- tion, and that this first flap has the formof a triangle. Allan (Journat General de Medecine, t. VIII.) on the contrary represents that De- sault formed his upper flap Avith the deltoid alone. Nevertheless it is certain that Giraud, (Ibid., p. 414,) a pupil of Desault, recom- mends cutting a loAver or axillary flap at first, then to divide the joint from beloAV upAvards, and to terminate with the upper flap. AMPUTATION OP THE UPPER EXTREMITIES. 557 /. Process of M. Larrey.—In operating after the manner of De- sault, the artery is divided at the first stroke of the instrument, and this might lead to serious accidents if, from any cause Avhatever, it should afterAvards become impracticable to terminate the operation promptly. M. Larrey has therefore considered that-it would be better to commence with the posterior flap, open the joint on its external side, and terminate Avith the inner flap. g. Another Process of M. Larrey. M. Larrey, (Clin. Chir., t. III., p. 563,) Avho has so often performed this operation in the army campaigns, describes another process Avhose advantages he greatly extols. In the same Avay as is done by Poyet, he first divides the Avhole thickness of the stump of the shoulder in the direction of the fibres of the deltoid, and to the extent of four inches. He then separates the two lips of the Avound, at the upper extremity of Avhich'he re-inserts the knife and plunges it from above doAvmvards, so that it may come out in front of the posterior border of the axilla, and thus form the outer flap. Returning to form in the same man- ner the anterior flap, and leaving betAveen them all the soft parts Avhich separate the two borders of the axilla, in order to avoid the artery and plexus of nerves, he then divides the deep-seated ten- dons and the capsule. After having divided the joint, he passes the knife behind the head and surgical neck of the humerus in order to terminate Avith the section of the pedicle (pedicule) which unites the two flaps below, obtaining by this means a Avound which is nearly oval. h. Process of Dupuytren.— In the place of forming the posterior flap by puncture, Dupuytren cuts it from Avithout inwards, that is, from the apex to the base, and in other respects proceeds in the same manner as M. Larrey. i. Process of M. Delpech.—If we omit to form an outer flap, or give this flap but very little length, and strike almost directly upon the posterior face of the articulation in order to open into and divide it, terminating by cutting a large inner flap, we have the process of Delpech. j. M. Hello (These No. 258, Paris, 1829) after having cut an outer and upper flap like Dupuytren, proposes that we should after- wards pass the knife betAveen the shoulder and the chest, to termi- nate the operation according to the rules of the circular method. This process adopted, he says, by Fouilloy, and which Laisne (Jour. Gen. de Med., t. VIIL, p. 401) compelled by the state of the tissues, had also already employed, is particularly serviceable Avhere the humerus is shattered, and Avhere the displaced boney fragments render the formation of any flap Avhatever by puncture more diffi- cult than usual. Two sailors thus operated upon in England about the beginning of the present century, Avere cured on the twentieth day. /•. Process of M. Lisfranc—M. Lisfranc, in order to avoid the objections made to the process of Grosbois, and at the same time to retain its advantages, causes the arm to be held a short distance from the trunk, places himself outside of it, applying the point of a S6B JTEW ELEMENTS OP OPERATIVE SURGERY. long knife in front of the posterior border of the axilla as if to raise up this border, divides the whole thickness of the muscles and the articulation itself from below upwards and from behind forwards, and brings the instrument out between the anterior border of the acromion and the coracoid process, raises the arm a little and in- clines it slightly backwards, passes around the upper and posterior half of the head of the humerus with the blade of the instrument, cutting in this manner his posterior flap, and then returning to the joint and finishing like Dupuytren or Delpech. C. The Ovalar Method.—Correctly interpreted, the origin of the ovalar method might readily be discovered in the processes of Poyet, Sharp, Bromfield (Observ. fy Cases, etc., 1773) or M. Lar- rey. It is nevertheless true, that it belongs neither to Beclard, to whom it is attributed in France, nor to M. Guthrie who was the first to describe it in England. I find it very accurately described in many theses of the school of Strasbourg, and especially in that of A. Blandin supported in 1803, and still more clearly in that of Chasley, who had already employed the term ovalar to designate the form of the wound. The several processes which it presents scarcely differ from each other. I. Process of M. Guthrie.—In the process of M. Guthrie, the two incisions which should describe a kind of V, and which are made to set out from the apex of the acromion, to descend oblique- ly, the one in front, the other behind, down to the lower extremity of the corresponding border of the axilla, comprise at first no more than the common integuments. The muscles are afterwards di- vided in the same direction and a little higher up, that is to say, on a line with the retracted skin. II. Process of Beclard or Dupuytren.—On the contrary, when we wish to imitate Beclard or Dupuytren, we go immediately down to the bone; but in both cases each side of the wound should be slightly convex in front and sufficiently superficial in its termination to avoid running any risk of wounding the vessels. The apex of the flap is detached and reversed downwards by a third stroke of #ie knife before proceeding to open into the articulation; in fact the base of the V remains untouched to the end of the operation, and is not detached until after having disarticulated the bone and grazed the posterior surface of its upper fourth. III. Process of M. Scoutetten.—M. Scoutetten after having, hke Sharp, brought the inner incision from above downwards, as far as the outward border of the axilla, while passing around on the ax- illary side of the arm, resumes it on the outside to prolong it from below upwards, with the precaution, carefully kept in mind, to di- vide only the skin under the root of the limb, and not to touch the vessels. IV. Process adopted by the Author.—a.—First Stage.—When the muscular fibres are divided very near their origin, their retraction must be inconsiderable; it is therefore advantageous, when the patient has the shoulder abundantly supplied Avith muscular tissues, to fol- low M. Guthrie, and divide tjb»e skin and cause it to retract before AMPUTATION OP THE UPPER EXTREMITIES. 559 proceeding farther. In an opposite state of things this precaution is unnecessary; the integuments and the muscles may then be di- vided with the same stroke of the knife. b. Second Stage.—The delicate point in the oval method, is the opening into the capsule. If the bistoury goes too deeply the fibrous pouch recedes, becomes folded on itself like a piece of wet linen, and is rather masked than cut. If it should strike within (en-deca) the anatomical neck of the humerus, the ligamentous adhesions will be but imperfectly destroyed, and the difficulties will appear still greater. To obviate this embarrassment, we should, after the lips of the wound are separated by the assistant and drawn back tOAvards the shoulder, seize the arm with one hand, make the head of the bone project, turn it upon its axis from without imvards, introduce flat-wise a very finely sharpened bistoury betAveen it and the tissues, place this bistoury afterwards at a right angle upon the capsule, on a line with or a little beyond the anatomical neck of the bone, and divide then upon its full edge, and perpendicularly all the tendons, commencing with the teres minor and finishing Avith the sub-scapularis, and while taking care to let nothing escape, use the head of the humerus as a point d'appui to make it roll upon its axis from within outAvards, in proportion as the instrument proceeds from behind forwards, or from without inwards. By this means we open freely into the articulation, and can luxate the arm with ease ; which enables us to make tension upon the parts of the capsule remaining, and Avhich we at length completely detach by directing the bistoury forwards, backwards and then inwards, as if for the purpose of grazing (raser) the bone. c. In the third stage the assistant, placed outside the shoulder, glides his thumb upon the artery in front of the glenoid cavity, com- presses this vessel in the species of pedicle Avhich unites the lower extremity of the two first incisions, while Avith a small knife or the same bistoury he has been using from the beginning, the surgeon makes the section of the base of the primitive V, and completes the separation of the limb from the trunk. V. When we wish the two incisions to set out from the acromion, we should make use alternately of the right and the left hand; but should Ave not be ambidexter, it is very easy to make the second incision from beloAV upwards, so as to unite it with the first. A good bistoury, rather convex than straight, answers for every stage of the operation. Some persons, however, prefer a small amputat- ing knife; and there are others who commence with the first and finish with the second of these instruments. § III.—Comparison of the different Methods. In all the processes Avhich have passed under consideration! to whatever method they may belong, the temporary suspen- sion of the course of the blood must be attended to. The in- direct ligature of Ledran and Garengeot is not to be trusted, and besides forms of itself an operation sufficiently grave. JUedran 560 NEW ELEMENTS OP OPERATIVE SURGERY. had already remarked (Oper., p. 571) that it could be dispensed with. If, like La Faye, Paroisse, (Opuse de Chir., p. 208,) and some others, wre apply a thread around the artery before complet- ing the loAver fiap, we rarely fail to include in it parts that ought to have been avoided. We cannot imitate Sharp and Bromfield without increasing the sufferings of the patient and protracting the duration of the operation. Compression, on the first rib, as recom- mended by Camper, Avhether by the thumb or Avith a hand-pelote, (pelote a manche,) or should we resort to the tourniquet of Dahl, applied upon the second rib in front of the clavicle, a kind of com- pression which Paul of Egina (Portal, Anat. Med., t. IL, p. 232) had already pointed out to arrest the blood, they exact conditions which do not ahvays exist, and Avould, if badly executed, expose the patient to the risk of perishing by hemorrhage under the hands of the operator. But we have it in our poAver, by doing as most of the moderns do, to prevent this accident by a plan far more secure and simple. For this purpose it is sufficient, as Ave have seen, to leave uncompleted the section of the fiap which includes the vessels, until after having divided the articulation. The previous and direct ligature upon the subclavian artery which Avas still made use of in 1821 by M. A. H. Stevens, (S. Cooper, American Edition of his Ele- ments of Surgery, 1822,) Avould not become necessary except in the event of extensive derangement (deformation) of the parts. In fact Avhile the knife is passing from above doAvmvards upon the posterior surface of the disarticulated humerus, the assistant placed behind, embraces the base of this Aap in order to compress it betAveen his thumb Avhich rests upon the bundle of vessels, and the other fingers Avhich act as a point d'appui upon the skin of the axilla. In place of using one hand only, there would be no objec- tion to our employing tAvo, if the thickness and width of the soft parts preserved seemed to render it requisite. By this mode of compression which is available for any one, it is evident that we may complete the operation without any apprehensions, and that the ligature upon the vessels afterwards requires no special direc- tions. Without knoAving Avho first gave this rule, Poyet, in his Thesis, supported in 1759, states that he folloAved it. Bertrandi (OpSrat. de Chir., p. 456) also distinctly mentions it, but Avithout designating its author. Others attribute it to Ledran (lb., p. 571) himself, who in fact describes it in 1742, but in an imperfect man- ner. HoAvever this may be, it is hardly over twenty years, and since the recommendations of Deschamps, (Allan, Jour, de Sidillot, t. VIIL,) M. Larrey (Clin. Chir., t. Ill,) and M. Richerand, that it has become generally adopted. The other arteries Avhich it is also sometimes advisable to tie, are the acromial, the external thoracic and circumfiex arteries, and the common scapula. We do not generally attend to them until after having secured the trunk of the axillary artery. If they should bleed too freely, or any circumstance compel us to protract the operation, each one of them may be tied as the knife divides them. As to omitting the ligature and depend- ing upon the elbow (coude) of the lower flap to stop the hemorrhage, AMPUTATION OF THE UPPER EXTREMITIES 561 all the surgeons of the present day, say Avith Decourcelles (Manuel des Operat, p. 391,) that Ave cannot trust ourselves to this. Out of so many processes, there is no one Avhich merits an exclu- sive preference, nor any one Avhich may not effect the object Ave have in view. That of Le Dran is the best Avhere the soft parts of the hollow of the axilla have alone preserved their normal condition. When, on the contrary, none of these tissues are healthy except at the stump of the shoulder, Ave are then compelled to have recourse to that of La Faye, as modified. If the disease should have extended farther upon each side than from above doAvn- Avards, the process of Garengeot or Cline Avould be applicable. The circular method Avould become necessary Avhere the skin had under- gone degeneration around the Avhole limb, and as high up nearly as the articulation, and might be replaced by the ovalar method, if it shou'd appear possible to save a little more of the tissues behind than in front. If the alteration has proceeded farther up on the outside than upon the inside, the process of Delpech Avould have its value. It Avould be the same Avith that of Sharp and Desault, or better still, Avith that of Laisne or M. Hello in the contrary case, provided the artery in the beginning has been avoided by the in- strument, and, as has been said above, protected afterwards during the remainder of the operation. Finally, Avhen the tissues are not more diseased on one side than on the other, but are more so in front or behind, it is advantageous to place the flaps vertically, and to give to each of them nearly the same length. We may then choose between the processes of M. Larrey, Beclard, and M. Lisfranc. The mobility or immobility of the limb, the position in which it is found fixed by the disease, and the relations of the head of the humerus Avith the glenoid cavity, and the processes of the scapula, often also make one process preferable to another. But it is at the bedside that the skilful surgeon may or can appre- ciate these several indications. In a patient in Avhom the Avhole of the arm was occupied by a cancerous affection, I Avas obliged to employ the ovalar process reversed. The patient, nevertheless, got Avell. Now, supposing that there is nothing in the state of the parts Avhich compels us to adopt one process in preference to another, Avhich is the method that offers the most advantages ? In the trans- verse method, there exists between the acromion and the lower border of the glenoid cavity, an excavation too deep and Avide to enable us in approximating the base of the flaps, to fill it up com- pletely, for the purpose of promoting easy union by the first inten- tion. We should then unquestionably adopt such processes as pro- cure a vertical cicatrix. The rapidity of that to Avhich M. Lisfranc gives the preference, leaves nothing to desire. The process of De- sault, reversed as it is by the modification of M. Larrev and Du- puytren, does not require a much greater length of time. The ovalar process, however, as it procures a Avound infinitely more regular, though it exacts more address and more accurate anatomi- cal knoAvledge, is, in my opinion, still preferable. By practice it 562 NEW ELEMENTS OF OPERATIVE SURGERY. ultimately becomes easy, and I have seen M. Chaumet, of Bordeaux, finish it in thirty seconds upon the dead body. I am not aAvare of any other than the circular method by the protest of M. Cornuau, or that of my own, Avhich are preferable to it, or can be substituted for it with advantage. AH these variations in the operation, how- ever, are of such trivial importance in practice, that it would be puerile to dwell upon them at the present day. The process of M. Manec and M. Lessere, (These No. 57, Paris, 1831,) avIio re- commended removing at the same time Avith the arm, one the acro- mion, the other the acromion-glenoid caAdty and extremity of the cla- vicle, cannot be applicable unless the bones of the shoulder be ac- tually diseased. I have already remarked that the disarticulation of the shoulder is an extreme measure, and that Ave ought to reject the advice of those Avho, like La Faye, recommend that it should be performed even in cases Avhere it might be dispensed Avith by applying the saw below the head of the humerus. It does not folioav, never- theless, formidable as it Avas first thought to be, that it is much more dangerous than amputation in the continuity. " We have so often performed, and seen performed successfully, extirpation of the arm," says M. Gouraud, " that Ave doubt if it is scarcely more dan- gerous than amputations betAveen the articulations, and it is ques- tionable, in fact, if in wounds from fire-arms it is not preferable to it." M. Bancel, in his Thesis, cites sixty successful cases. M. Larrey avers that he has found it succeed in ninety cases out of a hundred. Sabatier speaks in admiration of the success this surgeon had in fourteen cases out of seventeen; and Percy allows that out of seventy persons thus amputated, we lose only a sixth part. Immediate union is specially applicable to it, and for the subse- quent treatment, the same precautions pointed out under amputa- tions and operations in general are specially required, whether in relation to the dressings or the regimen, or to prevent visceral in- flammations, moderate the general reaction, and protect ourselves against the consequences which too often result from capital operations. Article VIII.—Amputation op the Shoulder. § I.—Indications. After amputation of the arm at the joint, it would seem that we could advance no farther upon the root of the limb for the purpose of its removal. Nevertheless, if the disease should have invaded a part of the shoulder as Avell as the arm; if the clavicle, acromion, coracoid process, and even the head of the scapula, should have all become implicated in the disorganization, Avhat should the surgeon do ? Should he remain a passive spectator of the progress of a fatal disease ? The Samuel Wood mentioned by Cheselden, and the three other patients Avhose history is given by Carmichael, Dorsey and Mussey, (Gaz. Med. de Paris, 1S38, p. 394,) had the amputation of the upper extremities. 563 shoulder entirely torn off, and nevertheless got well! M. Larrey, (Carteron, Bulletin de la Fac. de Med., t. IV., p. 218,) in his cam- paigns, has frequently been obliged to remove Avith the arm a large portion of the scapula or clavicle, and more than on one occasion has success rewarded his courage. After having disarliculated the arm, M. Clot believed it to be necessary to remove also the neck of the scapula, and his patient recovered, (Lancette Franeaise, t. IV., p. 84.) In 1808, moreover, M. Cuming, (Bull de Ferussac, t. XXII., p. 91,) at the Hospital of Antigoa, [Antigua 7] removed the Avhole of the shoulder, Avith the arm, in a patient Avho recovered perfectly. Since then, M. Brice, in the year 1827, was equally fortunate with M. Clot, in removing a portion of the clavicle and scapula at the same time Avith the arm, in a Greek soldier Avith a gun-shot wound. Amputation of the shoulder may also become necessary in order to save the arm. Janson has given an example of this kind. I find a second case in the thesis of M. Piedagnel (These No. 250, Paris, 1S27) Avhich belongs to Beauchene. A third belongs to M. Lucke, (Bull, de Fer., t. XXII., p. 89,) Avho per- formed the operation in 1828, as will be mentioned elseAvhere. Bonfils and M. Gensoul (Journal des Hopitaux de Lyon, p. 97- 100) have each removed the shoulder for a cancerous tumor, once, and M. Syme (Edinb. Med. and Surg. Journ., October, 1836) had a case which recovered after he had removed the acromion, glen- oid cavity, and corresponding portion of the clavicle, as M. Hunt (American Med. Recorder, Vol. I., 1818) had already done in a pa- tient forty-six years of age, who had already undergone amputa- tion of the hand, and afterwards disarticulation of the arm for the same disease. M. Mussey also (Gaz. Med. de Paris, 1838, p. 394) was obliged in one case to extirpate the entire shoulder, and the pa- tient recovered. (See Exsection of the Shoulder, farther on.) This amputation is sometimes required in cases of necrosis, ca- ries, and comminuted fracture, Avith more or less extensive disor- ganization of the soft parts, because simple disarticulation of the arm Avould not alloAV of our removing the whole disease. At other times, it is required for some degeneration, or for a tumor composed of abnormal tissues, and Avhich includes a part of the arm, and ex- tends beyond the joint. Again, the tumor and morbid degenera- tion may involve only the scapula and the tissues that surround it; in such cases Ave may preserve the arm. § II.—Operative Process. A. First Case.—We lay bare the diseased bones until Ave come to the sound parts; the flaps, formed and managed as in amputa- tion of the joint, are also cut out in this or that manner, according to the state of the tissues, and then reversed and held by assistants; if it should appear impossible to avoid the artery, Ave then make pressure upon it on the first rib, should it not seem more advis- able to apply the ligature to it at the outset. If it should become necessary to remove the three projections which terminate the 564 NEW ELEMENTS OF OPERATIVE SURGERY. scapula in front, the saAV should be applied behind the root of the coracoid process, or on the outer side of the spine of the scapula, in order to remove the whole at a single cut. When only one of them is diseased, either the acromion, the glenoid cavity or the coracoid process, it is better to saw from Avithout inwards, or from behind forAvards ; whilst the outer extremity of the clavicle requires that Ave should saAV from before backAvards, or from above doAvn- wards. It is unnecessary to remark, that in order to accomplish these different kinds of sections in a proper manner, Ave should make use of a saAV similar to that generally used for the section of small bones, or the chain saAV of Jeffray. Upon the supposition that there are only some splinters or fragments of bone Avhich may easily be removed from above the joint, we must confine our- selves to extracting these, and to the processes for disarticulation of the arm. B. Second Case.—As the form, size, and precise seat of the tu- mor in these cases can have no fixed relations, it is, for the same reason, difficult to trace out the rules for such an operation. It is, by falling back on his intimate knoAvledge of the parts, and the re- sources of his OAvn mind, that the surgeon Avill be enabled to deter- mine the precepts which should then guide him. In the year 1825, there Avere received at the Hospital of Perfectionnemenl, at the same time, tAvo men, having enormous colloid (collo'ides) tumors upon the shoulder. One died Avithout being operated upon, and the examination, after death, shoAved that the tAvo upper thirds of the humerus, and the greater part of the tissues that envelope it, together with the anterior half of the bones of the shoulder, were replaced by a lobulated, Avhitish mass, as friable as the texture of an apple or a green pear. M. Roux, Avith a desire to save the other, operated upon him Dec. 6, in presence of M. Marjolin, and a great number of students. The tumor which had existed four years, occupied the right arm, Avas double the size of the head of an adult, and of an ovate form Avith the point descending nearly doAvn to the elboAV, and its base prolonged as high up as to the root of the acromion. The patient Avas 54 years of age, strong, of good constitution, and in full vigor, and there Avas no indication that any of the viscera Avere affected. The first flap Avas circumscribed by a semilunar incision, Avith its convexity in front, and extending from the middle of the spine of the scapula to beloAV the anterior border of the axilla; two branches of the acromial artery being opened, they bled freely, and I compressed ihem Avith the fingers. A second flap, corresponding in its base to the iufra-spinous fossa, and of the same form as the preceding, Avas then cut upon the outside and behind ; a branch of the common scapular artery of considerable size being divided, it was immediately stopped by the finger. It was deemed proper to exsect the acromion in order to continue the dissection of the diseased mass with greater facility ; threads wore applied upon va- rious small arteries, and the incisions continued down to the clavi- cle and glenoid cavil y. These tAvo portions of bone Ave re immedi- AMPUTATION op the upper extremities. 565 ately removed by the saw. After a protracted search, the axillary artery Avas at last found. The tumor noAV Avas held only by a loose pedicle, which included the vessels, and Avhich I seized with my two hands in order to enable M. Roux to complete the removal of the limb without danger. Finally, the operator returning in search of the remains of the tumor, removed also Avith his saw the coracoid process, and the anterior fourth of the scapula. Although the patient did not lose more than tAvelve ounces of blood, he became pale and seemed greatly prostrated. During the day he remained very comfortable, but the night passed without sleep. On the 7th, in the morning, the pulse continued small, the chest constricted, and a cold SAveat Avas remarked upon his face, which retained its paleness; but there Avas no actual suffering. This state of exhaustion gradually increasing, death supervened on the 9th, at 7 in the morning, Avithout being preceded by delirium or any commotion, (agitation.) The necropsy exhibited nothing which could explain this result, which was as fatal as it Avas rapid. The tumor weighed tAvelve pounds ; a plaster cast of it Avas carefully taken, Avhich should be found in the museum of the Faculty, Avhere I deposited it. This kind of tumor, moreover, is very common. It gives to the limb a shoulder-of-mutton (gigot) form. Pelletan has noticed it, and Hey has given a plate of one. The tumor in the patient of M. Gensoul, and also of that of M. Syme, Avas similar to this. I have seen three other cases, and I could easily enumerate here twenty examples of the same kind. In the haunch I have seen tAvo cases of it : one, a Polish officer, who Avent to Bordeaux, and died there ; and the other, a young man Avho died at La Charite ; in this last the tumor Aveighed over thirty pounds. A patient, in whom I removed the arm, Avith the acromion also, had this tumor. Belonging, as they do, to the class of encephaloidal tumors, the tissue Avhich composes them is reproduced (repullule) Avith a fright- ful rapidity. C. Third Case.—So also Avhere the scapula alone and its depend- encies are affected, a definite rule for proceeding is Avanting ; for sometimes the tumor is Avholly on the outside of this bone, some- times on the inside, Avhile in other cases it projects from both its tAvo surfaces, comprising to a greater or less degree its Avhole sub- stance. On the other hand, it is evident that the disease, in place of a morbid, external growth, may consist of an extensive degene- ration of the bones. (See Exsection of the Shoulder, infra.) [Disarticulation of the Scapula and Arm together.—Avul- sion. The possible Disarticulation of the Scapula,—if such a phrase is allowable,—becomes a matter Avorthy of consideration from the new facts, of late years, upon the subject of limbs torn from the body. The subject of Avulsion of the Limbs, at the articulations, 566 NEW elements op operative surgery. generally caused by persons getting entangled, or suddenly drawn into portions of machinery, in manufactories, going with great ra- pidity, is one that has, within a few years, attracted considerable attention, while the recoveries from such frightful lacerations have led to some curious and, as it, seems to us, important pathological results for surgery. One of the most recent and terrific cases on record, which recovered, is related by A. King, M.D., of Glas- gOAV, (Cormack's London fy Edinburgh Monthly Journal of Med. Science, Feb. 1845, p. 96, &c) The patient, a stout boy, aet. 15, had his whole left arm, with the scapula entire, torn off, by his hand be- ing caught in the Avheels of a grain-mill, Oct. 10, 1843, leaving a jagged, irregular, and ghastly wound, commencing an inch from the sternal extremity of the left clavicle, and coursing along the under third of the neck, thence doAvmvards, forwards, and back- wards, terminating at the fourth false rib anteriorly and laterally, and three inches on the right side of the upper portion of the dor- sal division of the vertebral column posteriorly. The loss of integu- ment Avas chiefly behind and beloAV the situation of the left clavicle. The muscles on the front and side of the chest, Avith the exception of a very few fibres, Avere removed, exposing the intercostals; they had been dragged from their thoracic attachments, leaving the skin loose and puckered, as if too ample for the subjacent textures. No fragment of the scapula could be discovered in its situation. The clavicle Avas drawn doAviiAvards and forAvards, but maintained its connection Avith the sternum. The axillary artery projected from beneath the displaced clavicle, to the extent of two inches and a half, and pulsated strongly to within an inch of its orifice, but gave exit to no blood. On a minute examination of the torn ori- fices, the external coat of the vessel Avas found to be divided into three irregular pieces, Avhich encircled each other and held in their embrace a small coagulum of blood. There Avas no venous hemor- rhage, and no large venous trunk discovered. The nerves Avere torn at irregular.distances, varying from three to five inches from the surface of the Avound ; their extremities Avere greatly attenuat- ed, and the slightest irritation upon them gave rise to the most acute suffering. The artery Avas secured by a ligature, being deemed, as it certainly Avas, the most prudent course, for it Avould hardly have been otherAvise than an act of miAvarrantable temerity to have looked for its cicatrization after the torsion Avhich had been effected or forced upon it, by the violence of the accident. About two inches of the projecting portion of the clavicle was sawn off, and the integuments Avere drawn together by adhesive plaster, which Avas made to cover Avithout any stretching, the vessels, nerves, and indeed the Avhole wounded surface, Avith the exception of a small, irregular portion near the spine, about three inches in cir- cumference. The patient did not even swoon, but Avas found standing by the wheels, Avhich had been promptly stopped; and not until his tattered clothes, adhering Avith his torn-off shoulder and arm to the machinery, Avere being removed, did he evince even payi, and then complained but little. Not two cups of blood, in all, AMPUTATION OP THE UPPER EXTREMITIES. 567 were found on the floor, and on the arrival of the surgeon, half an hour after the accident, not a drop of blood oozed from the frightful wound ! Nor Avas there any hemorrhage afterAvards. The reac- tion Avas trifling, and appeared to be only Avhat Avas required by nature to restore tone to the system from so violent a concus- sion. The pulse continued for several Aveeks steadily at, or a little over, 130 in a minute, and soft and of moderate strength—the tongue clean, skin cool, and appetite good, and patient lively. The continued celerity of the pulse, in fact, might, as Ave think, be rea- dily accounted for by so great a destruction and sudden ablation of parts, without hemorrhage, which thus accumulated or concentrated just in the same proportion to this loss of substance the nutritive powers left in the circulation, and therefore the quantity of blood in the whole system; requiring consequently its more rapid passage through the heart and lungs. On the tenth day several portions of the integuments Avhich had been brought over the face of the nerves, and some of the ragged margins of the Avound had sepa- rated by sloughing; but healthy granulations Avere springing up on all sides. The plexus of nerves, Avhich had become exposed to the extent of three inches, lay together in a mass, and were partly sphacelous ; but Avhen touched by the dressings, or otherAvise, the boy manifested a degree of terror, says the surgeon, I have seldom seen equalled, and declared he Avould sooner perish than allow any interference. The ligature lay in contact Avith the nervous mass, and in consequence of the extreme sensibility of the part, was al- lowed to drop off with the sphacelated nerves, about the middle of the sixth week, after the boy had been walking about for some days in perfect health. A dissection of the torn-off limb and scapula ex- hibited a fracture midAvay on the humerus,—the integuments on the outside of the head of the humerus entire, but on the inner and an- terior surface of the bone, completely removed, and the nerves and blood-vessels exposed,—the nerves torn and separated into small bundles like pieces of cord, some 5\ inches long, and the shortest one inch from the shoulder joint,—the artery (the brachial) torn di- rectly across, about tAvo inches on the distal side of the shoulder- joint, and looking as if severed by a cutting instrument,—the inter- nal and middle coats, on being laid open, presenting the appearance of being slightly retracted and puckered,—the acromion and cara- coid processes of the scapula entire, but the other portions of the bone (scapula) so mutilated and crushed to minute fragments, Avith the surrounding muscles, that they could not be distinguished from each other. Dr. King draws attention to the leading feature of the absence of hemorrhage, and the trifling shock on the system produced by so immense and lacerated a Avound, unaccompanied, it may be said, even Avith syncope, and at no time stupor or fever, strictly so called. Such slight morbific effects from such terrible violence, which have been frequently noticed also in similar cases, lead to the supposition that,could disarticulation, thus almost instantaneously accomplished by a natural application of mechanic force, rapid and as it were 568 NEW ELEMENTS OP OPERATIVE SURGERY. spontaneous, Avhile the patient has scarcely time to be conscious of the operation, be thus performed intentionally and by art, and limbs thus quickly Avrung or twisted off from their joints, there would be less to be apprehended from consecutive symptoms, than after the most dexterous application of surgical instruments. The general arguments, also, advanced of late years Avith so much earnestness by Amussat and others, in favor of torsion of arteries (see vol. I. of this present Amer. ed. of Velpeau; also this vol. II.) in preference to ligatures, seem to acquire great weight from de- tails like those of the above remarkable, not to say almost marvel- lous and incredible, case ; for herein torsion Avas certainly exer- cised on a vast extent of surface and upon a gigantic scale as to the great trunks interested. In truth, the first ideas of torsion as a surgical expedient unquestionably came from the almost total ab- sence of hemorrhage in such Avounds, and Avhich dissection, as is seen in this case, proved to have been effected by the same breaking and rolling up of the tAvo inner coats and the resistance and pre- served integrity of the outer elastic coat, Avhich are shoAvn to be the results Avhere arteries are submitted to torsion by a surgical in- strument. Dr. King finds but a very few cases of avulsion on record. Belchier, (Philosophical Transactions, vol. XL, p. 313,) relating the case of the man Avho had the arm and shoulder-blade torn off by a mill, says he was not sensible of any pain, but only a tingling about the wound ; and actually did not know his limb was torn off, till he saw it in the Avheel! and soon recovering from his pain, or rather fright at this loss, came doAvn a narrow ladder to the first floor of the mill! The boy described by Mr. Carter, (Medical Facts, vol. II., p. 18,) whose left leg and thigh and part of the scrotum Avere torn off by a slitting-mill, was found by the surgeon lying on the floor un- der a blanket, seemingly free from pain, and only anxious because his parents Avould be in such trouble ! The same in the boy aged nine, Avhose leg M. Benomont (Hist, de I'Acad. de Chir., t. II., p. 79) states was» torn off at the knee by the Avheel of a carriage, but Avhose only trouble Avas an anticipated reprimand from his pa- rents. The girl aged eleven years, described by Dr. Clough, (Me- moirs of the Medical Society of london, vol. III., p. 519,) had strength to Avalk across the court, from the coach to the hospital, shortly after her humerus had been torn from the scapula in a mill. Two other cases (Traite Complet des Accouchem., par M. De la Motte, Obs. CCCXLI.; see also Dr. Cooper's case, Neiv York Jour. ofMe/icine, vo\. I., p. 284) are too imperfectly given to alloAVof more than merely this reference to them. In one case only, that of a child as related by M. Carmichael, (Medical Commentaries, vol. V., p. 80,) the avulsion of the left arm by a mill, though the patient recovered a little and spoke, Avas soon folloAved, but Avithout any loss of blood, by cold extremities, low tremulous pulse, and convul- sions over the Avhole right side of the body and face. In one case only, also, of the above Avas there profuse hemor- rhage : viz., in that of Belchier, (Loc. cit., p. 314 ; also Cheselden's Anatomy, p. 321.) AMPUTATION OP THE UPPER EXTREMITIES. 569 Dr. Jones (Jones on Hemorrhage, p. 42, cap. XII.) has clearly shown, in his valuable experiments, that in these lacerations, Avhich is seen also, says Dr. King, in the natural instinctive act of brute animals in bruising the umbilical cord, nature providentially guards against the loss of blood. The brittle, internal coats of the vessels give Avay, and their retracted debris fill up the outer, firmer, elastic coat, and this plugging up of the vessel, (See Costello's Encyclop., part V., art. Avulsion,) and also the now elongated conical narrow orifice of the external coat, all resisting the force of the circulation, naturally favor the deposition of coagulum lymph, and conse- quently, cicatrization. These are now the most approved vieAvs, and more recent observations have shown that the important part in this process is rather in the mechanical breaking, rolling, and push- ing up of the two inner coats, (as in torsion,) than in the deposition of lymph, as Dr. Jones imagined. [See notes supra, under arteries, &c] In the case of Dr. King, he justly remarks, as Ave think, that the lacerated fragments of the nerves exposed should have been imme- diately removed by the knife, which Avould have greatly diminished the present suffering, and danger of neuralgia afterwards. So should lacerated and contused portions of cellular tissue and fibre be removed by the knife to avoid sloughing and suppuration ; but in this case there Avere no such parts, as the Avhole mass appears to have been Avhipped off, smack and smooth, doAvn to the ribs ! It is true, as Dr. King says, that Ave see only the favorable side probably of most such cases, to Avit, the fortunate ones, while the fatal results are hushed up. But it must be confessed that their phenomena, viewed in any light, are pregnant Avith important re- flections, and lead, as in this case of Dr. King especially, to the conclusion almost irresistible, that the entire scapula and its muscles in front and much of those behind, together with the arm and a section also of the clavicle may be removed from the body and be folioAved notAvithstanding by a perfect restoration of health. It is difficult to conceive hoAV such a terrible and extensive destruction of soft parts, muscular tissues, vessels and nerves, and exposure of aponeurotic, cartilaginous and synovial surfaces and sheaths could have so resulted, and with scarcely any constitutional disturbance. It Avould seem to give a less formidable aspect to lacerated Avounds than that in Avhich they are usually regarded ; though there is no question scarcely in our mind that a smooth incision or separation Avith the knife, could it have been made in the proper directions and at the proper places of division, as in those Avhich nature herself for example had selected in this violent disrupture, the result would have been attended Avith less danger of a fatal issue and better prospects of cure. The natural and best line of division of the parts, however, for the most perfect torsion of the vessels, is doubtless the one here rudely adopted in such accidents. And the question therefore comes back to this, how far nature in such vio- lence is to be imitated by surgical art in attempting, in cases that may offer, such scapular disarticulations as the foregoing, and whether these are not to be considered valuable lessons in pointing 570 NEW ELEMENTS OF OPERATIVE SURGERY. out to us the path by no means yet Avholly explored, Avhere (as in anaplastic operations) unachieved triumphs that Ave can scarcely anticipate are still in store for surgery, so far as enormous destruc- tions, ablation and restitution of parts are possible without loss of life. Some consideration is undoubtedly to be attached to the extreme and almost instantaneous rapidity Avith Avhich such ablations are effected. This unquestionably has great and favorable inAuence upon the results, and it is to be received in some sort as an argu- ment in favor of the once highly lauded but noAV universally repro- bated achievement, Avhich most surgeons plumed themselves upon, of completing the most bloody operations Avithin a limited number of seconds. We notice some remarks on the above important case of Dr. King, made at a meeting of the Medico-Chirurgical Society of Edinburgh, Jan. 22, 1845, (Cormack's Jour., ib.) Dr. Watson on that occasion justly doubted that the slight hemorrhage in such cases depended on the formation of a clot, as it required according to his experiments seven days to form in a deligated artery. It was Avell observed by Dr. Douglass Maclaganthat the art of avul- sion Avas in the highest degree favorable to the interruption of the course of the blood, as he had proved many years since by experi- ments on the dead human subject and in living animals, in associa- tion with Prof. Turner. In dragging out arteries forcibly, until they gave Avay, the same result Avas produced, \iz., the cone-like prolongation of the tub-", and the shaping of it into the form of a pencil, pointed for writing. The prolonged outer coat formed the apex of the cone ; the inner coat Avas retracted Avithin and project- ing into the canal. This strengthens greatly the now received opinion that the actual plugging up of the artery by this species of membranous tamponing, has in fact, as seen in torsion, much more to do Avith the arrestation of the blood than has the formation or deposit of a clot of lymph. The clot alone, hoAvever, may be the tampon, as it Avould appear by the late interesting experiments of M. Amussat, (see our note on these, supra,) Avhich plugs up the cut extremities of an artery, causing thereby a spontaneous cessation of the hemorrhage. It is also a matter for reflection Iioav far avulsion is to be copied in using torsion on arteries. It Avould seem rea- sonable to suppose that torsion, so far as it respects the continued tAvisting or revolving of the artery round upon its long axis, by means of the forceps used, is too much insisted upon, and might injure and rupture in Ararious places the important outer tunic; and consequently that the first step in the process, viz., that of en- deavoring to break up the two inner coats and to push them tOAvards the cardial side, is the point to be most attended to; or that this last in fact is less important than the simple act of elongat- ing the artery by the forceps in the left hand, inasmuch as it Avould appear that this elongation itself, Avith little or no torsion, suffices to rupture the inner coats and to bring the outer elastic tunic like a hood or cap well over them as the inner ones retract. This it AMPUTATION OF THE LOWER EXTREMITIES. 571 might naturally be supposed it would do from the elastic external tunic submitting so readily to this traction, while the middle tunic, by the natural contractile action of its fibres and the brittleness of the inner coat, seem more disposed to recede or retract within the outer coat. In the living body, however, this elongating traction must necessarily be exercised Avith caution, inasmuch as a rupture of the trunk high up Avithin the tissues might be attended Avith seri- ous consequences. Actual Amputation of Scapula, fyc—In proof of the practicability of removing the scapula, as Ave have said in our remarks on the extraordinary case of Dr. King above, the entire scapula, together with the external extremity of the clavicle, have been subsequently amputated Avith complete success by Professor Rigaud of Stras- bourg (Seance of the Acad, of Sciences of Paris, July 15,1844.—Gaz. Med. de P haps Avith some advantage. Graefe and M. S. Cooper, on the other hand, maintain that it is full as advantageous to be placed always on the outside, or that it is at least not necessary to be on the inside 39 610 NEW ELEMENTS OF OPERATIVE SURGERY. for amputation of the right leg. If, in fact, Avhen on the inside and operating on the left leg, the corresponding hand be*ig tOAvards the upper part of the limb, is enabled to raise up the integuments in proportion as the right hand divides them; this cannot be done upon the right leg if Ave folloAv the rule laid doAvn. Consequently the precept which it Avould be proper to substitute for the ancient one, and which I have myself conformed to for a long time past, is this :—The operator is to place himself in such manner that the left hand may ahvays grasp the leg on the side towards the knee, un- less hoAvever he should be ambidexter; in fact in this last case there would no longer be any more necessity for his placing himself be- tween the tAvo limbs than Upon the outside of either. It Avould, moreover, be puerile for the surgeon to place himself outside, for the division of the soft parts, and then Avithin Avhen the bones only remain to be divided, as some English and German surgeons have recommended. Still more out of character (bizarre) Avould it be to leave the sound leg between the operator and the one to be ampu- tated, in order never to place himself between these parts. The foot being Avrapped in a fold of linen, is Avith the entire diseased portion of the leg confided to the last assistant. Second Stage.—The operator,provided Avith an amputating knife, cuts circularly through the Avhole thickness of the skin, commencing at the crest and finishing at the inner border of the tibia; he then, by means of a second cut, unites the tAvo extremities of this incision on the inner face of the bone, unless by a movement of rotation of the hand upon the handle of the instrument, and which I have already described, he should prefer passing round, without stopping, the whole circumference of the limb. DraAving back with his left hand the integuments thus divided, he detaches their cellular bridles, and raises them an inch or an inch and a half, or with the thumb and forefinger he seizes them by the upper lip of the wound, near the fibula. Then he dissects them with free strokes by means of the point of a knife or a bistoury, and promptly reverses them from below upwards, in order to form a sort of border or ruff. Third Stage.—Having brought back the knife to the base of thiscu- taneous ruff or circle and to the same point on the tibia, the operator incises from before backAvards, and from within outwards, so as to divide the aponeurosis and all the muscular fibres which rise above the level of (depassent) the anterior inter-osseous fossa. Depressing the Avrist, he divides in the same manner the peronei muscles, and then in gradually bringing the knife inwards, those of the calf or posterior surface of the leg, and again brings the instrument in front and detaches the aponeurosis on each side ; then immediately ap- plies its heel on the outer surface of the fibula and proceeds to cut from the handle to the point. When the point arrives upon the inner side of this last bone, Ave cut through the inter-osseous space, in order to divide all the deep-seated fibres, and while Avithdraw- ing the instrument to divide those also on the outer surface of the tibia. Replacing the knife below the limb and upon the same point of the fibula, the operator noAV again brings it back upon the AMPUTATION OF THE LOWER EXTREMITIES. 611 posterior surface of this bone; again traverses the inter-osseous space, and comes out from it in the same manner as in front; divides all the remaining muscles behind the tibia, and finds that he has described in this manner a perfect figure of 8, as has been said in speaking of amputation of the fore-arm. It is advisable, as in this last-mentioned member, to make a second cut Avith the bistoury on each border of the inter-osseous membrane. We then pass from behind forward and between the bones, the middle tail of the com- press split into three tails; the different parts of Avhich properly un- rolled and then united are confided to the assistant Avho is charged with holding back the muscular tissues. Fourth Stage.—The surgeon fixes the nail of his thumb at the spot where the tibia has been denuded, and applies the saw to this point, making at first only small cuts. He then elevates his wrist so as to complete the section of the fibula first, finishing with that of the bone upon Avhich he commenced ; since the fibula if alone Avould not present sufficient resistance to the action of the saw, and would also have its upper articulation exposed to a severe concus- sion, (ebranlement.) This last reason I think is far from conclusive, but the first is sufficient to justify the precept. As soon as the sec- tion of the fibula is completed, the assistant, who holds the lower part of the leg and the operator who embraces Avith his left hand the upper part, should take care to compress this bone Avith such firmness that it can no longer be shaken by the movement of the instrument. M. Roux advises to saw it higher up than the tibia : for Avhich reason he inclines the saw obliquely upAvards and out- wards. By this mode of procedure M. Roux thinks he places him- self more securely on his guard against the subsequent protrusion of the fibula. This is a matter of little importance, and the section of the two bones on the same line is full as good. Much less can I understand Avhy some in imitation of certain practitioners should recommend their section separately. In fact, to render the section of the fibula more easy, if the surgeon were placed on the out in- stead of the inside, all that would be necessary Avould be, after tracing out a groove of proper depth on the principal bone, (tibia,) to have the aids turn the leg into pronation and to make a slight depression of the wrist. V. Fifth Stage. The anterior angle of the tibia, upon which the skin is supported, and against Avhich it is pressed by the weight of the muscles of the calf, Avhich tend to drag it backAvards after the dressing, sometimes causes perforation of the tegumentary cover- ings. Surgeons have early thought of the means by which such a difficulty might be prevented, and Avhich is ordinarily avoided Avhen amputation is performed very high up on the limb. I have seen MM. Richerand and Cloquet, at the Hospital of St. Louis, obviate it Avhen it threatened, by applying a piece of pasteboard in the form of a splint to the posterior surface of the stump. A much surer method consists in removing with a cut of the saw the corner of the angle or the osseous border itself. It is not knoAvn to whom belongs the first suggestion of this improvement, unless it be to 612 NEW ELEMENTS OP OPERATIVE SURGERY. Assalini, \vho I believe first speaks of it in his Manual of Surgery. Military surgeons have been for a long time in the habit of practis- ing it. It Avas pointed out in the beginning of this century by an army surgeon, Avhose name has escaped me. M. Marjolin also, and Beclard, in teaching it in their lectures, have caused its adop- tion among French surgeons. MM. Guthrie, S. Cooper, and other English practitioners, have also long since made mention of it, Avith- out however appearing to accord to it any very great importance. In place of the anterior angle it is the inner border, it is said, that M. Sanson saAvs off, but there can be no fixed rule in this matter. Whether it is the border or the angle, Avhat to do is to remove the salient point, and that constitutes the Avhole affair. I have often adopted and often omitted it, and have noticed that it was only really necessary in thin persons with flabby integuments, and Avhen we amputate rather Ioav down. Perhaps in such cases it might be advisable to folioav the plan of M. V. Onsenort, Avho before round- ing off the cut surface of the tibia dissects a flap from the perios- teum, Avith Avhich he covers the end of the bone. 2. Process of Sabatier. The process of M. Sabatier only differs from the preceding in this, that this author prefers incising in the first place the integuments upon the anterior half of the limb, and that we should draw them back before continuing the circular inci- sion a little higher up behind. His reason is, that on the calf the skin retracts Avith the muscles, Avhile in front of the tibia and of the anterior aponeurosis it will go up no higher than it is raised up by force. This is a modification Avhich, Avithout having any thing objectionable about it, has nevertheless generally been neglected. Decourcelles (Man. des Oper., etc., p. 385, 1756) obtained the same result by keeping the limb flexed Avhile he incised the integuments in front. 3. Process of Physick.—M. Ch. Bell considers himself the in- ventor of a process Avhich Dorsey (Elem. of Surg., t. II., p. 317) ascribes to Physick, but which rather belongs to Decourcelles, (Operat, p. 385,) and Avhich is as follows : first the skin is divided, then the muscles of the calf are cut very obliquely from below up- wards, completing the circular section much nearer the knee on the anterior half of the leg, and terminating the operation as in the ordinary mode. 4. Process of B. Bell—M. Baudens (These No. 51, Paris, 1S29) after having circularly divided the soft parts,proposes that avc should detach all the muscles to the extent of an inch or two, Avith the point of the knife held in a direction parallel to the axis of the bones. This advice Avhich Avas given by Bell, and Avhich has been adopted by M. Champion in amputations of the arm or thigh, and for all amputations in general, may have its advantages, and is in concurrence with the precept lately revived with much earnestness by M. Hello, (These No. 25S, Paris, 1829.) 5. Dressing.—In operating at the place of election, Ave have in succession to seize the anterior tibial artery, associated with its nerve, and which must be separated from it in front of the inter- AMPUTATION OF THE LOWER EXTREMITIES. 613 osseous ligament, betAveen the tibialis anticus muscle and the exten- sors of the toes; then the posterior tibial artery, the peroneal and some branches of the surales, (des jumelles ;) and sometimes also the nourishing artery of the tibia. Very frequently the first of these vessels retracts far into the tis- sues, the reason of Avhich, according to M. Ribes, (Mem. de la Soc. Med. d'"F.mul, Arch. Gen. de Med., 2e ser., t. III., p. 199,) is found in the double curve Avhich the artery is obliged to make, in order to get in front of the inter-osseous ligament. M. Gensoul (These No. 109, Paris, 1824) on the contrary thinks that this [apparent] retrac- tion is owing to the fact that the muscular fibres Avhich surround the artery, being too adherent to mount upwards, make the vessel appear to retract much more than it in reality does, much more even than those of the posterior part of the limb which the muscles draAV up still higher. The difficulty of finding this artery, accord- ing to M. Sedillot, (Gaz. Med. de Paris, 1833, p. 363,) is owing to the knife mashing (macher) and bruising it in dividing the muscles of the inter-osseous space. Without absolutely rejecting the first and third of these explanations, I would more Avillingly adopt the second. When the section of the bones is made immediately below the tuberosity of the tibia, one trunk alone replaces the posterior tibial and the peroneal, but then Ave meet also with the nourishing artery Avhich here possesses considerable volume. Higher up still the anterior tibial itself may not have yet separated from the popli- teal, [i. e., strictly speaking, from the peroneo-iibial trunk of the popliteal, which trunk and the anterior tibial form the two great divisions, i. e., the bifurcation of the popliteal itself. T.] Avhich last artery alone [i. e., the popliteal] in that case requires a ligature, together Avith the inferior articular and the surales. Practitioners differ also as to the direction which should be given to the union of the wound. In France it is almost ahvays obliquely from Avithin outwards and from before backwards, as is recom- mended by M. Richerand. Many operators in England, among others M. Hutchinson, still unite the wound as formerly, directly from before backwards, hoping by this means to avoid the stagna- tion of the fluids and the pressure of the point of the tibia against the skin. To give in fact greater security to this method, M. Lar- rey advises to slit the skin in front and behind, to the extent of half an inch. There are others again who unite transversely after the recommendation of M. Guthrie ; but there can be no question that if we have adopted the precaution of removing the angle of the bone as has been pointed out, that the method of M. Richerand is the best ; and that, this alone enables us to bring the tissues in a line Avith the smallest diameter (epaisseur) of the limb, and that it presents in no Avay any obstacle, to the discharge of the pus. If the amputation has been mode very Ioav down, the leg should be supported upon a cushion, and kept slightly flexed and inclined upon its outer side; otherAvise Ave place the stump upon small pillows (oreillers) Avhich raise the ham much higher, and prevent the Avound from pressing against the mattress. 614 NEW ELEMENTS OF OPERATIVE SURGERY. II. The Flap Method.—It Avas to the leg particularly that Lowd- ham, Verduin, Sabourin, &c, Avere desirous of applying their method. It Avas upon this part of the limbs also that Garengeot, De la Faye and Le Dran made their first trials. But Louis, Lassus and Sabatier, having undertaken to establish the circular method, and the flap operation seeming to be more painful and difficult, it was almost entirely renounced. It is noAV, however, near thirty years since it was again revived among us by M. Roux and Du- puytren. Hey in England, and Klein and M. Benedict in Ger- many, who eulogize it much, succeeded in causing its adoption by some of their countrymen. Heliodorus (Peyrilhe, Hist, de la Med., in 4to, p. 392-393) also, Avho first divided the soft parts in front, then saAved the bones and finished Avith the section of the muscular masses behind, did he not folloAv the flap method, he Avho so accu- rately applied to supernumerary fingers the so called method of Ravaton? What appears, however, to have chiefly deterred the moderns from it is the size of the tibia, Avhose inner face, taken in whatever way Ave choose, can never be covered by any thing but the skin. The necessity, also, of taking the greater portion if not the whole of the flaps from behind, Avas another motive for its ex- clusion. As, however, there may be cases Avhere it becomes indis- pensably necessary, 1 believe it my duty here to point out the prin- cipal processes by Avhich this operation may be performed. a. Process of Verduin.—A two-edged knife, plunged into the leg at a point a little below where Ave intend to apply the saw, first cuts out at the expense of the calf, a semi-lunar flap of about four inches in length; the instrument being then brought in front is imme- diately afterAvards made to divide the integuments and muscles as in the circular method, at the base of the flap Avhich has been raised up; the inter-osseous fossae are then cleared out (degagees) and the bones sawed as in the usual way. Loder and M. Graefe (Rust's"Handbuch der Chir., t. I., p. 569) have modified this process in this, that in order to leave a less quan- tity of muscle they draAV the skin back forcibly Avhile making the incisions, and also preserve a small flap in front. b. Process of Hey.—In order to be more sure of the length of the flap, Hey advises to mark out the middle of the upper part (hau- teur) of the tibia by a circular line, then to trace out a second an inch lower doAvn, and then a third at four inches below the first; afterAvards he makes two others, one on each side, parallel to the axis of the limb, and Avhich are draAvn from the union of the two anterior thirds Avith the posterior third of the superior circular line doAvn to the loAvermost circular line. The first indicates the point where the bones are to be saAved ; the second that at Avhich the integuments are to be divided in front, and the third the place Avhere the knife must be arrested; while the two lateral lines give the form and extent of the flap ; Avhich in other respects Hey cuts out in the same Avay as Verduin and Lowdham. No one I should judge among us Avould be tempted to follow this scaffolding of geometric lines and rules. AMPUTATION OF THE LOWER EXTREMITIES. 615 e Process of Ravaton.—The circular incision made at four inches from the place where the amputation is to be performed, alloAvs of another being placed on the inner side and near the inner bor- der of the tibia, then a third on the outer border of the leg, and both of Avhich are to fall upon the first at a right angle. The two square or trapezoidal flaps, one anterior the other posterior, which result from these incisions, are then to be dissected from beloAV upAvards and raised up ; nothing more remains to do than to clear out (de- garnir) the inter-osseous space, introduce the split compress and saAV the bones. d. Process of Vermale.—In order to form the first flap, Le Dran (Operat. de Chir., p. 55) Avho states that he has performed the method of Ravaton and Vermale successfully, carries the knife from the inner to the outer side of the leg, and thus begins by form- ing the anterior flap ; nothing then is easier than to draAV back a little the fleshy tissues behind and cut out a posterior flap. e. Process of Dupuytren.— Instead of commencing with the an- terior flap, Dupuytren first plunges his instrument between the pos- terior surface of the bones and the soft parts, taking care to leave more tissues behind the fibula than Le Dran did. f. Process of M. Roux.—As it is next to impossible to preserve as much of the tissues in front as behind, M. Roux has proposed to make an incision on the inner face of the tibia about 2 inches in length, Avhich commences upon the inner border and runs obliquely from be- hind forwards, and from above doAvnwards, and terminates on the anterior border of the bone. This incision, Avhen the posterior flap is formed, readily alloAvs of our bringing the edges of the wound up to a level Avith the crest of the tibia, and of making a flap in front which possesses greater regularity and thickness. III. Ovalar Method.—By slightly modifying the circular method for the leg, Ave may easily transform it into the ovalar. For this purpose it is sufficient to divide the skin in such manner that one of the extremities of the antero-posterior diameter of the incision, shall be manifestly placed nearer the thigh than the other. Thus M. Baudens (Clin, des Plaies d'Armes-d-feu, p. 50) Avho extols this method, places the apex (soinmet) of his oval behind tOAvards the ham ; Avhile M. Sedillot (Gaz. Med. de Paris, 1833, p. 363) recommends that it should be in front towards the knee. IV. Appreciation.—All the flap processes in fact are reducible to that of Lowdham and that of Vermale, the one allowing of but a single flap, the other furnishing tAvo. When the skin is degene- rated much higher up in front than behind, and that Ave are obliged to amputate very near the knee, the first is the process that becomes necessary. I have seen M. J. Cloquet employ it successfully at the Hospital of Perfectionnement, upon a patient, who but for that Avould have evidently lost the thigh. Under all other circumstances, the method with two flaps appears to me more suitable, though it be a little more difficult. When there is only one flap Ave are obliged to make a right angle Avith it near its base in order to apply it against the bones. Immediate and complete union is next to 616 NEW ELEMENTS OF OPERATIVE SURGERY. impossible; and sufficiently acute pains rarely fail to come on. The accidents which may result from the method in question, jus- tify to a certain extent the fears of surgeons of the present day, and their repugnance to undertake it. By means of two flaps on the contrary Ave can easily close the wound; the parts being neither angulated nor drawn upon, are found in the conditions the most favorable possible for immediate reunion. In making trial, on the dead body Avith the process of Vermale, and which I have once at the Hospital of Saint-Antoine employed on living man, I omit the small preliminary incision of M. Roux; but I take care to embrace with the left hand the two sides of the leg, and to draw as much of the integuments as I possibly can towards the front. The point of the knife is then directed upon the inner face of the tibia; brought up to a line Avith the crest of this bone, Avhile pushing the skin before it; passed along in front of the inter-ossc- ous ligament; a little raised up in order to pass in front of the fibula, and again inclined backAvards, while the operator draAvs the tissues tOAvards him, at the moment the knife is cutting through the outer border of the limb. The flap being Thus cut out, Ave return to form a similar one behind, Avhile the rest of the operation being based upon the process of Dupuytren, presents nothing peculiar. In whatever manner Ave proceed, it is necessary that the inner angle of the wound should not be quite as high up as the other, if we do not Avish to run the risk of denudation of the bone and ne- crosis. As a general rule, the circular method merits the prefer- ence over the flap process, but this last presents advantages which we may profit by, Avhen either at the loAver or upper third, the soft parts on the periphery of the leg have degenerated much higher on one side than the other. By enabling us to preserve what is sound, it puts it in our poAver also to avoid removing so large a portion of the bones. The same may be said of the ovalar method. As to immediate reunion, Avhich some of these processes are said to ef- fect Avith more certainty than others, it will be necessary in the first place to establish the fact that this has ever actually been ac- complished, Avhich has not been done up to the present time. On this subject 1 fear more importance has been attached to the process itself than to the facts in the case. In no case do I find that the wound definitively closes Avithout any suppuration. M. Serre, (Gaz. M'-d., p. 825.) Avho in France zealously advocates primitive reunion, and Avho, to ensure it with more certainty, uses the suture after amputations, never, however, cures his patients under fifteen days. Noav I have obtained results no less satisfactory, by the method I have pointed out for treating amputations in general. [Ligature on the Femoral and External Iliac Arteries for Hemorrhage after Amputation of the Leg. One of the most complicated and embarrassing, not to say danger- ous, cases of surgery on record, (See Cormack's Lond. <$r Edinb. Monthly Jour, of Med. Science, Feb. 1843, p. 109, &c.,) in Avhich the AMPUTATION OP THE LOWER EXTREMITIES. 617 operator successively triumphed over the most formidable and alarming obstacles, and finally succeeded in saving the life of his patient, Avas that of an ostler, aged 20, brought to Gray's Hospital, Elgin, (England,) July 30, 1842, and placed under the care of Dr. John Paul, surgeon of that institution, Avho exhibited in the treat- ment undaunted courage and clear judgment. Though not stated, the patient, from his age and profession, is presumed to have been in robust health, at the time of the accident, Avhich was a commi- nuted compound fracture of both bones of the leg, and protrusion of the tibia, caused by his jumping from a gig to stop the speed of his horse. The fracture on the projecting portion of the tibia Avas removed, and the limb comfortably arranged in Liston's splint. On July 18th, an abscess, Avith an erysipelatous discoloration of the skin, and pain of the internal saphena formed on the side of the leg opposite to the Avound, from Avhich proceeded a copious fetid dis- charge. The ends of the bone having become displaced, Pott's splint Avas used. July 24th—the symptoms all abated, pulse be- came 80 and feeble. Porter Avas now substituted, and the calomel and opium omitted. July 27—the Avound discharging largely of fetid matter, fracture loose and easily moveable. August 2d—dis- charge healthy, pulse tranquil, tongue clean. Aug. 9—Profuse hemorrhage having come on this evening from the wound, amputa- tion by the double flap Avas performed above the knee, only four vessels requiring the ligature. The flaps Avere exposed for some hours to the action of the air, and then brought together by sutures and adhesive straps. On the evening of the 15th of August, though the union of the flaps Avas almost complete, and no unpleasant symp- tom had occurred, the stump being only slightly swollen, and the pulse someAvhat frequent, hemorrhage from the stump supervened but to no great extent; but sufficient, in the opinion of the surgeon, to justify a ligature upon the common femoral, nearly an inch below Poupart's ligament. The bleeding ceased immediately, and the wound was brought together by three sutures. During the five succeeding days, there continued constantly a strong pulsation from Poupart's ligament down to the ligature, but none below the latter, with more or less profuse discharge of colored matter from the stump, on the second day of this interval, brought on in some mea- sure, perhaps, by Avarm poulticing to the stump, to promote its dis- charge, Avhich had been scanty. On Aug. 28, hoAvever, the liga- tures from the stump had come aAvay, and the Avound in the groin was granulating. To the surprise of the surgeon, the hemorrhage was again renewed, in the afternoon of Aug. 30th, and this time from the common femoral It Avas immediately arrested by pres- sure, Avhichhad not to be continued but for a short time. Only three ounces of blood Avere lost. The ligature was loose in the Avound, and Avas removed. On the evening of the next day, the hemor- rhage from the femoral was renewed to the extent of 8 or 10 ounces. A ligature upon the external iliac Avas noAv immediately determined upon, as the only reliance, and it Avas accordingly ap- plied by means of an incision four inches in length, commencing 618 NEW ELEMENTS OF OPERATIVE SURGERV. an inch above Poupart's ligament, and keeping the line of incision nearer the ilium than is generally recommended. The edges of the wound Avere brought together by three sutures. Sept. 1.—Considerable febrile reaction, pulse 120 with thirst, and some retching, which were allayed by citrate of potash and morphia. Sept. 2.—Fever continues, and the Avound in the iliac region discharges some fetid matter; stump nearly healed. The fever hav- ing someAvhat subsided, but the pulse still remaining at 110, and the tongue becoming red, though the bowels had been well oper- ated upon, the patient Avas put on quinine in minute, half-grain doses, three times a day, with a glass of port Avine, sago, and ar- row-root. Sept. 16.—The pulse natural, tongue improving; discharge from the Avound healthy ; the ligature remains; the bowels Avell regulated by castor-oil. Sept. 30th.—Slight pulsation Avas observed to-day, in the common femoral in the groin, where the ligature was applied, being the first time since the application of the ligature, on the iliac. The wound in the groin, however, had entirely healed, Avith the exception of a very small point, and this point appeared to be a coagulum of blood protruding from the artery. Directed to be rubbed with the nitrate of silver and the wine to be omitted. To October 7th, the arterial pulsations mentioned, grew stronger and stronger, though the patient was otherwise doing well, as also the Avound in the iliac region. There Avas some slight diarrhoea, a red tongue, and quickness of pulse. The pulsation seemed so superficial, that the blood apparently Avas restrained only from gushing out by a small coagulum and the crust formed by the ni- trate of silver. Chalk mixture and opiates given. From thence for two days, to Oct. 11th, the patient appeared to improve and the pulsations to subside, but on this date they in- creased again. On the 13th October, upon the removal of a small coagulum, the blood instantly gushed out with violence. This was arrested by compress and bandage, but on Oct. 16, profuse hemor- rhage again took place, Avhich, after removing the dressings, was kept under by the hand till next day, when on the recurrence of an- other hemorrhage, the ligature was applied again a little higher up, by means of an incision, from the place of bleeding as far as about an inch above Poupart's ligament, this ligament being completely divided, and the vessel secured just as it Avas about to pass under the crural arch, being about two inches below Avhere it had been pre- viously tied in the iliac region, and one above where it had been tied in the groin. On Oct. 24, the wound began to discharge healthy matter, and to granulate. On the 26th of Oct. the ligature upon the femoral came away ; but that upon the external iliac not until November 18th folio Aving, leaving, however, the loop on the vessel. Dec. 1.—Both wounds healed, and the patient sitting up. Remarks.— In cases of great complication and danger, like the foregoing, and recoA7ery from which, as in the instance before us, AMPUTATION OF THE LOAVER EXTREMITIES. 619 was almost miraculous, proving conclusively how much, decision, boldness, and perseverance, hoAvever thwarted or disconcerted, may do to save human life, Dr. Paul thinks, that the tying of the femoral beloAV the profunda, Avould be sufficient, if the blood should come from the femoral itself; but if it comes from any branch of the profunda, the main artery must be secured above where the profunda comes off. In the instance above, not knowing the source of the hemorrhage, he tied the common femoral nearly an inch below Poupart's ligament, and this controlled at once the bleeding from the stump; but at the end of a fortnight, when the ligature sepa- rated, hemorrhage took place from this vessel. Pulsation continued very strong at the ligature, from the time of its application till it came away, evidently showing, says he, that no clot was formed; and the occurrence of hemorrhage, he adds, Avas no doubt owing to this not taking place. From this and other cases, he comes to the conclusion that a ligature on the common femoral is an unsafe operation; the cause probably being, as he thinks, the Avant of space there for the formation of a clot; for so many collateral branches are given off that the blood does not remain quiescent above the ligature. The return of pulsation to the common femoral, and the blood getting into this vessel on the thirty-first day after the external iliac was tied, and the reneAval of the hemorrhage from the common femoral on the forty-fourth day after the application of the ligature to the external iliac, must, he thinks, have been OAving in a great measure, if not entirely, to the retrograde motion of that fluid in the epigastric; for the circumflex ilii was divided and tied, in se- curing the external iliac. It appears, then, that placing a ligature on the external iliac, only cuts off the supply of blood from the common femoral for a certain time ; for, on the thirty-first day after tying the former vessel, pulsation Avas observable in the latter; and if the external iliac had been tied for aneurism in the groin, the operation Avould not have been successful Avithout, he thinks, again securing the vessel Avhere he did. In the last operation, con- tinues Dr. Paul, if I had not been certain that the circumflexa ilii had been previously secured, I Avould,on exposing the artery under Poupart's ligament, have dissected its trunk up tOAvards the point where it had been tied in the iliac region, and by this means I Avould have been enabled to tie both circumflexa ilii and epi- gastric arteries ; but the circumflexa ilii being impervious, secur- ing the femoral artery Avhere I did, under the crural arch, had the same effect as placing a ligature upon the epigastric itself, the source Avhence the blood came. In the treatment, then, of secon- dary hemorrhage after amputation of the thigh, if the bleeding vessel or vessels cannot be secured on the stump, I would, in the first place, tie the superficial femoral, at a sufficient distance below the origin of the profunda, on the ground that the blood came from the main trunk. This foiling, I Avould at once secure the external iliac rather than the common femoral; for the result of tying the latter vessel appears to be so unfavorable, that I believe it ought 620 NEW ELEMENTS OP OPERATIVE SURGERY. never to be thought of either to arrest secondary hemorrhage after amputation, or to cure aneurism, as hemorrhage from this vessel, on the separation of the ligature, so frequently happens. This case, to the same extent that it poAverfully strengthens the objections against a ligature upon the common femoral for any dis- ease, becomes also a cogent reason, if not an argument, in favor of availing ourselves of the ingenious and successful mode of employ- ing compression to this trunk, as adopted by the surgeons of Dub- lin for aneurism; (see our note on this subject, under Aneurisms, above ;) for if Avhat Dr. Paul says be true, the femoral must hence- forward be throAvn out of the category of arteries to which liga- tures can be applied. Not that Ave pretend that compression could, in a case like the above, be substituted for the necessity of a liga- ture someAvherc upon its trunk above the stump ; all we Avish to say is, that such cases show that, in dealing Avith the femoral as for popliteal aneurisms, Ave must come to something besides the liga- ture ; and this there is every hope for believing Drs. Hutton, Bel- lingham, and others of Dublin, have nearly or quite accomplished in their perfected compressors to the femoral trunk. (See a similar case of Dr. Mott's, under his Remarks on Aneurisms, &c., supra.) T.] § II.—Amputation at the Knee. A. The disarticulation of the leg, though obscurely alluded to by Hippocrates (De Articul, t. IL, p. 381, edit. Vanderlinden) and Guy de Chauliac, (Trad, de Joubert, p. 464,) and more clearly specified by Fabricius de Hilden, (Observat. Chirurg., p. 504,) did not, however, seriously attract attention until the last century. Not- withstanding the efforts of J. L. Petit, (Malad. Chirurg., t. III., p. 20,) Hoin and Brasdor, Avho endeavored to bring it again into re- pute, it Avas recommended by no one, and M. Blandin Avas almost the only person who had the courage to reproduce the arguments of Brasdor in favor of it; it was, in fact, an operation which at the first glance seemed destined to be proscribed from modern surgery, until I myself, in 1829, made the attempt to re-introduce it into practice. De la Rocque (Planque, Biblioth., t. V., p. 12, in 4to.) informs us of the case of a young girl seventeen years of age, Avho Avas am- putated at the knee, and recovered perfectly. In one of the cases mentioned by J. L. Petit, the amputation of the knee appears to have been had recourse to only because the instruments to perform it in the continuity were Avanting. The other Avas a young man who had both bones of the leg in a state of exostosis and caries throughout their Avhole extent. There is every reason to believe that these tAvo operations, of which J. L. Petit Avas a Avitness only, resulted in a perfect cure. A slater, Avho nineteen days before had fallen from a height of thirty-two feet, Avas received into the hospital of Dijon on the 26th of July, 1764. His leg Avas in a state of gan- grene as high up as the knee. Iloin (Mem. de I'Acad. Royale de Chir., t. V., p. 508, 1819) disarticulated the leg, and though there AMPUTATION OF THE LOWER EXTREMITIES. 621 were not soft parts sufficient to alloAV of immediate reunion, the man ultimately got Avell. In the month of July, 1771, he Avas still living, could use his Avooden leg Avith freedom, and ascended the scaffoldings and upon roofs as he had done before the accident. Gig- noux, (Ibid., p. 512,) of Valence, speaks of a young girl Avhose leg had been separated from the thigh by gangrene, and whose health for the last four years had been completely restored. Sabatier (Med. Opir., t. IV., p. 548., 1824) mentions having seen a boy in Avhoma ball had carried aAvay the leg Avithout Avounding the patella, but without being followed by any unpleasant consequences. Dr. Smith, (Journal des Progres, t. I., p. 240,) in the year 1824, disar- ticulated the leg in a young lady, who, ever since, has been enabled to Avalk by means of a wooden substitute. A scrofulous patient was amputated in the same manner, in the year 1824, at the hos- pital of Saint Louis, by M. Richerand. A variety of accidents, such as purulent abscesses and collections, it is true, at first alarmed the surgeon, but the Avound, nevertheless, ultimately cicatrized. M. Dezeimeris, in 1829, met, in the streets of Paris, Avith a male adult who had been amputated at the knee. This person could Avalk Avith ease, but by means of a cuish (cuissart) and Avithout using his stump as a point d'appui on the artificial leg. M. Bour- geois has told me that he has noticed a case in every respect simi- lar, at Etampes. Rossi considers this operation as very simple, and says he has performed it twice Avith success ; but the patient Avho was operated upon by M. Blandin, at the hospital Beaujon, died on the tenth day after the operation, in consequence of phlebitis. B. Appreciation.—Thus have we 14 authentic cases of amputa- tion at the knee joint, and of these, 13 cures; Avhich, it cannot be denied, is for the first, a most encouraging result. Amputation in the co- tinuity has certainly never furnished more satisfactory pro- portions. To those Avho Avould object that the amputation in the pa- tients of Gi^-.uux and Sabatier Avas performed as much by nature as by the surgeon; that gangrene had done part of the work in the Cases mentioned by Hoin; that that of M. Blandin ultimately died ; that all Avere young subjects, and could not use their stump for a long time ; Ave may reply:—l,that if the Avound properly closed after the spontaneous fall of the limb, or after gangrene had already commenced the division of the tissues, there is no reason Avhy it should be otherAvise Avhen the operation has been performed by art; 2, that the accidents to which one of the patients came near falling a victim, do not belong to disarticulation more than to pure and simple amputation of the leg, and that his death, Avhich occurred eight months after, Avas the result of his primary affec- tion ; 3, that Ave cannot see Avhy adults should have less chances of success from this amputation than young persons; 4, that the length of the cure must be imputed to peculiar circumstances, and pot tp the character of the operation ; 5, finally, that M. Smith had no complaint to make in respect to any of these inconveniences. B,ut let us continue the exposition of facts. 622 NEW ELEMENTS OF OPERATIVE SURGERY. In the month of January, 1830, I received into the Hospital of Saint-Antoine, an orphan boy, aged 19, Avho was addressed to me by M. Kapeler. The operation was fixed for the 14th of the same month. As there was not a sufficient quantity of soft parts remain- ing behind, I proposed to obtain a flap in front, of a certain length. The wound reunited but imperfectly. No accident happened, and though there still remained exposed a transverse surface an inch in Avidth from before backAvards, which the flaps would not cover, the cicatrix, nevertheless, Avas completed at the expiration of tAvo months. This patient, Avhom I have often since seen, enjoys the most perfect health. The stump bears and transmits the Aveight of the body to his Avooden limb Avith the same facility as if he had undergone only amputation in the continuity of the leg. A man, 29 years of age, of good constitution, and born in the colonies, Avas sent to me at the Hospital of Saint-Antoine on the 24th of May folloAving, by M. Thierry, who had been sent for to him for a comminuted fracture of the left leg. Gangrene soon made its appearance, folloAved shortly after by an ichorous suppuration, which becoming more and more copious, with pains excessively acute at the time of dressings, and even in their in- terval, and an almost continued febrile movement, with diarrhoea, &c, soon made me, on the other hand, entirely despair of saving the limb. I decided upon amputation at the knee, and perform- ed it on the 4th of June. The febrile reaction made it neces- sary to bleed on the first and second day. No accidents after- wards occurred up to the fifth; but on the sixth and seventh, a superficial erysipelas made its appearance, and reproduced the fever. In spite of this intercurrent phlegmasia, and of two small purulent patches, which formed at a later period at the angles of the condyles, and finally, of the consequences pvoduced by devia- tions in regimen, causing, in fact, a re:>l attack of indigestion, the cure was completed by the sixtieth day. In the month of July, 1830, I had to examine, at the Bureau of Hospitals, a young man aged nineteen years, who had been am- putated seven years before, and Avho came to ask for a new wooden leg. He told me that the operation had been performed upon him at the Hopital des Enfants. The cicatrix was behind, and though the inner condyle, from being an inch longer than the other, could alone rest upon the artificial limb, he has, nevertheless, ahvays been enabled to walk as Avell as if he had undergone amputation below the joint. Since that period, the disarticulation of the leg has been per- formed once Avith success, by M. Nivert of Azai-le-Rideau, on an adult man, who had his limb shattered by the discharge of a musket, (coup de feu.) M. Baudens, (Bulletin de VAcadbmie Royale de Medecine, t. I.,) has published an additional case; M. Chaumet has informed me of another successful one by M. Picho- zel; and an American surgeon has related to me that he has performed it twice with a fortunate result. Some other practition- AMPUTATION OP THE LOWER EXTREMITIES. 623 ers have not had the same good fortune. A patient operated upon by M. Jobert, (Plaies d'Armes-a-feu, p. 293,) died in consequence of suppuration in the thigh. M. Laugier, who performed it twice, lost both his patients, and I have seen myself four fatal termina- tions. It is true that in all of them the amputation Avas performed under the most unfavorable circumstances. I am informed by M. Blandin, that the state of his patient scarcely allowed of the slight- est hope, even before the operation. It Avas the same with tAvo pa- tients on Avhom I performed this operation at La Pitie, in 1831. The one an old man, with gangrena senilis, died on the twenty-eighth day in consequence of the mortification having reappeared in the stump. The other, an extremely fat woman, with an enormous encephaloid (cerebroide) cancer of the leg, which prevented me from preserving the integuments, except on the inner side, Avas at- tacked Avith an extensive suppuration throughout the body of the thigh, and with a large ulceration upon the sacrum ; she died on the sixty-second day, Avithout there ever having appeared, hoAvever, anything of a bad character in the Avound itself. One of M. Lau- gier 's patients had at the same time a comminuted fracture of the thigh; and one of those upon whom I have performed the opera- tion at La Charite, a Avoman seventy-six years of age, died, ex- hausted in consequence of the long continuance of her sufferings. I should add, hoAvever, that my fourth patient, who was a man of 47 years of age, Avas strong and in favorable conditions. I fear, therefore, that I may have exaggerated the safety of this operation when I attempted to revive it in 1830, (Archiv. Gen. de Med., t. XXIV., p. 44.) It remains proved, however, that the objections which have been made against it have no solid foundation: 1, By exposing, it is said, large and cartilaginous surfaces, we incur the risk of formidable accidents. But this cartilaginous plate which in- vests the condyles, is a protecting covering, (lame,) entirely destitute of sensibility, and which will remain for weeks tentirely denuded, without the slightest inconvenience resulting from it. As the pre- tended synovial membrane, Avhich Bichat has provided it with, does not exist, it is utterly impossible for this surface to become inflamed; 2, It produces an enormous wound, which it is next to impossible to cover by the surrounding soft parts. This is a mis- take. This wound, so vast in appearance, is reduced, on a close examination, to a division of the integuments, and some fibrous layers and muscles. Provided the skin can be preserved to the ex- tent of two or three inches, it is always quite sufficient to procure immediate reunion. 3, This wound is made on tissues Avhich are not capable of becoming inflamed to the degree required, or which do not allow of a prompt and solid cicatrix, as in the fleshy part of the limbs. Persons are deceived on this point as Avell as on the other. Nothing is better than the cutaneous tegument; this alone is perfectly adequate (propre) to the formation of a good cicatrix. Let the Avhole synovial surface of the condyles be covered Avith it. and it Avill agglutinate as Avell as upon the cut surface of a bone or large-sized muscles. 4. This operation being more painful and 624 NEW ELEMENTS OF OPERATIVE SURGERY. more difficult, is not followed by as rapid a cure as an ordinary amputation. This objection is not more solid than the preceding ones; as the facts above indicated sufficiently establish. 5. An- other objection, and one Avhich has been most insisted upon, is, that it leaves the patients after the cure in the same state as those Avho have had the thigh amputated, that is to say, that they are com- pelled to walk Avith a cuish instead of a Avooden leg. I confess that this, for a long time, Avas an objection in my mind. But this is one, in fact, which it is not necessary to discuss at present, as the cases I have related are before us to determine its just value. What then should be the reasons that ought to induce us to pro- scribe it ? After amputation of the thigh, however low down Ave may perform it, the point d'appui, for the artificial substitute, can only be made upon the ischium. The motions of the haunch are al- most completely abolished, and progression is made in the same way as if the coxo-femoral articulation Avas anchylosed. After disarticulation of the leg, hoAvever, the point d'appui is found at the extremity of the femur. The thigh preserves all its movements, and the patient is in the same condition as if he had a simple an- chylosis (soudure) of the knee. If it be true that, in respect to the functions of the limb, it is infinitely better to perform amputation of the leg in the continuity than to perform it upon the thigh, the ad- vantages of disarticulation at the knee should equally be deemed to be placed beyond all dispute, because the Aveight of the body is transmitted to the artificial limb in the same way after this last opera- tion as after the first. The wound in the one belongs almost en- tirely to the skin, and involves no bone and no aponeurosis ; the sur- face to cover is convex, regular, destitute of every kind of rough- ness, and has nothing to fear from muscular retraction. In the other, on the contrary, the solution of continuity comprehends a vast en- veloping aponeurosis and all its concentric laminae, muscles Avithout number and of considerable volume, a bone Avhich is denuded with the greatest facility and whose section produces a concussion (ebran- lement) Avhich is far from being ahvays Avithout danger, and,finally, the entire cellular tissue Avhich unites all these various parts. In the knee, one artery alone of any considerable size is divided; tor- sion or compression controls this almost Avith as much certainty and ease as the ligature. At the thigh, besides the principal artery, we have a multitude of secondary branches, Avhich all require to be tied Avith care. If the amputation of the leg in the contiguity is dangerous, it is because of the large and deep synovial cul-de-sac Avhich is pro- longed upon the sides of the condyles, and upon the anterior sur- face of the femur. Purulent inflammation, if once established in this cavity, becomes almost as formidable as in a great articulatioa Soon reacting upon the body of the thigh, it creates there a swell- ing, an erysipelatous blush, and a cakiness, (emp.itement,) which are not long in extending outAvardly to the hip—ending in suppurar tion and abscesses, which pervade the Avhole extent of the muscu- lar tissues. It was from these causes that three of my patient* AMPUTATION OF THE LOWER EXTREMITIES. 625 perished, as well as those of MM. Blandin, Jobert, and Laugier. The boy operated upon by M. Richerand experienced similar acci- dents ; and when they make their appearance, there is real cause for serious apprehensions. If this cause of dangers could be abstracted, my first opinion on amputation at the knee would re- main correct. The disarticulation of the leg, therefore, without be- ing a serious operation for the reasons put forth by the surgeons of the present time as by those of the last century, is, hoAvever, on the other hand, sufficiently so not to be undertaken Avhen it is pos- sible to amputate lower doAvn. 0. Operative Process.—The patella, which J. L. Petit re