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BY
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ELEMENTS
OF
SURGERY:
FOR
1f1i3 wsss 9&%©®sf®8s
WITH PLATES.
BY
JOHN SYNG DORSEY, M. D.
ROFESSOIl OF ANATOMY 1ST THE UNIVERSITY OF PENNSYLVANIA, ONE OF THE
fiUBOEONS TO THE PENNSYLVANIA HOSPITAL, AND TO THE
PHILADELPHIA ALMS HOUSE, &C.
IN TWO VOLUMES
WITH NOTES
BY J. RANDOLPH, M. D.
for want of timely care
Millions have died of medicable wounds.
AHMSTROJfGs
THIRD EDITION
VOL. I.
fmorv university :
THE A. W. CALHOUN MEDICAL UBR^jg- * |3
PHILADELPHIA: "C
JPT 3ED BY EDWARD PARKER, No. 178, MARKpi' .&T^EET
William Bro-wn, Print'r >t '
1823.
Eastern District o f Pennsylvania, to Sutt:
BE IT REMEMBERED, That 011 the tenth day of October, 111 the for¬
ty-eighth year of the Independence of the United States of America, A. D,
1823, Edward Parker, of the said District, hath deposited in this office the
title of a book, the right whereof he claims as proprietor, in the words fol¬
lowing, to wit:
" Elements of Surgery : for the use of Students; with Plates. By John
" Syng Dorsey, M. D. Professor of Anatomy in the University of Penn-
" sylvania, one of the Surgeons to the Pennsylvania Hospital, and to the
" Philadelphia Alms House, &c. In two volumes. Third Edition, with
"Notes, by J. Randolph, M. D. Vol. I. For want of timely care millions
" have died of medicable wounds.—Armstrong."
In conformity to the act of the Congress of the United States, intitled
" An act for the encouragement of learning, by securing the copies of maps,
charts, and books, to the authors and proprietors of such copies, during the
times therein mentioned—and also to the act, entitled, " An act supple¬
mentary to an act, entitled, ' An act for the encouragement of learning, by
securing the copies of maps, charts, and books, to the authors and proprie¬
tors of such copies during the times therein mentioned,' and extending the
benefits thereof to the arts of designing, engraving, and etching historical
and other prints."
D. C \LDWELL,
Clerk of the Eastern District of Pennsylvania.
>
TO THE
STUDENTS OF SURGERY
THROUGHOUT THE UNITED STATES,
THIS
IMPERFECT ATTEMPT
TO FACILITATE THEIR STUDIES
IS VERY RESPECTFULLY
INSCRIBED,
5
o
n/*
ADVERTISEMENT
TO THE
SECOND EDITION.
A second edition of the " Elements of Sur¬
gery" being demanded, an opportunity is af¬
forded for additions and corrections, in some
degree corresponding with the present improv¬
ed state of Surgery.
The work was originally intended chiefly as
a text book " for the use of Students" in the
University of Pennsylvania, and to this purpose
it has been found sufficiently adapted. The
author has, however, had the additional gratifi¬
cation to find that it has been employed by pub¬
lic and private teachers, in various parts of his
native land; and flattering testimonials in its fa¬
vour, have also reached him from foreign coun¬
tries.
Thus sanctioned, he ventures to lay before
the public a new edition, conscious of its im¬
perfections, but confident that they will not be
scanned with illiberality, nor condemned with
rigour.
Philadelphia, LSt November, 1818.
PREFACE.
Numerous circumstances combine to ren¬
der necessary an A merican Epitome of Practi¬
cal Surgery; those members of the medical
profession who, by talent and experience, are
best qualified to compose it, are fully occupied
by other duties, and indifferent to that species
of reputation which might accrue from such a
publication; the labour has therefore, in the pre¬
sent instance, devolved upon one in many re¬
spects inadequate to the performance, and fully
sensible of the imperfections of his work.
An American, although he must labour un¬
der many disadvantages in the production of an
elementary treatise, is in one respect better
qualified for it than an European surgeon. He
is,—at least he ought to be,—strictly impartial,
and therefore adopts from all nations their re¬
spective improvements. Great Britain and
France have been foremost in the cultivation
f modern surgery, but their deficiency in phi-
Viii PREFACE.
losoplric courtesy and candour has in some in¬
stances greatly retarded its progress; to illus¬
trate this remark, it will be sufficient to state
that the doctrines of adhesion so ably develop¬
ed in England have been shamefully neglected
in France; and that French surgery in frac¬
tures finds no advocates in Britain. Some of
the best writings of Desault have never been
translated into the English language,* and
those of John Hunter are unknown or disregard¬
ed throughout the continent of Europe. This
spirit of hostile rivalship, extending from the
field of battle to that of science, cannot fail to
exert a pernicious influence on practical sur¬
gery,—a truth too palpable to escape the ob¬
servation of any foreigner who visits an Euro¬
pean hospital. An American, in walking their
wards, sees with surprise, in London, a fractur¬
ed thigh rudely bound in bundles of straw, and
the patient discharged limping with a crooked
limb. In the French capital he witnesses an
amputation, and is disgusted by the officious
zeal with which the surgeon crams a handful
*1 am happy to state that Mr. Dobson is now publishing a
translation of two very interesting volumes of Desault, for which
the public will be indebted to the industry of Dr. E. D. Smith
of South Carolina
PREFACE. 'ix
of lint between the stump and the flap which
covers it, with an express design to prevent
their adhesion. It is difficult to reconcile
these facts with one equally true, that among
the most distinguished men who have ever
adorned the profession of surgery, are living
characters in London and Paris.
As the present work is intended chiefly for
the use of students, it is to be considered in the
light of a mere introduction to other surgical
writers, and that ceremony over, a particular
acquaintance with them is earnestly recom¬
mended to every one who intends to practice
this important branch of the healing art.
Before closing these prefatory observations,
1 take the opportunity of disclaiming, except in
a few instances, all pretensions to originality.
I have availed myself freely of the writings of
preceding authors, and my extracts are in many
instances of very unusual length; the only apo¬
logy I shall offer for this liberty is, that i have <
considered it the most useful and honest me¬
thod of communicating information. Having
made this acknowledgment, 1 shall now state,
that I believe there will be found in the follow¬
ing work many observations of practical im
vol. i.—b
X PREFACE.
portance, which are not contained in any other.
These 1 principally owe to my connexion with
Dr. Physick, and a careful attention to his prac¬
tice during a period of lifteen years. Whether
my readers will estimate them as I do, remains
to be ascertained.
In the succeeding pages my chief attention
has been directed to practical precepts, and
these I have endeavoured to deliver with clear¬
ness; 1 am not without a hope that they will
prove useful not only to medical students, but
also to country practitioners, and to the younger
surgeons in the navy and army.
An apology is due for the manner in which
some of the engravings are executed, but I
trust they will be found less deficient in correct¬
ness than in elegance.
It has been well remarked by Mr. John Bell,
that " a book once published is like a life come
to its final consummation ;—irrevocable ; -
needing no apologies if generally good, admit¬
ting none if it be not so » If any author, how¬
ever, my justly claim the lenity of criticism, it
is the medical practitioner, who writes and pub¬
lishes under circumstances every way hostile
PREFACE. XI
to correct composition, and detects in his pro¬
gress defects and errors, when the printer's
stamp, like that of fate, has fixed their perpe¬
tuity.
Philadelphia, Nov. 1st9 1813*
EDITOR'S PREFACE.
Two large editions of this work having been
exhausted, and its lamented author, after the
preparation, but before the publication of the
last edition, having closed the career of his
useful labours, the present editor, at the soli¬
citation of the publisher, consented to superin¬
tend the publication of this edition, sensible
that he could not render a more useful and ac¬
ceptable service to the medical student, than to
present to him an edition of this highly esteem¬
ed elementary work, with annotations embrac¬
ing some of the more important discoveries and
improvements which, within the five years last
past, have enriched the department of surgery.
In the performance of this duty, the editor has
studiously endeavoured to confine himself ex¬
clusively to the enumeration of those improve¬
ments which experience has sanctioned, and by
rendering his notes as concise and practical as
possible, trusts he has conformed them to the
didactic character of the original work, which
its distinguished author never intended should
xiv EDITORS PREFACE.
be considered as a complete treatise, but rattier
as an elementary compend of the principles and
practice of surgery, as then taught in the Uni¬
versity of Pennsylvania.
The editor flatters himself that his labours
will be esteemed of some value by those for
whom the work was originally intended, and
hopes any omissions and errors in the notes will
be viewed with indulgence, when it is recollect¬
ed that they were hastily prepared while the
work was passing through the press.
Philadelphia, October 1st, 1823.
CONTENTS OF VOL. I.
CHAPTER I,
Page
General remarks on accidental injuries, and their effects, 1
Union by the first intention, - 2
Ecchymosis, 3
CHAPTER II.
Of inflammation, - - ... .4
CHAPTER III.
Of hectic fever, - - - - - 13
CHAPTER IV.
Erysipelatous inflammation, - - - - 15
CHAPTER V.
Of (Edematous inflammation, - - - - 18
CHAPTER VI.
Of gangrene and mortification, - - - 20
CHAPTER VII.
Of burns, ----- - 33
CHAPTER VIII.
The effects of cold, - - - - 37
Chilblain, ----- 38
xvi
CONTENTS.
Page
CHAPTER IX.
Of wounds, - 41
Of incised wounds, -
05 hemorrhage, - - - - ib.
CHAPTER X.
Of contused wounds, - - - -59
Lacerated wounds, - - - ib.
Punctured wounds, - - - ib.
CHAPTER XI.
Of gunshot wounds, - - - - 63
CHAPTER XII.
Of poisoned wounds, - - - -72
CHAPTER XIII.
Of particular wounds, - - - - 77 -
Wounds of the scalp, - - - ib.
Wounds of the face, - - - 78
Wounds of the eye, - - - ib.
Wounds of the lip, - - - ib.
Wounds of the tongue, - - - ib.
Wounds of the throat, - - - 79
CHAPTER XIV.
Of wounds penetrating cavities, - - - 84
Wounds of the thorax, - - - ib.
Emphysema, - - 93
CHAPTER XV.
Wounds penetrating the abdomen, - . 97
Wounds of the abdominal viscera, - -
CHAPTER XVI.
Wounds of joints, - - \ 07
CONTENTS.
CHAPTER XVII.
Wounds of nerves and tendons,
Wounds of veins,
CHAPTER XVIII.
Of fractures, -
Compound fractures,
CHAPTER XIX.
Particular fractures,
Fractures of the ossa nasi,
CHAPTER XX.
Fractures of the lower jaw,
CHAPTER XXI.
Fractures of the vertebm,
CHAPTER XXII.
Fractures of the ribs,
CHAPTER XXIII.
Fractures of the sternum,
CHAPTER XXIV.
Fractures of the bones of the pelvis,
CHAPTER XXV.
Fractures of the scapula,
CHAPTER XXVI.
Fractures of the clavicle,
CHAPTER XXVII.
Fractures of the os humeri,
VOJj. I.—c
xviii
CONTENTS.
CHAPTER XXVIII.
Fractures of the fore-arm,
CHAPTER XXIX.
Fractures of the wrist and hand,
CHAPTER XXX.
Fractures of the thigh,
CHAPTER XXXI.
Fractures of the patella,
CHAPTER
Fractures of the leg,
CHAPTER
Fractures of the bones of the foot,
CHAPTER
Of wounds of bonest
Exfoliation,
CHAPTER
Of dislocations,
CHAPTER XXXVII.
Of particular dislocations, -
Dislocation of the lower jaw,
CHAPTER XXXVIII.
Dislocations of the vertebras,
CHAPTER XXXIX.
Dislocations of the bones of the pelvis and thoraxt
CHAPTER XL.
Dislocation of the clavicle,
XXXII.
XXXIII.
XXXIV.
XXXV.
CONTENTS xix
Page
CHAPTER XLI.
Dislocations of the os humeri, - - 243
CHAPTER XLII.
Dislocations of the fore-arm, ... 251
CHAPTER XLIII.
Dislocations of the hand, - - - 257
Luxations of the bones of the carpus and me¬
tacarpus, - 259
Luxations of the fingers, ... 260
CHAPTER XLIV,
Dislocations of the thigh, - 264
CHAPTER XLV.
Dislocations of the patella, - - 276
CHAPTER XLVI.
'' " Of internal derangement of the knee joint" - 278
CHAPTER XLVII.
Dislocations of the bones of the leg, - - 282
CHAPTER XLVIII.
Of Dislocations of the foot, ... 285
CHAPTER XLIX.
Injuries of the head, - - - 291
CHAPTER L.
Of concussion of the brain, - - 293
CHAPTER LI.
Of compression of the brain, - - - 298
from effused blood, - - ib.
XX
CONTENTS
Page
from depressed bone, - - 306
Of inflammation of the brain and its mem¬
branes from external violence, - - 310
Operation of trepanning, - - - 311
Hernia cerebri, - - - - oak
CHAPTER LII.
Diseases of the eye and its appendages, - - 329
Inflammation of the eye-lids—psorophthalmy—
lippitudo—hordeolum, - - 329—331
Ectropium, - - - 331
Entropium, - - 332
Lagophthalmy, - 335
CHAPTER LIII.
Of ophthalmia, ----- 336
CHAPTER LIV.
Unguis or pterygium, ... - 343
CHAPTER LV.
Opacity of the cornea and artificial pupil, - - 346
Ulcers of the cornea, - 348
CHAPTER LVI.
Fistula lachrymalis, - - - - 350
CHAPTER LVII.
Of cataract, - - - - •- 356
CHAPTER LVIII.
Of extraction, - - - - - 367
CHAPTER LIX.
Of couching, ----- 374
CHAPTER LX.
Of congenital cataract, - - - 381
CONTENTS.
Hypopion,
Staphyloma,
CHAPTER LXI.
Extirpation of the eye,
Tapping of the eye,
CHAPTER LXII.
Of polypus, -
CHAPTER LXIII.
Of ranula, -
CHAPTER LXIV.
Of salivary fistula,
CHAPTER LXV.
Of abscess of the antrum maxillare,
CHAPTER LXVI.
Diseases of the tongue,
CHAPTER LXV1I.
Diseases of the uvula and tonsils,
CHAPTER LXVIII.
Of foreign bodies in the (esophagus,
CHAPTER LXIX.
Of strictures of the oesophagus,
CHAPTER LXX.
Of obstructions in the glottis and trachea,
Operation of laryngotomy,
CHAPTER LXXI.
Accidents and diseases of the ear,
... V . „
n
.
.
.
-
.._
j
ELEMENTS
OF
SURGERY.
CHAPTER I.
General Remarks on Accidental Injuries, and their
Effects.
It is the business of the surgeon to provide remedies
for the various accidents to which the human body is
liable; the treatment of many of its diseases is also com¬
mitted to his care. As accidental injuries are more
simple and intelligible than diseases, it will be proper
to commence an elementary work on surgery with some
general explanations of their nature and effects.
The most simple accident, which can possibly occur,
appears to be that degree of concussion, " in which the
only effect produced, is a debility of the actions or func¬
tions of a whole or part, similar to that occasioned by
a bruise, in which the continuity of the substance is
not interrupted; in such a state, the parts have little to
do, but to expand and reinstate themselves in their na¬
tural position, actions, and feelings; and this is what
happens in the concussion of the brain.v
The rupture of a small blood-vessel is perhaps the
next in order of simplicity; when the continuity of the
jk. VOL. I.—A
te ■
o
ELEMENTS OF SURGERY.
part is broken, extravasation takes place, and the blood
is effused into the common cellular membrane, into the
interstices of some part, or into a circumscribed cavity.
But should the vessel be either very large, or essential
to life, such as the femoral, bracheal, or coronary ar¬
teries; or should the rupture take place in a vital part,
as the brain, in such cases the injury may kill from the
extravasation alone, however inconsiderable may be the
original mischief.
Another species of injury is that in which the rup¬
tured parts have an external opening, constituting a
wound. The nature and circumstances of wounds will
be considered in another place. The operation of res¬
toration in this case consists, first in the coagulation of
the extravasated blood between the ruptured parts lay¬
ing as it were the foundation of union, next in closing
the ruptured vessel, or in promoting its inosculation,
and afterwards in bringing about an absorption of the
superfluous coagulated blood. Whether in these cases
a new portion of vessel is formed, or whether the origi¬
nal vessel re-unites without the intervention of a new
cylinder, is not easily determined.
This mode of restoration is called union by the first
intention; it is evident that it can only happen in cases
where the extent of the divided parts is small, and their
surfaces nearly in contact. In this case, the blood ef¬
fused by the accident is the bond of union, and it evi¬
dently becomes living flesh.
When the quantity of blood poured out is very great,
even in parte not essential to life, considerable incon¬
venience results from the inability of the absorbents to
remove it. An effusion of blood under the skin, or in
* Fractures of tendons, simple fractures of bones, and many other in
juries, in which there is no external communication, are considered by Mr
Hunter as similar in nature to this accident.
ELEMENTS OF SURGERY.
the interstices of any part of the body, is called Ecchy-
mosis, and in some cases calls for surgical treatment.
As the subject will not be resumed, I shall state here
the proper remedies. They are rest, moderate pres¬
sure, and cold applications; as cold lead water, cold vi¬
negar and itater, fyc. by the use of these means the
blood will generally be absorbed, during which process
the skin, which had been of a dark purple colour, be¬
comes blue, green, yellow, and assumes a variety of
hues. The blood most frequently in Ecchytnosis co¬
agulates, but it sometimes remains fluid; and in this
latter case, is apt to inflame and suppurate; to prevent
which, a puncture should be made with a lancet into
the cavity containing the blood, which must be emptied
by gentle pressure. After which care should be taken to
approximate the sides of the puncture, that they may
speedily unite. If, notwithstanding these remedies, the
parts inflame and suppurate, the case is to be treated
like any other abscess. If, from this, or any other
cause, union by the first intention is prevented, another
mode of restoration is effected by means of inflamma¬
tion.
4
ELEMENTS OF SURGERY
CHAPTER II.
Of Inflammation.
A complete acquaintance with this subject is essen¬
tial to every practitioner of surgery. In the following
remarks I shall endeavour to describe its phenomena
without attempting to investigate the theories which
have been formed to explain them.
Inflammation generally commences with an increas¬
ed sensibility of the part; pain is soon perceived, attend¬
ed with heat, redness, and tumefaction; the pulsation of
the arteries in the inflamed parts occasions a throbbing,
which in some situations is very distressing to the pa¬
tient, as when the inflammation is seated in one of the
fingers. The pain is attributed by Mr. Hunter to a
spasm of the vessel, analogous to cramp, tetanus, &c.
The tumefaction is owing to the enlarged diameters of
the vessels, and to the effusion of serum and coagulat¬
ing lymph in their interstices. The heat of an inflamed
part never transcends the heat of the animal at the
source of circulation, though the sensation would lead
to a contrary belief.*
Inflammation is divided by surgeons into healthy and
diseased. By healthy is understood, that which has
for its object the restoration of injured parts; by dis¬
eased, that in which some morbid peculiarity is super¬
added to the simple act of inflammation, as in erysipe¬
las, carbuncle, &c.
The remote causes of healthy or phlegmonous inflam-
* The heat and redness are probably owing to the increased rapiditv ot
circulation; but in what particular manner is not clearly understood.
ELEMENTS OF SURGERY.
5
illation, are various irritations of a mechanical or che¬
mical nature; wounds, bruises, acrid substances, &c.
Sometimes inflammation appears to arise as a conse¬
quence of febrile diseases, forming what has been called,
critical abscess; and in other instances no evident cause
can be assigned: these cases are very improperly con¬
sidered spontaneous, as they have certainly a remote
cause, although it be not obvious.
The 'proximate cause of inflammation has been a
source of much theoretical discussion. Mr. Hunter
considered it as an increased action of Jjhe blood-ves¬
sels, and this at the present time is a generally received
opinion.*
A variety in the exciting cause seems to have no ef¬
fect in varying the nature of healthy inflammation;
though different circumstances of the constitution or
part, affect its progress very materially. Strength of
constitution; a vigorous circulation of the blood; and
* On this subject see Hunter on the blood, &c. and also Dr. Wilson's Es¬
says on Febrile Diseases, in which the doctrines of Mr. Hunter are ingeni¬
ously, though I think, unsuccessfully opposed. Mr. John Pearson, with his
usual accuracy, remarks, " by proximate cause is to be understood a real phy¬
sical cause, so inseparably connected with the disease, that the presence of
the one implies the agency of the other: upon the existence and duration
of the proximate cause, depends the existence and duration of the disease;
and if the former be changed, there is a correspondent change in the lat¬
ter." This is precisely what Dr. Rush means when he declares, in the Ian-
guage of Gaubius, the proximate cause of a disease to be, " ipse morbus."
That mere increased action is not the proximate cause of inflammation, can
easily be proved. Now since the action of inflammation is altered from
healthy action, and since we cannot tell in what this alteration consists, it
appears to me best to confess, that in the present state of our knowledge,
the proximate cause of inflammation is not distinctly known. The degree
of action in inflammation varies very greatly; sometimes it is feeble, and
sometimes violent. The nature of the altered action of vessels in inflamma¬
tion, is not more likely to be discovered, than the nature of those actions
which in the liver form bile, in the kidneys urine, &c. The mere alternate
contraction and dilatation of blood-vessels offer no explanation on any of
these subjects.
6
ELEMENTS OF SURGERY.
vicinity to the source of circulation, are circumstances
highly favourable to its progress, and under opposite cir¬
cumstances, inflammation frequently terminates unfa¬
vourably. The legs, when inflamed, heal much less
readily than the superior parts of the body. The co¬
lour also of an inflamed part, depends on similar circum¬
stances. An inflamed leg is darker than an inflamed
arm. When seated in very vascular parts, as skin, cel¬
lular membrane, muscle,—it is more rapid in its pro¬
gress and more favourable in its termination, than ill
those which are less so; as bone, tendon, or ligament.
As an exception to this remark, however, we must state,
that when inflammation attacks vital parts, notwith¬
standing their great vascularity, it does not proceed so
favourably as in those of a similar structure, which are
less essential to life.
Healthy inflammation is always greatest at the part
nearest the external surface of the body. When it at¬
tacks the socket of a tooth, it affects the external part
next the cheek; when it occurs in the vicinity of the
rectum, it affects the skin and cellular texture, leaving
the intestine sound.
The effects of local inflammations upon the constitu¬
tion, depend much on their extent and situation. Where
they are small, very little inconvenience results; where
they are extensive, or seated in vital parts, greater irri¬
tation, and considerable fever, are the consequences.
Inflammation occurring under a tendinous fascia, pro¬
duces more effect on the constitution than the same de¬
gree of inflammatory action in other parts. The fever
produced is called symptomatic, and is generally attend¬
ed with a quick, tense, full pulse, and sizy blood *
* In forming a judgment of the effects of inflammation on the constitution
particular regard must be had to the original construction and prevailing
condition of the system. Some persons are very seriously affected by slight
ELEMENTS OF SURGERY.
7
Healthy inflammation is always attended by one ol*
more of the following effects—an adhesion of the in¬
flamed parts, one to another; the formation of pus, and
the removal of portions of the body by the absorbent
vessels. The uniform occurrence of these effects in¬
duced Mr. John Hunter to describe inflammation in
three different stages; the adhesive,suppurative, and ul¬
cerative. The various parts of the body differ in their
susceptibility of adhesion,, suppuration, and ulceration.
The cellular membrane; the circumscribed cavities, as
the abdomen, thorax, tunica vaginalis, very readily form
adhesions:—Mucous membranes, on the contrary, as
the nose, mouth, alimentary canal, the air-cells of the
lungs, the trachea, &c. very seldom adhere, but readily
suppurate. It is generally found that deep-seated parts
suppurate less readily than superficial: hence, if a mus¬
ket-ball be lodged at any considerable depth in the
body, it excites adhesive inflammation, and a cyst forms
round it; but if it be lodged nearer the surface, it pro¬
duces suppuration, an abscess forms, and it is discharg¬
ed.
The symptoms of inflammation which have been de¬
scribed, exist very evidently in the adhesive stage, but
when suppuration is about to commence, they are great¬
ly aggravated ; the pain and throbbing become more
violent, the heat is augmented, the swelling is more
prominent, the colour more intense, and approaching
to a pale scarlet. Shivering fits come on, the swelling
grows softer, and matter is formed, fluctuation may be
perceived by examination with the fingers : an imme¬
diate abatement of the symptoms now takes place.
If the inflammation be seated in the cellular mem-
attacts, while others can bear most extensive inflammations without much
apparent inconvenience. We have known a slight scratch from a thorn
produce such violent inflammation and fever, as to jeopardize the life of
the patient, Ed,
s
ELEMENTS OF SURGERY.
brane, the process of ulceration now commences, and
the absorbent vessels remove the solid parts of the body
to make room for the lodgment of the pus secreted,
and also to prepare a way for its escape. In this man¬
ner an Abscess is formed, which may be defined a cir¬
cumscribed cavity, containing pus. In a common phleg¬
monous abscess, we have a good example of the three
effects of inflammation which have been briefly noticed.
At its margin, where the inflammation is least violent,
the inflamed vessels secrete coagulating lymph, which
agglutinates and firmly unites the cells of the cellular
texture, circumscribing the cavity, and preventing the
escape of the matter into the surrounding parts. To¬
wards the centre of the abscess inflammation has tran¬
scended the adhesive stage, and the blood-vessels have
relieved themselves by a secretion of pus. This process
immediately excites the action of the absorbing vessels,
which remove the solid matter to form a cavity to con-
lain this pus.
The natural cure of an abscess consists in the ab¬
sorption of all the solid matter intervening between the
pus and the cuticle, by the rupture or bursting of which,
an outlet is made for the evacuation of the cavity, after
which small projecting vascular spots appear, in every
part of it, called granulations, which are formed of the
coagulating lymph of the blood, which fill up gradually
the cavity, and unite one with another, forming solid
flesh—a formation of cuticle takes place on the sur¬
face, and thus the parts are restored nearly to their pris¬
tine state.*
The terminations of inflammation are various. In
some instances it terminates by what is called resolu¬
tion. In this case all the symptoms gradually subside}
* For a particular account of the process by which cavities are filled up
I refer to Mr. Hunter, and a paper by Mr. James Moore.
1
ELEMENTS OF SURGERY.
9
and the parts are restored to their natural colour and
appearance.
The secretion of pus, already noticed, is to be consi¬
dered one of the terminations of inflammation. A se¬
cretion oj serum frequently puts a stop to the inflamma¬
tory process. The inflammation from cantharides ter¬
minates in this way. Instances of this we see also in
inflammation in the brain, ending in hydrocephalus. In
the thorax, terminating in hydrothorax, &c.
Hemorrhagy has occurred in some cases, and put an
immediate stop to inflammation.
Hard tumours occasionally form by the secretion of
coagulating lymph in the interstices of parts, and this
has been called a termination of inflammation in scirrhus.
In other instances the violence of action or the kind
of action exhausts the vital powers of the inflamed part,
and the inflammation terminates in mortification.
treatment op inflammation.
In the treatment of inflammation the first object is,
to remove if possible the remote causes, if they continue
to act. The next is to lessen the inflammatory action.
The remedies to effect this latter object are general, or
constitutional, and local. Those which act on the con¬
stitution are,
1st. Blood-letting. This is a powerful remedy in
the treatment of inflammation. The quantity of blood
to be drawn, and the frequency of its repetition, can
only be estimated by the violence of the inflammatory
symptoms. Whenever parts essential to life are in¬
flamed, as the brain, or the contents of the thorax, or
abdomen, repeated and copious bleedings become ne¬
cessary.
2d. Low Diet—Tends not only to diminish the fuk
VOL. I.—B
10
ELEMENTS OF SURGERY.
liess of the vessels, but also to lessen irritation, am
should be strictly enjoined.
3d. Purging is often necessary in the treatment of
inflammation. But in many cases it is inconvenient 011
account of the necessity which it occasions for moving
the patient, as in cases of fractured bones. Blood¬
letting must therefore be substituted.
4th. Certain Neutral Salts—Sulphate of Soda.
Sulphate of Magnesia, Nitrate of Potash, &c. are use¬
ful, by promoting the secretions, and are generally com¬
bined with preparations of antimony ; in which case
they occasion nausea, and diminish the action of the
blood-vessels.
5th. Rest is essential, for motion occasions irritation,
and many inflammatory affections are found difficult of
cure, because the inflamed parts cannot be kept at rest;
fistula in ano affords an illustration of this remark.
6th. Position. The posture of the body should be
such as to favour the return of blood from the inflamed
part. In many local inflammations, posture is of ex¬
treme importance. The elevation of the feet in cases
of inflammation on the lower extremities, is found
highly useful. It forms indeed one of the methods of
depleting by emptying the blood vessels of the affected
part.
7th. Opium may be given to relieve pain in some
cases.
The local remedies, are, 1st. Bleeding from the in¬
flamed part by cupping, leeches, and scarifications.
Local blood-letting is most effectual after general bleed¬
ing has been premised.
2d. Cold Applications are sometimes of service
but they should only be carried so far as to be pleasant
to the feelings of the patient. A very common appli¬
cation which is intended to reduce the temperature of
elements of surgery.
11
inflamed parts, is a solution of sugar of lead, with or
without the addition of vinegar. 3j of acetate of lead,
to §iv of water, answers the purpose as well as any-
other preparation. It is to be applied on linen rags ;
and, as it soon acquires the temperature of the part,
these rags should be often changed.*
3d. Blisters are, in certain cases, of great use in
diminishing inflammation. They must be applied di¬
rectly over the inflamed part; and in many cases, pro¬
duce a speedy cure.
All these remedies tend, by diminishing the violence
of inflammation in its adhesive stage, to prevent suppu¬
ration, which is generally to be attempted : but cases
occur in which this event is desirable, and others in
which it is inevitable. The best application in such cases
is a soft poultice of bread and milk, with the addition
•of a little sweet oil, or fresh lard; or ground linseed and
water.
When suppuration has taken place, and a fluctuation
of matter can be perceived, if it be not soon evacuated
by absorption, it becomes necessary to expedite the cure
by an artificial opening.
Abscesses should be opened early, when situated
near the larger cavities of the body, as the thorax or
abdomen, instances having occurred in which they have
discharged their contents into these cavities, occasion¬
ing fatal consequences. In paronychia, or other very
painful collections of matter, especially where the pus
is confined under a tendinous fascia, an early opening
should be made;—when situated near large joints;—
when they impede respiration or deglutition;—when
* By adding to these lotions a solution of opium, some laudanum, or a
strong infusion of the humulus lupulus or common hop, we allay the pain¬
ful irritation of the part, mitigate considerably the sufferings of the patient,
and accelerate the cure.—Ed.
12
ELEMENTS OF SURGERY.
they occasion nervous fever, or other constitutional at-
fections, they should be opened early. The best ap¬
plication after the cavity of an abscess is evacuated is a
soft linseed or bread and milk poultice.*
There are two ways of opening abscesses; by inci¬
sion or puncture, and caustic. The lancet is to be pre¬
ferred whenever we can choose; if the patient, how¬
ever, from great fear of a cutting instrument obstinately
refuses to submit, caustic may be substituted—a piece
of caustic vegetable alkali rubbed over the part eight
or ten minutes, will occasion a slough and give vent to
the pus.
The properties of pus have been well described by
Mr. Home. It is a light straw coloured fluid of the con¬
sistence of cream, composed of globules swimming in
a fluid, which fluid is coagulable by muriate of ammo¬
nia—a property which distinguishes pus from all other
animal fluids. Healthy pus is perfectly bland, free from
all acrimony. It is heavier than water, and sinks in it
without mixing. Pure pus does not readily putrefy; but
when mixed with blood or extraneous matter it ferments
and becomes putrid, acquiring a fetid smell, and is now
acrid and irritating. It is evidently a secreted fluid
poured out by the inflamed vessels which assume the
nature of a gland.
* A very ready mode of preparing the linseed poultice, is to mix the lin¬
seed meal with warm water until it acquires a proper consistence. If the
linseed meal be not at hand, it is easily prepared by passing common flax¬
seed through a coffee-mill.
ELEMENTS OF SURGERY.
IS
CHAPTER III.
Of Hectic Fever.
Fever results from every extensive local inflamma¬
tion. This fever is called symptomatic, but if the local
disease continue for a great length of time, and until
the system is weakened, febrile symptoms of a very dif¬
ferent character ensue and constitute what is called
hectic fever.
The symptoms of hectic, are, great weakness; a fre¬
quent small pulse, a moist skin, copious flow of urine,
moist tongue, loss of appetite, nausea, occasional vomit¬
ing, night sweats, diarrhoea, frequent chills succeeded
by flushes of heat; watchfulness to a distressing degree,
and flatulency together with the several symptoms of
indigestion.
Hectic fever has been ascribed by Dr. Cullen and
many others to the absorption of pus. This opinion is
however without foundation, and many facts concur to
prove that copious absorption of matter may take place
without hectic fever, and many cases of hectic fever
occur unattended by an absorption of pus. Of the
former we have examples in the absorption of matter
from buboes and other abscesses, which are not follow¬
ed by symptoms of hectic, and of the latter we have in¬
stances in those cases of scrofulous joints in which hec¬
tic fever precedes suppuration, an occurrence by no
means unusual.
The cure of hectic fever will in vain be attempted,
whilst the local disease which gives rise to it continues.
If the local inflammation be absolutely incurable, and
in such a situation as to admit removal by a surgical
14
ELEMENTS OF SURGERY.
operation, this ought always to be done. The effects
of removing even a small local irritation, are in some
instances truly astonishing. Patients apparently on the
brink of the grave, become convalescent in a few hours.
If however the part can neither be cured nor remov¬
ed, the strength of the patient must be supported by an
invigorating diet and tonic remedies. The Peruvian
bark and opium are here valuable medicines, and must
be administered according to the exigency of the case.*
* Exercise in the open air, when the state of the atmosphere, and the
circumstances of the local disease will admit of it, will be found one of the
most valuable means for counteracting the debilitating effects of this fever
Ed.
V
ELEMENTS OF SURGERY,
15
CHAPTER IV.
Erysipelatous Inflammation.
This has been considered a disease of the cutis vera;
it differs from healthy inflammation in many circum¬
stances. It commences at a particular spot and very
rapidly extends itself, sometimes over a large portion
of the body. In some cases it is preceded by a chill
and general fever, in other cases the local affection is
first observed.
The colour of the skin when affected with erysipelas
is a bright scarlet. There is less tumefaction than in
phlegmon, but yet some elevation of the inflamed part,
and a decided line of distinction where it terminates.
Pressure on the skin causes the redness to disappear,
but on removing it the colour quickly returns. The
pain differs from that of phlegmonous inflammation ; it
is of a burning kind, and attended" in many instances
with intolerable itching, especially when seated on the
nates and perineum. When it occurs in the face, it is
attended with greater tumefaction than in any other
part, and is more dangerous. The cellular membrane
around the eyes is much swollen and appears as if dis¬
tended with a fluid having a semi-pellucid appearance.
In some cases it is attended with vesications, which con¬
tain a fluid somewhat acrid, when these burst, scabs are
formed and a sore beneath them.
In erysipelas there is never a secretion of coagulating
lymph. It either terminates in resolution, or in a kind
of suppuration, or else in gangrene. When suppura¬
tion takes place, as there is no secretion of coagulating
lymph to circumscribe the abscess, the pus travels
h
16
ELEMENTS OF SURGERY.
through the cells of the cellular membrane, occasioning
violent inflammation and gangrene, the parts slough
out, and have a very strong resemblance to wet tow.
I have seen death occasioned in such a case by the very
extensive diffusion of the matter through the cellular
texture producing mortification wherever it went.
Where the affection is limited in extent and moderate
in degree, it generally gets well in a week or ten days,
the skin casting off its cuticle in small flakes like bran.
The constitutional symptoms are in many cases very
severe, great debility, head-ache, nausea, vomiting fol¬
lowed by violent fever and delirium.
The remote causes of erysipelas cannot be distin¬
guished from those of common inflammation. The
state of constitution, appears to influence them in
producing phlegmon in some cases and erysipelas in
others.
TREATMENT.
The remidies are the same as for common inflamma¬
tion. Bleeding is generally indicated; purging—low
diet—neutral salts, and antimonials are to be adminis¬
tered according to the exigency of the case. In Lon¬
don, bark and tonics are very frequently exhibited with
advantage, but an opposite plan of treatment is requir¬
ed in America. As a local application, rye meal or
wheat flour is found pleasant and useful; poultices and
all unctuous substances do mischief. Cold lotions are
sometimes used with advantage; a solution of acetate of
lead is the best. Blisters are a remedy of great effica¬
cy; in some instances they occasion an immediate ces¬
sation of the disease. The late Dr. Pfeiffer, of this
city was in the habit of employing them for many-
years with advantage in cases of erysipelas. When
ELEMENTS OF SURGERY.
17
suppuration takes place large openings must be made
for the evacuation of the pus and sloughs.*
* The application of mercurial ointment to the inflamed part has been
found highly beneficial. Mr. Astley Cooper, however, and some others con¬
tend that the same good effects may be obtained from the application of any
unctuous substance.
In lie erysipelatous inflammation which attacks new-born infants, Dr.
Chapman has used mercurial ointment with the happiest effects.—Ed.
VOL. I.-— C
18
ELEMENTS OF SURGERY-
CHAPTER V.
Of (Edematous Inflammation.
The fallowing remarks of Mr. Hunter contain a
very accurate account of this affection. c< What I
would call the oedematous inflammation is, when the
extravasated fluid is water. It has very much the ap¬
pearance of the adhesive, and comes probably the near¬
est to it of any, being of a scarlet colour, but much
more diffused. The fluid extravasated, being princi¬
pally the serum, renders the swelling more diffused than
even the inflammation itself. It is very painful, or
rather sore, but there is not so much of the throbbing
sensation as in the adhesive inflammation; it appears to
be only the surface, but most probably goes much deeper:
for in such cases the extravasated fluid is in too large
quantity to be furnished by the cells of the cutis alone,
but in this we have not the same guide as in the adhe¬
sive, namely, the swelling and inflammation correspond¬
ing with each other.
" The difference between this inflammation and the
adhesive arises, I conceive, from the principle of inflam¬
mation acting upon a dropsical disposition, which is
always attended with weakness, whereas a greater de¬
gree of strength would have produced the adhesive in¬
flammation under the same cause or irritation, and what
makes me conceive this is, that in many cases of ana-
sarcous legs we have exactly this inflammation, come on
from distention, which adds to the extravasation of the
serum, as well as in most cases of scarifications of oede¬
matous parts to evacuate the water. When inflammation
takes place it is much more lasting than the adhesive.
ELEMENTS OF SURGERY.
and, I believe, seldom or ever produces suppuration^
but if it should run into this stage it is more general,
and the whole cellular membrane, in the interstices of
parts, is apt to mortify and slough, producing very ex¬
tensive abscesses, which are not circumscribed."
The remedies before the secretion of water takes
place, are the same as for common inflammation. We
shall add a few words on this subject in the chapter on
ulcers.*
* The application of laudanum diluted with water, has been found, after
repeated trials, to be one of the best local remedies for the inflammation
which is apt to accompany the cedema of the lower extremities. Linen
cloths may be soaked in this solution and applied immediately over the
parts.—En.
20
ELEMENTS OF SURGERY.
CHAPTER YI.
Of Gangrene and Mortification.
Mortification is the entire death of a part ot the
body, gangrene is that state or condition which imme¬
diately precedes it. It is gangrenous so long as it re¬
tains sensibility, motion, and warmth; when these cease
and it acquires a livid, brown, or black colour, it is
mortified, or in a state of sphacelus.
Mortification is of two kinds: the one is not preceded
by inflammation, the other is.
I. Mortification, not preceded by inflammation, may
be occasioned by a variety of circumstances. Inter¬
ruptions to the circulation of the blood, as the applica¬
tion of a ligature to the arterial trunk supplying the part,
or pressure on the large veins by which the return of
blood is prevented, as in strangulated hernia. Conti¬
nued pressure on a part of the body, occasions mortifi¬
cation: this is seen in the hips and backs of patients
who have been long confined to one posture in bed.
Disorganization by external violence, intense heat or
cold, also produce mortification which is not preceded
by inflammation. When mortification from any of
these causes commences, the parts become livid, cold,
purple, black, lose all sensibility, become covered with
vesications, containing a bloody dark serum, and at
length putrefy, and emit a foetid smell.* These cases
admit of no remedy. A soft bread and milk poultice
is to be applied to prevent the dead parts from becom¬
ing hard and dry, and thereby adding to the irritation.
* The process of " sloughing," in surgical language, signifies the sepa¬
ration of dead and living parts.
ELEMENTS OF SURGERY.
21
If the part mortified be very extensive, the constitution
sinks, and death takes place. The use of tonics and
stimulant medicines, are necessary in these cases. Pe¬
ruvian bark, elixir of vitriol, and opium, are among the
most useful.
When a part has been exposed to intense cold, the
greatest care should be taken to raise its temperature
gradually, as it is found invariably to mortify when heat
is suddenly applied. It should firsi be placed in ice or
snow, afterwards in cold water, and very gradually
warmed.
In some rare instances, mortification comes on with¬
out any evident cause, except extreme debility. I have
known an instance of this after a severe attack of yel¬
low fever. This is, probably, not preceded by inflam¬
mation.
II. Mortification, in many instances, is preceded by
inflammation. 1. It may arise from the violence of the
inflammatory action exhausting the vital powers of the
part; or, 2dly, from some peculiarity in the nature of
the inflammation.
1. "Inflammation is an increased action of that
power which a part naturally possesses, and in healthy
inflammations at least, it is probably attended with an
increase of power. In cases however which are to ter¬
minate in mortification, there is no increase of power,
but on the contrary a diminution of it. This, when
joined to an increased action, becomes a cause of mor¬
tification, by destroying the balance which ought to
subsist between the power and action of every part."
(Hunter.)
When inflammation has either not been properly
treated, or has resisted the remedies usually successful,
and is about to terminate in mortification, the pain and
fever suddenly ceases, the heat is diminished, the red
22
ELEMENTS OF SURGERY.
colour is changed to a dark purple, and the swelling
which was tense and hard, becomes softer. The cuti¬
cle is elevated in various places and vesications form,
filled with a darkish and sometimes a transparent fluid.
This gangrenous condition rapidly progresses to a com¬
plete mortification, attended with putrefaction.
The constitutional remedies for it are all such as, by
lessening inflammatory action, have a tendency to pro¬
duce resolution or suppuration. These have been al¬
ready mentioned in the chapter on inflammation.
Wherever the violence of the symptoms leads to an ap¬
prehension of gangrene, the evacuations by bleeding,
purging, &c. are to be increased, and carried as far as
the state of the system will warrant.
The indiscriminate use of evacuating remedies, is
however by no means proper. The sudden diminution
of strength which frequently precedes mortification, de¬
mands a very opposite mode of treatment, and here to¬
nic remedies are strongly indicated. Wherever the in¬
flammatory action suddenly subsides, and with it the
symptomatic fever, and a great diminution of vigour is
perceived in the patient's constitution, the use of tonics
and a generous diet, with fermented liquors, especially
wine, are to be directed. These remedies have no ef¬
fect certainly on parts already mortified, but they for¬
tify those which are not, and thereby prevent the pro¬
gress of the gangrene.
The Peruvian bark has long been celebrated for its
virtues in this particular case. It is a valuable tonic,
but has probably no specific virtues, and has done great
mischief when administered during an inflammatory
state of the system. The encomiums lavished on it at
the beginning of the last century, appear to have been
extravagant, and surgeons no longer recommend its in¬
discriminate exhibition in cases of gangrene. When
ELEMENTS OF SURGERY.
23
the stomach rejects it in substance, it may be adminis¬
tered in decoction, but it often produces so much nau¬
sea, that its exhibition is necessarily precluded.
The local remedies which have been used in cases of
mortification, are various. In the first place, if there
exist any local irritation which has a tendency to keep
up the inflammatory action, and thus extend the mis¬
chief, these are to be removed. The application of
cataplasms and poultices can have no effect on the mor¬
tified parts except by keeping them moist, or correct¬
ing the foetor which exhales, but these are important
objects and should not be neglected. A poultice of
bread and milk mixed with laudanum; of linseed, or of
scraped carrots well boiled in milk, answers in genera!
every purpose, and if renewed once in three or four
hours keeps the parts sufficiently clean, but in warm
weather when the smell is very foetid, the addition of
finely powdered charcoal to the poultice of linseed, §ij,
to the pound, has some effect in rendering it more to¬
lerable. A poultice consisting of oatmeal and beer,
stirred together until they have a proper consistence, is
much used by surgeons with a similar intention. The
fermenting cataplasm, with or without the addition of
charcoal, is also a useful application. It is made in
several ways; the easiest and therefore the best, is by
mixing equal parts of yeast, flour and honey—if requi¬
site, powdered charcoal may be added.
Certain stimulating applications have been much
used; the various balsams, resins, aromatics, alcohol,
&c. They are in general laid aside. The tempera-
rature of the local applications should be attended to;
if they be applied too hot, they increase inflammation,
and if too cold, they weaken the parts. The tempera¬
ture should be nearly that of the part to which they
ELEMENTS OF SURGERt.
/
are applied, and they must always be light, so as not to
offend by pressure.
Scarifications, if ever, are very rarely necessary.
There can be however no doubt of the propriety ol
making punctures through mortified parts whenever
there is confined acrid matter beneath them, irritating
the living parts-, they should never extend into sound
flesh. In cases of gangrene from erysipelas, this prac¬
tice is particularly necessary. Wherever extensive
sloughing of the cellular membrane from any other
cause, as extravasated urine, &c. takes place, they are
equally proper, but they should never be used with a
view to expose the sound parts, in order to apply local
remedies to these. When performed with this view,
they occasion great pain and inflammation, and must
therefore add to the danger and spread the mortifica¬
tion.
The knife should not in general be used with a view
to separate the dead from the living parts; this separa¬
tion will be readily effected by a natural process insti¬
tuted by the absorbent vessels, and to them it should be
committed.
When gangrene is situated in one of the extremities,
it has been the practice of some surgeons to amputate
the member. The dangers attending this practice, and
the fatal result of a great number of cases, have induc¬
ed modern surgeons to lay it aside.
When the limb is completely mortified and putrid,
and the absorbents have begun to separate the dead
from the living parts, portions of the putrid flesh may
be cut off to diminish the smell, but this should be done
with great care, so as in no instance to injure the liv¬
ing parts. After the whole of the soft parts are sepa¬
rated by the absorbents, the bones may be sawed
through; but it commonly happens that the bone has
ELEMENTS OF SURGERY.
25
mortified higher than the flesh, and therefore, the same
process of separation by the absorbents must be wait¬
ed for, so that the only advantage arising from the ope¬
ration is a removal of the inconvenience of a putrid and
offensive mass, the cure not being at all expedited by
the operation.
I shall conclude this account of the local treatment
of mortification consequent to inflammation, by recom¬
mending in every instance the application of a blister,
large enough to cover all the sound parts in contact
with the diseased. This remedy was introduced into
practice by Dr. Physick, who was led to apply it from
the success of blisters in cases of erysipelas. He first
employed it in January 1803, and from that time until
the present, has had the greatest reason to be pleased
with its effects. A great number of cases have occur¬
red in various parts of the United States, in which an
immediate cessation of the progress of the gangrene has
been the result of its application. I have witnessed its
effects in a variety of instances, and have no hesitation
in recommending it, in preference to all other local re¬
medies. After the first dressing of the blister, it will
generally be found that the mortification has ceased to
progress, and in a very short time the separation of the
sloughs commences.
2. Mortification, it was observed, appears in some
cases to arise from something peculiar in the nature of
the inflammation which precedes it, independently of
its apparent violence. The pustule of small-pox and
carbuncle are specimens of this. ,
The inflammation of the small-pox pustule terminates
by occasioning the death of that portion of cutis vera in
which the inflammation was situated.
Carbuncle. This is a tumour beginning on different
parts of the body, most frequently on the back; the
L VOL. I.—D
26 ELEMENTS OF SURGERY.
pain attending it is very great, and of a burning kind
the skin itches, and under it is found a very hard cii
cumscribed tumour, which becomes of a dark red co¬
lour. A kind of imperfect suppuration takes place un¬
der the skin, attended with gangrene of the cellular
membrane, and skin; sloughs form, and several open¬
ings are thus made into the cavity of the tumour, which
discharges a fetid pus.
The size of these tumours varies greatly; in some in¬
stances, they are small, in others many inches in diame¬
ter—I have seen them extending quite across the back.
In general they occur in advanced life, and in those
who have lived well. When they are very large, they
often terminate fatally; in those instances where seve¬
ral occur at once, they are also fatal. Carbuncle oc¬
casionally forms on the head, or high on the neck,
and these cases generally terminate unfavourably when
they are large. In sound constitutions and in patients
not very far advanced in life, a cure may commonly be
expected.
The cure depends greatly upon the state of the con¬
stitution, and this must influence our prescriptions : in
general great debility attends, and demands a cordial
invigorating diet. Opium must be given to relieve pain,
and the bark and elixir of vitriol may often be used
with advantage.
As a local remedy, the application of a blister is to be
preferred to all others; I have known it produce imme¬
diate relief of the distressing burning sensation which
invariably attends this complaint, and occasion a speedy
separation of the sloughs. As soon as matter fluctuates
under the skin, an incision must be made to discharge
it, and a free passage is to be kept open for the evacua¬
tion of pus and sloughs. A plaster of common basili-
con after the blister has been cut is to be applied, and
ELEMENTS OF SURGERY. 21
if poultices are used, they should be very light and fre¬
quently changed.*
* We subjoin the following valuable practical remarks of Professor Phy-
sick on the application of caustic alkali in the treatment of carbuncle, pub¬
lished in the third number of Dr. Chapman's Medical and Physical Journal.
" With a view," says the Professor, " of communicating the method of
using the caustic, which I wish to propose, the progress of carbuncle may
be divided into three stages. The first stage is that in which the disease is
forming, and in which the peculiar inflammation exists in tl\e cellular tex¬
ture under the skin, that ends in death or mortification. This is attended
by a burning pain, and sometimes by fever. Carbuncle, in this stage, sel¬
dom proves fatal, unless it be very large, or when situated on the head, or
where the constitution has been previously impaired.
"The second stage is that in which pimples appear with orifices through
the skin, which, gradually increasing, join, and eventually form one or
more large openings, through which the mortified parts, and acrid fluid pass
out. These effects are produced by the ulcerative process, which, during
the whole time of its continuance, is attended with the most severe and dis¬
tressing pain that is experienced in the course of the disease. The patient's
constitution also suffers so materially, owing to loss of appetite, want of
sleep, and fever, that death is the consequence in severe cases, and in others
the recovery is difficult and tedious
" The third stage is that in which an ulcer remains, attended, however,
with no peculiarity from its cause.
"In the first stage, all irritating treatment appears to be very injurious,
by increasing the peculiar inflammation then existing, and thereby extend¬
ing it. Hence the bad effects of incisions, scarification, and stimulating ap¬
plications in the beginning of the complaint; and such, too, is the reason
why caustic has been, sometimes, found injurious. From the great power
of blisters in checking mortification, when proceeding from some kinds of
inflammation, I once entertained high expectations of their utility in the
treatment of anthrax. But though I have found them serviceable in abating
the burning pain attending the inflammation, they have not shown any
power in counteracting its progress to mortification.
"In the second stage, the inflammation having ended in the death of the
cellular texture in which it is situated, a process begins for making an open¬
ing through the skin to allow the dead parts and acrid fluids to pass out.
The commencement of this process is pointed out by the appearance of
pimples and small orifices, as above described, and it is at this period, that
the application of caustic vegetable alkali upon the skin so perforated, and
on that covering the middle of the tumour, in quantity sufficient to destroy
it completely, proves highly beneficial. In all cases, in which I have used
the caustic in this manner, the suffering of the patient ceased as soon as the
pain from the caustic subsided. It operates by destroying, in a few minutes,
that portion of the skin covering the mortified parts, which, if left to be re¬
moved by ulceration, would require several days for its completion, occa¬
sioning the chief part of the pain and danger attendant on, and consequent
28
ELEMENTS OF SURGERY.
Besides the cases of mortification which have beer,
described, there is a species of mortification which
takes place in the toes and feet of old persons, whether
or not it is preceded by inflammation is undetermined;
Mr. Hunter thinks it is.
The following account of this singular affection is
taken from the writings of Mr. Pott.
"It is very unlike to the mortification from inflam¬
mation, to that from external cold, from ligature, or
bandage, or to that which proceeds from any known
and visible cause, and this as well in its attack as in its
progress. In some few instances, it makes its appear¬
ance with little or no pain ; but in by much the majo¬
rity of these cases, the patients feel great uneasiness
through the whole foot and joint of the ankle, particu¬
larly in the night, even before these parts show any
mark of distemper, or before there is any other than
a small discoloured spot on the end of one of the little
toes.
" It generally makes its first appearance on the in¬
side, or at the extremity of one of the smaller toes, by
a small black, or bluish spot: from this spot the cuticle
is always found to be detached, and the skin under it
to be of a dark red colour.
" II the patient has lately cut his nails, or corn ; it
is most frequently, though very unjustly, set to the
account of such operation.
" Its progress in different subjects and under different
circumstances, is different; in some it is slow and long
in passing from toe to toe, and from thence to the foot
and ankle; in others its progress is rapid and horribly
painful: it generally begins on the inside of each small
toe, before it is visible either on its under or upper
part, and when it makes its attack on the foot, the up¬
per part of it first shows its distempered state, by tu-
ELEMENTS OF SURGERY.
29
mefaction, change of colour, and sometimes by vesica¬
tion, but wherever it is, one of the first marks of it is a
separation or detachment of the cuticle.
<£ Each sex is liable to it; but for one female in whom
I have met with it, I think I may say, that f have seen
it in at least twenty males; I think also that I have
much more often found it in the rich and voluptuous,
than in the labouring poor: more frequently in great
eaters, than free drinkers. It frequently happens to
persons advanced in life, but it is by no means peculiar
to old age. It is not, in general, preceded or accompa¬
nied by apparent distemperature either of the part, or
of the habit. I do not know any particular kind of
constitution which is more liable to it than another;
but as far as my observation goes, I think that I have
most frequently observed it to attack those, who have
been subject to flying uncertain pains in their feet,
which they have called gouts, and but seldom in those
who have been accustomed to have the gout regularly
and fairly. It has, by some, been supposed to arise from
an ossification of vessels; but for this opinion I never
could find any foundation but mere conjecture.
" The common method of treating this distemper is,
by spirituous fomentations, cataplasms actually and po¬
tentially warm, by dressings of the digestive kind, as
they are called, animated with warm, pungent oil and
balsams, &c. and, internally, by the Peruvian bark.
" I wish I could say that this, which, with little altera¬
tion, has been the general practice, had been most fre¬
quently successful; but I am, from long and repeated
experience, obliged to say that it has not.
" I am sensible, that many of my readers will be sur¬
prised at my affirming, that the Peruvian bark will not
stop a mortification, a distemper in which, for some
years, it has been regarded as specific; but I must beg
30
ELEMENTS OF SURGERY.
not to be misunderstood; I mean to confine my obsei
vation and my objection to this particular species of
mortification, Which I regard as being sui generis : and
under this restriction I must repeat, that i have seldom,
if ever, seen the bark successful: in all other cases,
wherein it is used or recommended, no man has a high¬
er opinion of it; but.in this I cannot give it a praise
which it does not deserve.
" I believe I may venture to say, that f have tried it
as fairly, as fully, and as variously as any man has or
can : I have given it in the largest quantities, at the
shortest intervals, and for the longest possible space;
that is, as long as the patient's life would permit. I
have given it by itself in decoction, extract, and sub¬
stance: I-have combined all these together: I have
joined it with nitre, sal. absynth. with snakeroot, with
confect. cardiac, with volatile salts, and with musk, as
different circumstances seemed to require, or admit: I
have used it as fomentation, as poultice, as dressing : I
have assisted it with every thing which has been usual¬
ly thought capable of procuring, or assisting digestion;
still the distemper has continued its course, perhaps a
little more slowly, but still it has ended in death.
" I am sorry to rob one of our great medicines of any
part of its supposed merit; but as, on the one hand, its
claim, in this instance, is unjust, and as on the other, I
hope to add as much to the character of another, the
res medica will be no sufferer.
" Some time ago, I had a patient labouring under
this complaint, who from antipathy, obstinacy, or some
other cause, could not be prevailed on to take bark in
any form whatever. I made use of everv argument, but
to no purpose: fomentation, poultice, and the usual
dressings were applied in the usual manner; the dis¬
ease advanced some days more, some days less, and at
ELEMENTS OF SURGERY. • 31
the end of a fortnight, the small toes were all complete¬
ly mortified ; the great one became blackish, the foot
much swollen, altered in colour, and the disease seem¬
ing to advance- with such hasty strides, that I supposed
a very few days would determine the event. The pain
in the foot and ankle was so great, and so continual, as
totally to deprive the patient of sleep. On this account,
and merely to procure some remission, I gave two grains
of opium at night, which not having the desired effect,
I repeated it in the morning. Finding, during the fol¬
lowing day, some advantage, I repeated the same
dose night and morning, for three days; at the end of
which time the patient became quite easy, and the ap¬
pearances on the foot and ankle were visibly more fa¬
vourable. Encouraged by this, I increased the quan¬
tity of the medicine, giving one grain every three or four
hours, taking care to watch its narcotic effect, and to
keep the belly empty by glysters. In nine days from
the first administration of the opium, all the tumefac¬
tion of the foot and ankle totally subsided, the skin re¬
covered its natural colour, and all the mortified parts
plainly began to separate; in another week they were
all loose, and casting off, the matter was good, and the
incarnation florid. During the whole of this time I con¬
tinued the use of the opium, varying its quantity as cir¬
cumstances required, but never gave less than three or
four grains in twenty-four hours.
" When the sloughs were all cast off, the bones sepa¬
rated, and I had only a clean sore to dress and heal, I
gradually left off the medicine.
" To relate cases which are nearly, or at least materi¬
ally similar, is of no use: I shall therefore only say, that
every opportunity, which I have had since of making
the experiment, has still more and more convinced me
of the value and utility of this medicine, and of its
S2
ELEMENTS OF SURGERY.
power of rescuing from destruction, persons under this
affliction.
" I cannot say that it has never failed me: it certainly
has; but then it has been under such circumstances, as
I think would fairly account for the failure."
In addition to Mr. Pott's account of this species of
moi tincation, I shall just add, that in the only case of
it 1 have ever seen, the application of a blister produc¬
ed an immediate termination of the mortification.
»'>• 1 ' **'' " \ . sjt ' .''IT .• 0
ELEMENTS OF SURGERY,
33
CHAPTER VII.
Of Burns.
The application of excessive heat to the body, occa¬
sions severe pain, and inflammation. Its consequences
are more or less serious in proportion to the degree of
heat applied and the time of its continuance.
When the degree of heat is not very great it produces
pain, redness and slight inflammation which subsides
spontaneously when the heat is removed. A greater
degree of heat occasions more severe pain; vesications
form filled with serum, and the true skin under these
vesicles is much inflamed. If the burn be extensive,
fever attends and suppuration takes place. If the heat
be still more intense, the life of the part is destroyed.
As a general remark it may be stated that burns are
dangerous in proportion to their extent. A burn which
destroys the life of a small part of the body, will pro¬
duce but little effect on the constitution, whilst an ex¬
tensive burn, even if very slight in degree, will occa¬
sion death. I once saw a child scalded on the backy
from the neck to the hips, by falling into a tub of water
in which her mother was washing clothes; the heat oc¬
casioned a few vesications, but the inflammation ap¬
peared slight, and yet on the fifth day the child expir¬
ed.
When the heat is so intense as to destroy the life of
the part, less pain is experienced than in light burns,
but when the eschar begins to be separated by the ab¬
sorbents the pain is augmented; very little pain appears
to be suffered by those wrho are scalded, and die a few
hours after the accideot. la instance, I Jhav#
VOfc. JL—-E
u
ELEMENTS OF SURGERY
known the patient to complain of nothing but extreme
coldness. In these cases, drowsiness and coma fre¬
quently attend. Burns which affect parts essential to
life, generally terminate unfavourably. Burns on the
head often occasion death, by affecting the brain. When
the larger joints are burned, there is great danger from
the violent inflammation which follows.
Treatment. There is no branch of surgery on
which a greater diversity of opinion and of practice
exists than in the treatment of burns; remedies appa¬
rently opposite in their nature succeed in the hands of
different practitioners, and whilst one surgeon strenu¬
ously recommends the use of ice and cold water, an¬
other proposes an application of hot spirit of turpentine.
A late writer on this subject, Mr. Kentish, who has
had very extensive opportunities of applying his princi¬
ples, declares that the stimulating plan of treatment is
most successful, and he advises the constitution to be
stimulated with opium and ardent spirits, and the part
affected to be dressed with a liniment composed of
spirits of turpentine and basilicon. The theories which
have led Mr. Kentish to this practice, are by no means
satisfactory, though the local application he has recom¬
mended is extremely valuable.
The method which is found to succeed best by the
surgeons of this country, is to attend as in all other
cases to the state of the constitution, and to accommo¬
date the general remedies to it. If there be great pain,
opium is to be administered. If considerable fever
arise, blood-letting and evacuating means are to be used.
If, on the contrary, weakness and want of action ap¬
pear to require them, stimulating remedies must be re¬
sorted to.
As a local application to a burn I have found nothing
so generally successful as the ointment recommended
ELEMENTS OF SURGERY.
35
by Mr. Kentish. The common basilicon thinned by-
being mixed with the oil of turpentine, forms a liniment,
which when spread on rags and applied to the burned
surface, occasions great relief from pain, and hastens
the formation of new parts. Mr. Kentish premises to
this dressing, a lotion with brandy, or hot oil of turpen¬
tine, or hot alcohol. This is in general unnecessary,
and the liniment may be applied without delay, and at
any period within a few days after the accident.
It is not to be denied that cases occur in which this
application so generally successful produces pain and
increases inflammation. In some instances, however,
this has arisen from a want of caution in the applica¬
tion. The surgeon, or his nurse, has been careless
enough to apply the stimulating ointment to the sound
skin, where it inevitably occasions much inflammation
and pain. To obviate this inconvenience the plasters
should be cut into small portions and applied to the
burned surface only.
If, notwithstanding this caution, the liniment excites
pain and inflammation, it must be removed and another
application substituted. A great variety have been
used. Yinegar in many cases affords great relief; lime-
water mixed with oil is a very soothing application;
scraped potatoes, a linseed poultice, lead water, are all
useful in different instances, and if one should not afford
relief, the others may be tried.*f
The ulcers left by burns have some peculiarities.
They shoot out fungous granulations which do not rea¬
dily cicatrize, and when these ulcers do heal, they con-
* Ice has been strongly recommended by Sir James Earl; it alleviates
pain, and may be applied in bladders over the other dressings.
-j- Completely covering the burned or scalded surface, when practicable,
with carded cotton, has been found one of the most convenient and effica*
cious applications.—En.
36
ELEMENTS OF SURGERt.
tract so much, as in many cases to occasion great dis¬
tortions.
To arrest the growth of fungus, prepared chalk
should be sprinkled over the sore, and if this be not suf¬
ficiently powerful, burnt alum, or the common escharotic
applications may be used.
To prevent deformity from the union of parts which
ought not to adhere, we should be extremely cautious
whilst the sores are healing, to interpose plasters be¬
tween them, and by applying splints and bandages to
preserve them in a proper posture. From neglect of
this caution great mischief has often arisen. I have
seen the chin of a boy adhering firmly to his breast; by
which his mouth was kept constantly open, and his
whole appearance was greatly deformed. The fingers,
when severely burned, are particularly apt to adhere
together. When this unfortunately happens, we must
cautiously dissect them loose, and prevent their re-union
by proper dressings.
ELEMENTS OF SURGERY. 37
CHAPTER VIII.
The Effects of Cold.
The power of resisting the effects of cold by pre¬
serving a temperature nearly similar in all changes of
the atmosphere, is one of the characteristics of living
matter.
The human body possesses this power in a very great
degree, and like all its other faculties, it is augmented
by habit. The inhabitants of northern countries are
subjected occasionally to degrees of cold which would
Unquestionably destroy the natives of the torrid zone.
The degree of cold which may be endured without loss
of life, cannot in the human subject be ascertained.*
In hospital practice and among the poor, the surgeon
frequently finds toes and fingers, feet and hands, slough¬
ing off in consequence of exposure to cold. He is not
often called until it is too late to prevent this effect.
When he is, the great object is to restore the warmth
pf the parts very gradually. A limb has been frozen
perfectly stiff, and by being rubbed in snow, afterwards
immersed in cold water, and then very gradually warm¬
ed, its life has been preserved. The sudden applica¬
tion of heat never fails to occasion inflammation, and
mortification very quickly follows. After the tempera¬
ture has been gradually raised, and action and sensa-
* A woman in a fit of intoxication was overtaken in a snow storm. " The
pnow accumulated over her to the height of about six feet, a sort of hollow
cone being left from her head to the surface, through which breathing was
performed; from this situation she was removed, after having laid eight
days in the snow/' Her life was preserved, though she lost great part of
her feet. Other instances are recorded of long exposure to intense cold,
without fatal consequences. Our present subject is more particularly the
effects of its looal application.
£
ELEMENTS OF SURGERY.
39
hig winter. Some persons suffer most from them dur¬
ing the autumn, others not until spring; sometimes they
continue a few days, or weeks, and sometimes during
the whole winter. When violent the patient is unable
to move about, and is affected with considerable fever.
When suppuration occurs, the bone becomes carious,
and even death has followed the irritation of a chilblain.
To prevent the formation of chilblains in young per¬
sons, they should be accustomed to wash in cold water,
and not to be much in very warm rooms, especially
avoiding sudden changes from cold to heat, or the re¬
verse.
The remedies for chilblains vary according to the
degree of inflammation; the several remedies for inflam¬
mation, however, do not relieve the pain and itching
which attend this complaint, and one thing it is impor¬
tant to know, which is, that the remedies most success¬
ful in one case, produce no effect upon another; when
inefficient, therefore, they must be varied. In some
cases great relief is obtained from lotions of a spiritu¬
ous nature, alcohol, laudanum, brandy, and the like, and
in others poultices afford most relief. Leeches are of¬
ten useful where the inflammation is so violent as to
produce fever 5 cold water or snow applied to the part,
sometimes produces great relief; it should be repeated
several times in the course of the day, and continued
until the pain and itching abates. A bath of quicklime
prepared by throwing a piece of fresh burnt lime as
large as a man's fist into a quart of water, is recom¬
mended by Richter as a valuable remedy; the affected
part is to be immersed in this bath, and kept in it half
an hour every morning and evening.
Oil of turpentine affords in many cases great relief,
40 ELEMENTS OF SURGERY.
Balsam copaiva, basilicon ointment, tar ointment, and
various other resinous applications are found useful.*
When chilblains ulcerate, they are to be treated as
ulcers from other causes. When mortification takes
place, poultices are to be applied until the sloughs se¬
parate, and then the sore is to be dressed in the usual
manner.
* Some persons derive great relief by keeping the chilblain covered
■with a portion of adhesive plaster.—Ed.
§
38
ELEMENTS OF SURGERY.
tion are perceived, frictions with flannel wet with ar¬
dent spirit are to be used. The patient should then be
placed in bed and kept warm; perspiration is to be pro¬
duced by warm drinks, and by keeping him perfectly
at rest, the ill effects will speedily subside.
When mortification occurs, it has been my practice
for several years to apply blisters, with a view to hasten
the separation of the dead parts, and the ulcers left I
have found to heal very soon when treated with basili-
con rendered stimulating by the addition of a little spi¬
rits of tunpentine.*
Chilblain, is a local inflammation situated generally
upon the heels, toes and fingers, but sometimes upon
the nose and ears, resulting from exposure to cold.
This inflammation varies in degree; when moderate, a
redness is observed upon the skin, attended with heat
and itching, which after a time, spontaneously subsides.
In a greater degree the swelling is larger, of a deeper
red colour, and sometimes purple, or dark blue; the
heat, itching, and pain are very great. Sometimes
small vesicles arise, which burst and occasion very ob¬
stinate ulcers. In the most violent cases mortification
occurs, preceded by the usual vesications containing a
dark coloured fluid.
Chilblains arise most frequently from exposure of the
parts to sudden and great vicissitudes of temperature.
They occur oftenest in persons accustomed to indul¬
gence, in women and children.
They generally make their appearance in the winter,
disappear during the summer, and return the succeed-
• In cases of suspended animation from cold, there is no necessity for the
very gradual application of heat; on the contrary, it is recommended to
bring the patient into a warm room and rub him with flannels. His feet
and legs are to be immersed in tepid water, and bladders filled with it are
to be applied to the thorax.
ELEMENTS OF SURGERY.
41
i CHAPTER IX.
Of Wounds.
A wound may be defined, a recent solution in the
continuity of a part communicating externally, and pro¬
duced by mechanical violencei
Wounds differ in their nature and appearances from
an endless variety of circumstances. They admit,
however, of a general division into Incised, and Con¬
tused, the latter including punctured, latcerated, and
gun-shot wounds. Incised wounds are made with a
sharp cutting instrument, and the neighbouring parts
sustain no injury. Contused wounds are those in which
the surrounding parts are bruised and injured,
of incised wounds.
When these are of small extent, and made in fleshy
parts, unaccompanied by a division of any considerable
blood-vessel, the surgeon by approximating the sides of
the wound and retaining them in contact, enables them
to unite, and they very speedily heal. All incised
wounds, however, are attended with some loss of blood,
and this is in many cases so great, as to form the chief
danger of the case; as there is no subject of more im¬
portance to the surgeon than that of hemorrhage, it will
be proper in this place to offer some remarks on it.
of hemorrhage.
In order to ascertain the natural process by which
the bleeding from a wound is arrested, it is requisite to
attend to the phenomena which follow the opening of
large blood-vessels. It is now nearly a century since
vol. i.—f
42
ELEMENTS OF SURGERY.
Mr. Petit commenced the investigation of the present
subject, and since his time a variety of theories have
been advanced, to explain the natural means b} which
the bleeding from divided arteries is stopped. Dr. Jones
in a late publication has collected into one view these
various and discordant doctrines; has selected from each
what appeared founded upon fact, and by very nume¬
rous and interesting experiments, seems to have gone
far in developing the truth.
If the vessel opened be a large artery, an immediate
jet or stream of blood is perceived; this blood is of
bright scarlet colour, and issues not in a regular current,
but per saltum, every contraction and dilatation of the
vessel propelling it with alternately greater and lesser
velocity.*
* To comprehend this subject fully, it is necessary to recollect some cir¬
cumstances connected with the anatomy of arteries, which we shall here
rery briefly state.
" The coats of an artery are three ; the internal is extremely thin and
smooth, it is elastic and firm in the longitudinal direction, but so :weak in the
circular as to be very easily torn by the slightest force applied in that direction.
It is vascular and capable of inflaming."
The middle coat is composed chiefly of muscular fibres, arranged in a cir¬
cular manner; they differ from common muscular fibres in being more
elastic. As this middle coat has no longitudinal fibres, the circular fibres
are held together by a slender connexion, -which yields readily to any force ap¬
plied in the circumference of the artery.
" The external coat is remarkable for its whiteness, density, and great
elasticity. When an artery is surrounded by a tight ligature, its middle and in¬
ternal coats are as completely divided by it, as they could be by a knife, whilst
the external coat remains entire."
" Besides these proper coats all the arteries in their natural situations are
connected by means of the fine cellular substance with surrounding mem
branous sheaths. If an artery be divided, the divided parts, owing to their
elasticity, recede from each other, and the length of the cellular substance, con¬
necting the artery with the sheath, admits of its retracting a certain way within
the sheath."
"Arteries are furnished with, arteries, veins, absorbents, and nerves, a
structure which, makes them susceptible of every change to which living parts are
subjected in common ,■ enables them to inflame when injured, and to pour out co¬
agulating lymph by which the injury is repaired, or the tube permanently closed
—(Jowes.)
ELEMENTS OF SURGERY.
43
" An impetuous flow of blood, a sudden and forcible
retraction of the artery within its sheath, and a slight
contraction of its extremity, are the immediate and
almost simultaneous effects of its division. The natural
impulse however with which the blood is driven on, in
some measure counteracts the retraction and resists the
contraction* of the artery, the blood is effused into the
cellular substance between the artery and its sheath,
and passing through the canal of the sheath which had
been formed by the retraction of the artery, flows freely
externally, or is extravasated into the surrounding cel¬
lular membrane, in proportion to the open or confined
state of the wound. The retracting artery leaves the
internal surface of the sheath uneven by lacerating or
stretching the cellular fibres that connected them. These
fibres entangle the blood as it flows, and thus the founda¬
tion is laid for the formation of a coagulum at the mouth
of the artery, and which appears to be completed by
the blood as it passes through this canal of the sheath,
gradually adhering and coagulating around its internal
surface, until it completely fills it up from the circum¬
ference to the centre/' (Jones.)
The diminished force of the circulation of the blood,
its speedy coagulation, and its extravasation into the sur¬
rounding cellular texture, are circumstances which con¬
tribute greatly to put a stop to the hemorrhage. The
coagulum which acts as a plug to the open orifice, is
situated not actually within this orifice, but within its
surrounding sheath, and as it is outside of the vessel,
Dr. Jones has called it external; a coagulum, however,
is found within the arterial tube, as high as the nearest
collateral branch, this is not sufficient in volume to fill
up the vessel and adheres to the artery no where except
* The retraction refers to the diminished length, and the contraction to
the diminished volume or diameter of the artery.
44
ELEMENTS OF SURGERY.
at the divided extremity; this clot is called the internal
coagulum.
The wounded artery afterwards inflames and its ves¬
sels (like those of any other inflamed part) secrete co¬
agulating lymph in sufficient quantity to fill up the ex¬
tremity of the artery between the external and internal
coagula. This lymph appears to unite these coagula
together, and adheres firmly all round to the internal
coat of the vessel. It is this secreted lymph which con¬
stitutes the permanent barrier to the flow of blood, and
this barrier is rendered stronger by a contraction of the
wounded extremity of the vessel, and by an effusion of
lymph between its coats, and into the surrounding cel¬
lular substance, by which these parts become incorpo¬
rated together very firmly. If the wound in the integu¬
ments remains open, the effused lymph connects the
artery to the subjacent and lateral parts, and gives it a
new covering which entirely excludes it from the out¬
ward wound.
The same circumstances are also remarkable in the
portion of the vessel most remote from the heart. Its
orifice is usually more contracted and its external co¬
agulum smaller than the one which attaches itself to
the other cut end of the artery.
The impervious extremity of the artery no longer al¬
lowing blood to circulate through it, the portion which
lies between it and the first lateral branch, gradually
contracts till its cavity is completely obliterated, and its
tunics assume a ligamentous appearance; the external
coagulum which in the first instance had stopped the
hemorrhage is absorbed in a few days, and the coagu¬
lating lymph effused around it, by which the parts were
thickened, is gradually removed, so that they resume
their cellular structure.
At a still later period the ligamentous portion is r^
ELEMENTS OF SURGERY.
45
duced to a filamentous state, so that the artery is as it
were completely annihilated from its cut end to the first
lateral branch; long however before this final change is
accomplished, the inosculating branches have become
considerably enlarged, so as to establish a free commu¬
nication between the disunited parts of the main artery.
When an artery has been divided at some distance
from a lateral branch, three coagula are formed : one
of blood externally, which shuts up its mouth; one of
lymph, just within the extremity of its canal, and one of
blood, within its cavity, and contiguous to that of lymph.
But, when the artery has been divided near a lateral
branch, no internal coagulum of blood is formed.
The external coagulum is always formed, when the
divided artery is left to nature ; not so however, if art
interferes, for under the application of the ligature it can
never form. If agaric, lycoperdon, or sponge be used,
its formation is doubtful, depending entirely upon the
degree of pressure that is used ; but, the internal co¬
agulum of blood will be equally formed, whether the
treatment be left to art or nature, if no collateral branch
is near the truncated extremity of the artery; and last¬
ly, effused lymph, which, when in sufficient quantity,
forms a distinct coagulum. just at the mouth of the ar¬
tery, will be always found, if the hemorrhage is perma¬
nently suppressed.
When, instead of a complete division of an artery, it
is only partially divided or punctured, the cessation of
bleeding is not so easily effected by natural means;
hence it was the custom of the ancients in such in¬
stances to divide completely a punctured artery.
Mr. Petit appears to have given the best account ot
the process by which the bleeding from arteries parti¬
ally divided are stopped. Dr. Jones, after a great num¬
ber of experiments performed wit]i a view to elucidate
46 ELEMENTS OF SURGERY.
this subject, confesses that he has little to add to Mr.
Petit's account.
The blood is effused into the cellular substance, be¬
tween the artery and its sheath, for some distance, both
above and below the wounded part; and when the parts
are examined, a short time after the hemorrhage has
completely stopped, we find a stratum of coagulated
blood between the artery and its sheath, extending from
a few inches below the wounded part, to two or three
inches above it, and somewhat thicker, or more promi¬
nent over the wounded part than elsewhere.
Hence, rather than say the hemorrhage is stopped
by a coagulum, it is more correct to say, that it is stop¬
ped by a thick lamina of coagulated blood, which,
though somewhat thicker at the wounded part, is per¬
fectly continuous with the coagulated blood lying be¬
tween the artery and its sheath.
When an artery is punctured, the hemorrhage im¬
mediately following, by filling up the space, between
the artery and its sheath, with blood, and consequently
distending the sheath, alters the relative situation of the
puncture in the sheath to that in the artery, so that they
are not exactly opposite to each other; and by that
means a layer of blood is confined by the sheath over
the puncture in the artery, and, by coagulating there,
prevents any further effusion of blood.
But this coagulated blood, like the external coagu¬
lum of a divided artery, affords only a temporary bar¬
rier to the hemorrhage ; its permanent suppression is
effected by a process of reparation, or of obliteration.
It has been doubted by many respectable surgeons
whether arteries when wounded, can heal without an
obliteration of the cavity of the vessels, in such a man¬
ner as to carry on the circulation of blood. The ex¬
periments of Dr. Jones upon a number of animals prove
ELEMENTS OF SURGERY.
47
that in brutes this very generally happens, when the
artery is wounded only to a small extent; the cicatri¬
zation in these cases is so complete, that no vestige of
the wound can be perceived, either on the external or
internal surface of the artery, and that even oblique
and transverse wounds, when they do not exceed one-
fourth of the circumference of the vessel, are filled up,
and healed by an effusion of coagulating lymph from
their inflamed lips, so as to occasion little or no ob¬
struction to the canal of the artery. It may still be
questioned whether in the human body the same mode
of union is effected.
When an artery of considerable magnitude is punc¬
tured, even by a sharp lancet, the circular fibres of the
artery in most cases contract so much, as to separate
the sides of the wound to a considerable distance from
each other, it appears as if a piece of the vessel had
been actually removed.* To effect the reparation here,
a coagulum forms as explained by Mr. Petit, inside of
the artery, and extends through the wound, to a coagu¬
lum situated on the outside of the vessel,! 'n this man¬
ner the aperture is temporarily closed, and the perma¬
nent closure depends on the secretion of coagulating
lymph, which is poured out in considerable quantity,
and in many cases (probably a large majority of cases)
obliterates the arterial tube; but in some instances the
artery heals as in the experiments upon brutes related
by Dr. Jones, and then the cicatrization is completed
without a destruction of the arterial cavity. Mr. Petit
* Such is the common opinion, but I have seen several cases of punctured
arteries, in which no gaping was evident, the wound being a mere slit, the
sides of which were nearly or closely in contact, though they had not united.
As this has been the case in all the punctured arteries I have seen, I cannot
doubt that it very often happens.
-j- The inner clot he calls "bouchon," a cork, or plug, the external is call¬
ed "couvercle."
48
ELEMENTS OF SURGERY^
records an instance of this, and in professor Scarpa ^
learned treatise on Aneurism, I find another very de¬
cided instance in which this mode of union was effected
in the brachial artery of a man. Scarpa denies that
when the artery heals in this manner the cure is radi¬
cal. He supposes the vessel weaker at the cicatrix
than at any other part. A case of wounded brachial ar¬
tery which healed without an obliteration of its ca¬
nal may be found in the New York Med. and Phil.
Journal, No. 4.
Having thus stated the natural process by which a
wounded artery is repaired, we may next mention that
these powers of reparation appear to exist in an inverse
ratio to the size of the vessel, small vessels healing
much more readily than large ones.
In incised wounds the flow of blood is always much
greater than in contused wounds of similar parts. The
effect tfhich laceration has in preventing hemorrhagy
may be estimated from a case related by Cheselden, in
which a miller's arm was torn off, together with the
scapula from the chest, of course some of the largest
arteries of the body were divided, and yet no fatal he¬
morrhagy ensued. I have known a boy's arm ground
off in a mill, within a few inches of the shoulder, and so
little bleeding resulted, as scarcely to stain his clothes.
Dr. Physick has attributed this effect of contusion, 1st,
To the diminished power of the vessels to carry on the
circulation. In an incised wound the vessels are only
injured at the divided surfaces ; in a contused wound
they are injured to a considerable distance, and there¬
fore circulate the blood less rapidly. 2dly, In a con¬
tused wound the blood escapes less readily by the
external opening, and becomes extravasatedinto the cel¬
lular texture, making lateral pressure upon the blood-
ELEMENTS OF SURGERY.
49
vessels.* 3dly, The blood coagulates much more
promptly in contused than in incised wounds, and this
coagulation is a powerful barrier to the escape of the
blood. The extremities of divided vessels are often ac¬
tually killed by the contusion, and blood, when in con¬
tact with dead matter, speedily coagulates. The coagu¬
lation of blood in the divided extremities of the ves¬
sels, forms another obstacle to hemorrhage.
TREATMENT OF INCISED WOUNDS,
In the treatment of an incised wound, the first ob¬
ject is to stop the bleeding. In many cases a wound
bleeds profusely at first, and gradually stops without any
attention from the surgeon. In some cases moderate
pressure upon the wound by holding its sides in con¬
tact, puts a stop to the flow of blood, and this, if no
large artery be obvious, should always be tried. If,
upon removing the pressure the wound continues to
bleed, or if previously to trying this, a bleeding artery is
observed, it must be taken up upon the point of a tena¬
culum, and a ligature applied round it.
If the bleeding is so great as to prevent an accurate
inspection of the wound, so that the artery cannot be
perceived, pressure must be made upon the trunk of
the main artery which supplies the parts with blood.
This pressure may be made with a finger, or if the
wound be seated in an extremity, with a tourniquet; that
of Petit is to be preferred for simplicity and facility of
application to all others.f When the tourniquet is to
be applied, it must be placed above the knee or elbow,
* The lateral pressure is increased by ecchymosis, from a number of rup¬
tured blood-vessels fahich have no external communication, and bleed into
the interstices of the neighbouring parts.
-j-1 mean the tourniquet in common use, invented by Petit, and improved
l>y Freke.
VOL. I.—GT.
50
ELEMENTS OF SURGERY.
because, as there is only one bone in these parts, a cir¬
cular bandage will compress all the vessels of the limb.
After the tourniquet is applied and screwed so tight as
to interrupt the circulation, the surgeon is to wash the
wound with a sponge and warm water, and then, whilst
his eye is fixed on it, the screw is gradually loosened,
and the divided vessels may be seen by the stream of
blood escaping from their extremities.
It is to be recollected, that if the wound be too high
up on an extremity for the application of a tourniquet,
the compression of the vessel may still be effected. The
subclavian artery may be compressed as it lies over the
first rib, and the circulation in the arm may thus be
completely prevented, and from pressure in the groin,
the trunk of the femoral artery ceases to pulsate. In
every instance where the bleeding does not speedily
cease, and the orifice of the bleeding artery can be
seen, it is to be tied up. And whenever large arteries
are wounded, there is no other mode of stopping the
hemorrhage to be confided in.
Dr. Jones having made a number of experiments to
ascertain the effects of the ligature upon an artery in¬
cluded in it, and properly tied, states, that the internal
and middle coats of the artery are cut through and
kept in close contact by the ligature; inflammation su¬
pervening, they adhere and unite firmly.
There are however some situations in which it is ex¬
tremely difficult to tie up a wounded artery. If a ves¬
sel be opened in a deep wound of small extent, it be¬
comes sometimes necessary to dilate the wound, in order
to expose it. Sometimes we are able by enclosing in
the ligature a portion of flesh through which the artery
passes, to put a stop to hemorrhage. In other cases
the application of lint aud moderate pressure effects the
purpose (but this can only be trusted when the bleed-
ELEMENTS OF SURGERY. 51
ing is from small vessels.)* The application of stiptics
and escharotics, is nearly out of use among surgeons;
and yet cases sometimes occur, in which they may be
employed with advantage, as when the bleeding vessel
is beyond the reach of the ligature, and in such a situa¬
tion, as to preclude compression.! I have once known
the hot iron necessary to put a stop to a most alarming
hemorrhage from a large artery in the posterior fauces,
which had been wounded in extirpating a tumour from
the mouth. It sometimes happens that a proper pos¬
ture of a limb restrains hemorrhagy. The posture
should be one in which gravity favours the descent of
blood through the veins, and retards its motion in the
arteries.
The form of the ligatures used by surgeons is not an
object of much consequence when the vessels are small;
when a large artery however is to be secured, Dr. Jones
recommends them to be round and very firm; he statesa
that though a slight force only is necessary to cut
through the internal and middle coats of an artery, it
is better to tie the vessel more tightly than is necessary,
merely to cut through its inner coats, because the cut
surfaces will be more certainly kept in contact, the se¬
paration of the ligature expedited, and the danger of ul¬
ceration spreading to the newly cicatrized part diminish¬
ed. This direction of Dr. Jones, I believe useless, and
except in the larger arteries, it is quite sufficient to tie
the ligature with force enough to command the he¬
morrhage, and even in the largest arteries, I believe
* A piece of fine sponge secured by moderate pressure over the bleed¬
ing surface, will sometimes be found a very valuable remedy for the sup¬
pression of hemorrhage.—Ed.
j- Powdered agaric. Flour sprinkled over the surface, by exciting coagula¬
tion often stop* the bleeding, Sp. turpentine; alum, blue vitriol, the mineral
acids, lunar caustic* &c. &«.
ELEMENTS OF SURGERY.
the direction has frequently induced surgeons to break
their ligatures by unnecessary force.
I would here state, that round bobbin forms an ex¬
cellent ligature for the larger arteries, and for smaller
vessels, a number of sewing threads waxed together ol
a proper thickness may be used.
Shortly after the first edition of this work was pub¬
lished, Dr. Physick suggested to the author the pro¬
priety of testing by experiment, the value of an improve¬
ment he had long contemplated in the formation of liga¬
tures—this was accordingly done, and has resulted in
the substitution of certain animal substances for the
materials formerly employed.
It has long been a desideratum among surgeons, to
be able to remove the ligature from a wound after the
blood-vessel on which it has been applied is healed.
Many weeks, and in some cases months, have been
found to elapse before the ligature is detached, during
all which time the sore is prevented from healing, and
in some cases hectic fever and a fatal termination have
resulted. There can be no reasonable doubt entertain¬
ed, that all the processes requisite for the complete ob¬
literation of a blood-vessel, secured by ligature, are
completed in a very short space of time, probably in
two or three days.* It follows that if the ligature ap¬
plied, be made of materials capable of securing the
vessel during this space of time, and liable to decom¬
position and solution in the animal fluids afterwards, the
requisite advantages will be obtained. Dr. Physick
was induced to believe that leather would be found to
possess these properties; he had remarked that the strips
of adhesive plaster applied over ulcers, retained their
strength of texture a few hours and then became dis-
* Vide Travers' Experiments, in the 6th vol. Medico-Chir. Transactions.
ELEMENTS OF SURGERY.
53
solved in the pus discharged from the sore; should the
leather be found to dissolve too rapidly, there were other
animal matters which he proposed to substitute.
The first experiment made to ascertain the correct¬
ness of these opinions, was the application of a buck¬
skin ligature to a large artery in a horse. It restrained
the bleeding and was dicharged in a liquid state in two
or three days.
Some time after this experiment, Dr. Hartshorne em¬
ployed ligatures of animal matter for securing the blood¬
vessels in the human subject He amputated a leg at
the Pennsylvania Hospital, and tied up the vessels with
strips of parchment, which were found to answer ex¬
tremely well. At the first dressing the ligatures were
found dissolved, and never occasioned any inconve¬
nience.
Pursuing the enquiry, I performed a number of expe¬
riments with various animal substances, as catgut, parch¬
ment, various kinds of leather, &c. The best method
of constructing ligatures which I have been able to de¬
vise, is by cutting French kid leather into strips, from
a fourth of an inch to half an inch in width, peeling off
what is called the grain, or coloured, polished surface:
the strips are then wet and stretched—they gain greatly
in length and are diminished in breadth by this process;
and ligatures may be prepared of any requisite strength
by varying the width of the strips. I have employed them
in amputations, and in a number of the capital opera¬
tions, and never have seen any occasion to regret their
use, but on the contrary, to consider it one of the most
valuable improvements in modern surgery.
I have not thought it requisite to leave the ligatures
hanging out of the wound, after accidents or operations,
but have cut them very close to the knot and treated
the case as if no ligature were employed, In some in-
54
ELEMENTS OF SURGERY.
stances union by the first intention has taken place, the
ligature probably being dissolved and absorbed, at least
it has never afterwards appeared, but in others suppu¬
ration and abscess have been produced.
Since the experiments above cited have been made,
I find that Mr. Lawrence has proposed to cut off the
ligatures after operations, close to the divided vessels.
How well the practice may succeed where they are
composed of durable materials, future experience may
decide, but I cannot forbear the expression of a belief,
that the animal ligatures will supplant all others except
in a few particular cases which will readily suggest
themselves to the surgeon. For example, in closing"
wounds of the abdomen, when they can be taken out
at pleasure—in cases of hare-lip, &c.
The leather ligatures are rather more bulky than
those made of thread or silk: a little practice, however,
will enable the surgeon to make them very neatly, and
to employ them in arming his needles, as conveniently
as any others. In several cases in which I nave am¬
putated scirrhous breasts, and have necessarily removed
much skin, I have, from the heat of the weather, been
induced to dress the patient on the third day, and at
this period not a vestige of ligature has been observed,
except at the upper part of the wound, when this has
been dry, in which case the leather is not destroyed so
rapidly.
The femoral is the largest artery 1 have as yet secur¬
ed with a leather ligature; I should not, however, hesi¬
tate to employ one for tying any other vessel in the
body when necessary. It would be easy by soaking
the ligatures in linseed oil ; or in certain resinous sub¬
stances, to render them more durable, but I have not
found this expedient necessary.*
* The first publication on this subject was made by Dr. Pbyack, in the
Eclectic Repertory, dated July 9th, 1816.
aJUijr J.WAV,
ftjiujr ?tii) AU.IV*
ELEMENTS OF SURGERY. 55
When the bleeding from an incised wound is arrest¬
ed, the next thing demanding the attention of the sur¬
geon, is the removal of all extraneous matter; the clot¬
ted blood, dirt, &c. must be carefully washed away, and
the sides of the wound are then to be approximated
and kept in contact. The measures to be employed
for this purpose are strips of adhesive plaster, com¬
presses, bandages, and a proper position of the part,
rest, and lastly sutures.
The adhesive plasters are in most cases sufficient,
when aided by bandages and a proper posture, without
the use of the needle. The sides of the wound being
placed in contact, are to be held so by an assistant, and
the surgeon is to apply strips of plaster spread on linen
or leather across the wound. These strips should be
of considerable length, so as to act on a large surface
of sound skin, and from half an inch to an inch in
width. They should be placed at a small distance one
from the other, so as to allow the escape of any extra-
vasated fluid through the interstices. If this caution
be neglected, and the plasters placed so as to cover the
whole wound, they often convert it into an abscess, by
preventing an outlet for superfluous blood or serum, and
in case of suppuration the pus is confined, the parts
already united are torn asunder, and the inflammation
is extended.
If, from the small extent of the wound and other cir¬
cumstances, there is reason to expect its union by the
first intention, or by the adhesive inflammation, nothing
more is necessary than to apply a compress of folded
linen, or a pledgit of dry lint over the adhesive strips,
and secure them by a few turns of a roller.
Should there be no good prospect of so speedy a cure,
and reason to expect suppuration, a pledgit of lint
spread with simple cerate, and covered with a pledgit
56
ELEMENTS OF SURGERY.
of tow or folded linen, may bd placed over the adhesive
strips and confined by the many-tailed bandage, or rol¬
ler; but it is of no importance to make any difference
of treatment on account of the uncertainty respecting
the manner in which the wound is to heal, and it is best
to treat incised wounds generally as if the union by the
first intention were certain. The pledgit of tow or
linen which adds somewhat to the pressure, and is cal¬
culated to absorb any fluid which may escape from the
wound, may readily be superadded if found necessary.
In all incised wounds the sides should be placed and
kept as much as possible in contact. There can be no
application to wounded flesh more natural or proper
than the flesh from which it has just been violently se¬
parated, and if it do not adhere to it entirely, yet in all
probability a very considerable part will, and thus the
extent of the wound will be lessened.
The rapidity with which incised wounds sometimes
unite, is really astonishing to any one not Conversant
with these wonderful powers of nature. I have seen
a considerable tumour cut out from the breast, and in
forty-eight hours a complete union of the wound had
taken place. The wound may be examined in warm
weather in forty-eight hours, in winter it is best not to
disturb the dressings for three or four days.
If fever and inflammation attend, the usual depleting
remedjes are to be used; if, on the contrary, there be
reason to apprehend tetanus, wine, opium, and a gene¬
rous diet are to be prescribed.
The blood effused from the wound is in many cases
the bond of union in incised wounds, but very often this
is lost and adhesive inflammation supervenes; in this
case the secreted coagulating lymph becomes the unit¬
ing medium, and this is soon assimilated to the wound¬
ed part, becoming bone, tendon, muscle, of skin, ar
ELEMENTS OF SURGERY.
57
cording as the wound has been in any of these parts.
The cicatrix, however, differs considerably from the
originally formed parts
Posture is of great consequence in the treatment of
wounds. The sides of a wound on the anterior part of
the thigh cannot be kept in contact, unless the leg be
kept extended upon the thigh; to aid the surgeon still
more in relaxing the parts, the thigh should be flexed
on the pelvis. A wound through the tendo achillis
should be treated by extending the foot upon the leg,
&c.
Sutures by attending to these preceding directions
are very rarely necessary; and if possible ^hey ought to
be dispensed with, as they produce considerable pain,
occasion great and permanent irritation by creating a
number of punctured wounds, which are kept from
healing by the ligature left in them; this ligature passes
through a part of the original wound, and never fails to
excite suppuration in that part; in addition to these ob¬
jections, sutures occasion deformity by increasing the
extent and irregularity of the cicatrix.
Notwithstanding these objections, sutures are some¬
times necessary in wounds of projecting parts, as the
ears, nose, tongue, lips, scrotum, &c. Sometimes the
peritoneum is wounded, and in these cases ligatures are
necessary to keep its edges in contact. In all these in¬
stances the interrupted, or twisted suture are to be used.
The interrujoted suture consists in making the neces¬
sary number of stitches with an armed needle, and
tying them in such a manner as to keep the sides of
the wound together.* The twisted suture is chiefly
used in wounds of the lip; in the annexed plate these
* The knots should be on one side of the wound. It is right to have
the needle shaped so as to form a regular segment of a circle, and to have
two cutting edges continued from the point.
VOL. I.—H
T VAJI A» A*
58
ELEMENTS OF SURGERY*.
sutures are represented. In the twisted sutures two or
more pins of silver with moveable steel points are pass¬
ed through the flesh, and a ligature twisted round
them, so as to confine the sides of the wound in con¬
tact In treating hare-lip, this suture is generally em¬
ployed. The pins ought to be made of smooth silver
wire, the extremities of which fit into steel points which
Are taken off when the ligature is applied. If these
be not at hand, a piece of wire filed sharp at the end
will answer, but after the ligature is bound on, the point
must be cut off with a pair of scissors, or a file.
When ligatures have been applied upon bleeding ar¬
teries, the ends of them are to be left long enough to
project a short distance out of the wound, they are to
be left out of one of its angles, (the most depending if
practicable,) and the wound treated as we have already
directed.
When in cases of incised wounds it becomes evident
that union cannot be effected without suppuration, the
adhesive plasters, and every pressure, every irritation
are to be removed, and a soft poultice substituted.
When suppuration is fairly established and granulations
begin to form, the means already recommended for re¬
taining the sides of the wound in contact, are to be re¬
sumed, and a cure will generally be soon effected.
ELEMENTS OF SURGERY. 59
CHAPTER X.
Of Contused Wounds.
In contused wounds, besides the simple solution of
continuity, there is an injury of the adjacent flesh,
greater or less according to the nature and violence of
the force applied.
Contused wounds are produced by blunt instruments,
ft has already been remarked, that these wounds bleed
less profusely than simple incisions, and the reasons of
this difference have been explained.
The indications of cure are to prevent excessive in¬
flammation, to wait for the separation of the bruised and
dead flesh, and when suppuration is established and gra¬
nulations form, to approximate and retain in contact
the sides of the wound.
The best local application is a boiled bread and milk
poultice. If inflammatory symptoms run high, blood¬
letting is to be directed. If great pain or irritation come
on, opiates may be given; should gangrene result, a
blister is to be applied.
Lacerated wounds partake of the nature of con¬
tusion, but there is a difference, as their mode of union
proves. A severely contused wound never heals by the
first intention, because there is an interposition of clot¬
ted blood and injured flesh, between the sound parts,
whereas I have known half the scalp torn off in a lace¬
rated wound, and the whole of it has reunited by tha
first intention, except the edges which were greatly
bruised.
Punctured wounds have considerable depth, and
very little external opening: they are made by pointed
60
ELEMENTS OF SURGERY.
instruments, as a small sword, bayonet, nails, needles.
They are attended with various consequences, accord¬
ing to the nature of the parts injured. In other wounds
the nature of the mischief is generally apparent; in
punctured wounds, the surgeon is unable to ascertain
with accuracy the parts which are injured; important
nerves, blood-vessels or tendinous fasciae are sometimes
wounded; very violent inflammation often follows a
small punctured wound, and collections of matters are
sometimes formed, great irritation occasionally occurs,
the constitution suffers and fever comes on. Tetanus
is a frequent occurrence after punctured wounds^
though I have as often seen it a consequence of other
contused wounds. Convulsions, tremour, and nervous
affections, are also occasioned.
In the treatment of punctured wounds, the first thing
demanding attention is hemorrhage. If any blood-ves¬
sel of considerable size have been opened, it must be
sought for by dilating the orifice of the wound with a
probe and scalpel; the vessel being exposed in this
manner, should be tied up with a ligature. In some
cases, the bleeding, at first profuse, gradually ceases,
and although from the rapidity with which it flowed,
there may be reason to apprehend the puncture of a
large artery, yet the patient is unwilling to suffer his
wound to be dilated in order to secure the vessel; and
it is a fact that such vessels have sometimes healed with¬
out the interference of art. I have been informed of
a case in which a very large artery in the thigh, proba¬
bly the femoral,* was opened by a small sword, and al¬
though the stream of blood at first was very alarming,
yet it soon ceased, and did not recur, until the tenth
* I speak thus cautiously, because there was no dissection, but I have no
doubt that the wounded vessel was the femoral artery, because the stream
of blood was so copious at first as to lead the surgeons present to that opi -
riion.
ELEMENTS OF SURGERY.
61
day, when an officious surgeon forced his probe into
the vessel and the patient died in consequence of the
bleeding; there is great reason to believe that this pa¬
tient would have recovered but for the improper inter¬
ference of his surgeon. Whenever therefore the bleed¬
ing ceases spontaneously, or after the wound is dressed,
the patient should be kept still and watched carefully,
as a return of hemorrhage is to be apprehended. If
the puncture be on a limb, a tourniquet may be applied
and left loose, so that an assistant may have it in his
power in a moment to put a stop to the effusion of blood,
until the artery is finally secured by a ligature.
The healing of a large artery, however, is an event
seldom to be trusted to, and there is no surgical maxim
of greater importance than the necessity of tying up all
wounded arteries when it is practicable, ft is only in
cases where this cannot be done that the surgeon is to
avail himself of other means for suppressing the he¬
morrhage. As all such means furnish important re¬
sources to the surgeon, I shall mention a plan which I
have known successful in stopping the flow of blood
from an artery in the foot. The patient was a child
in whom several unavailing attempts to tie up the divid¬
ed vessel had been previously made, and the wound was
in a state of great inflammation. A compress was ap¬
plied over the trunk of the anterior, and another over
that of the posterior tibial arteries about two inches
above the ankle: over these a strip of sheet copper was
passed round the leg, and a tourniquet was applied over
the copper; in this way, when the tourniquet was tight¬
ened, the tibial arteries were compressed, and the bleed¬
ing ceased, the copper prevented the tourniquet from
compressing any other vessel, so that the circulation in
the foot was not interrupted. In a few days the wound
healed vyithout any recurrence of hemorrhage. Proba-
62 ELEMENTS OF SURGERY.
bly in some analogous cases similar measures may bf
found successful.
When punctured wounds contain foreign substances
which are easily felt, they may be dilated sufficiently to
allow the extraction of these substances, but in most in¬
stances it is best to permit them to be discharged by sup¬
puration.
When convulsions, or great nervous irritation follow,
the dilatation of a punctured wound frequently puts an
immediate stop to these symptoms-, a small incision
upon a probe passed into the puncture, will suffice for
this purpose.
When punctured wounds occur in extremely hot
weather, it is safest to enlarge them by the scalpel, or to
apply stimulating substances to excite inflammation;
there is reason to believe that tetanus has in this way
been often prevented.
Erysipelatous inflammation in some instances follows
punctured wounds, especially of the scalp; an enlarge¬
ment of the wound has been found useful in these cases,
and a blister should be applied over the inflamed parts.
> These are the principal circumstances in punctured
wounds, which call for dilatation; when suppuration is
established, if matter be formed and confined, an outlet
must be made for it as in any other case. The prac¬
tice of dilating indiscriminately all punctured wounds is
highly reprehensible. A soft poultice is the best local
application. If the pain be great, opium may be admi¬
nistered, and if fever or inflammation run high, bleed¬
ing and depleting remedies may become necessary.
They are always, however, and particularly in hot
weather, to be prescribed with caution, as they cer¬
tainly render the system more liable to tetanus; punc¬
tured wounds sometimes unite by adhesive inflamma¬
tion, but if extensive they generally suppurate.
ELEMENTS OF SURGERY.
63
CHAPTER XI.
Of Gunshot Wounds.
Since the application of gunpowder to the purposes
of war, a new class of wounds has attracted the atten¬
tion of surgeons, the nature and peculiarities of which
have only within a few years been well understood.
" Gunshot wounds are made by the forcible projec¬
tion of hard obtuse bodies, the greatest number of which
are musket balls.
" They vary according to the kind of body projected,
the velocity of the body, and the nature and peculiari¬
ties of the parts injured. The kind of body projected,
is principally musket balls, sometimes cannon balls,
sometimes pieces of broken shells, and very often on
board of ship, splinters of wood. The effects of cannon
balls on different parts of the ship, are the principal
causes of wounds in the sailor, for a cannon ball must
generally pass through the timbers of the ship before it
reaches him; a greater number will be wounded by the
splinters thus torn off, than by the ball itself. The
wounds occasioned by these splinters, differ in no re¬
spect from contused and lacerated wounds from other
causes.
" Gunshot wounds are in general contused wounds,
from which contusion there is most commonly a part of
the solids surrounding the wound deadened, as the pro¬
jecting body forced its way through these solids, which
is afterwards thrown off in form of a slough, and which
prevents such wounds from healing by the first inten¬
tion, or by means of the adhesive inflammation, from
which circumstance most of them must be allowed to
64
ELEMENTS OF StfRGERT.
suppurate. This does not always take place equally in
every gunshot wound, nor in every part of the same
wound; and the difference commonly arises from the
variety in the velocity of the body projected; for we find
in many cases, where the ball has passed with little ve¬
locity, which is often the case with balls, even at their
entrance, but most commonly at the part last wounded
by the ball, that the wounds are often healed by the
first intention.
" Gunshot wounds, from the circumstance of com¬
monly having a part killed, do not generally inflame so
readily as those from other accidents; this backward¬
ness to inflame, will be in the proportion that the quan¬
tity of deadened parts bear to the extent of the wound.
u From the circumstance of a part being deadened,
a gunshot wound is often not completely understood at
first; for it is at first, in many cases, impossible to know
what parts are killed, whether bone, tendon, or soft
part, until the deadened part has separated, which makes
it a much more complicated wound than at first was
known or imagined; for it very often happens, that some
vise us, or a part of some viscus, or a part of a large ar¬
tery, or even a bone, has been killed by the blow, which
does not show itself till the slough comes away. If, for
instance, it is a part of an intestine that has received a
contusion, so as to kill it, and which is to slough, a new
symptom will most probably appear from the sloughs
being separated, the contents of the intestine will most
probably come through the wound; and probably the
same thing will happen when any other containing vis¬
cus is in part deadened; but those cases will not be so
dangerous, as if the same loss had been produced at
first, for by this time all communication will be cut off
between the containing and contained parts; nor will it
be so dangerous as when a considerable blood-vessel is
ELEMENTS OF SURGERY.
deadened; for in this case, when the slough comes off,
the blood, getting a free passage into the wound, as also
out of it, probably death will immediately follow. If
this artery is internal, nothing can be done; if in an ex¬
tremity, the vessel may generally be taken up. When
the bone is deadened, an exfoliation must take place."
{Hunter.)
The velocity with which the ball passes has a great
influence on the circumstances of these accidents. If
the velocity be small, there is not so great a chance of
their being compounded with fractured bones; but if
the velocity be sufficient to break the bone it hits, the
bone will be much more splintered than if the velocity
had been very considerable, for where the velocity is
very great, the ball, as it were, takes a piece out. In a
very hard bone the splinters will be most numerous.
The direction of a ball is influenced by the celerity of
its motion. If it move with but little force, it is easily
altered from its straight direction, by a bone; where
the velocity is greatest, the course is most direct.
The greater the velocity of a bullet, the greater will
be the extent of the deadened parts, consequently the
slough is always greater at the entrance than at the
exit of a ball, and in some cases the part at which it
passes out, heals by the first intention or by suppura¬
tive inflammation without casting off any slough.
Gunshot wounds, like all other contused wounds,
bleed less than simple incisions; the explanation of this
has already been offered. If, however, large vessels
are killed by the ball, when the sloughs separate there
will be great danger of hemorrhage from the opening
formed in the artery.
There is very frequently extraneous matter contain¬
ed in gunshot wounds, as the bullet carries in with it
all the clothing which had been on the wounded part>
vol. i.—i
ELEMENTS OF SURGERY.
and often remains itself in the wound, much altered in
form from the effects of bones upon it. I have seen a
bullet beat out nearly as thin as paper, by passing
through a rib and lodging in one of the vertebrae. These
extraneous substances however do less mischief than
in any other kind of wounds, because as they are in
contact with dead parts, they occasion no irritation, and
as these dead parts are themselves foreign matter and
must be discharged by suppuration, the wound is not
much delayed in healing by their presence.
TREATMENT OF GUNSHOT WOUNDS.
The various phenomena of gunshot wounds, being of
a nature not very readily explained by the older sur¬
geons, induced some to believe that they were poison¬
ed, others imagined the ball to be intensely hot, and
supposed the peculiarities of these accidents to depend
on the burning of the sides of the wound. The essen¬
tial difference, and the only difference between gunshot
and other contused wounds, is found to consist in the
death of those parts through which the ball has passed,
and the necessity for the separation of these parts be¬
fore union can be effected.
It was formerly the custom to dilate all gunshot
wounds, and much mischief has resulted from the prac¬
tice. There is nothing in the nature of this kind of ac¬
cident that calls for dilatation in every case, nor is there
any thing forbidding the practice when particular cir¬
cumstances render it proper. If an artery be opened
by a gunshot wound, and the enlargement of the wound
by a knife will enable the surgeon to tie it up, he ought
surely to perform the operation. In general it is un¬
necessary to dilate a gunshot wound for the purpose of
extracting a bullet or other extraneous matter, because
suppuration must come on, and this process will gene-
ELEMENTS OF SURGERY.
67
rally effect the object. If extraneous matter is perceiv¬
ed, and can easily be removed, it may be done; but it
is wrong to enlarge the wound or take much pains to
effect, what will be more readily done at a future period.
The same reasons which would induce a surgeon to
dilate a punctured wound, or any other kind of wound,
should lead him to dilate a gunshot wound; these rea¬
sons have been already stated.
When a ball can be found without difficulty, it is
right to extract it by means of forceps; the course of a
ball, however, is so extremely irregular, that we are not
always able to find it. The glancing of balls is in many
cases very surprising. Mr. Hunter has seen a bullet
enter the skin over the tibia, and pass round the leg
under the skin without injuring either the bone or the
skin. Wiseman relates cases where balls have passed
through joints without occasioning an injury to the
bones or cartilages. When the velocity of a ball is
nearly spent, a slight resistance will turn it from its
course; balls have been known to pass round half the
skull between the cranium and scalp, and then pass out
opposite the part at which it entered. In the same way
they have passed round the thorax, and glancing from
a rib and kept from passing out by the resistance of the
skin. Mistakes have been occasioned by these irregu¬
larities, and bullets are said to have passed through the
head and chest in many cases where no such thing has
happened. The posture of the body when the wound
was received, should be attended to when the course
of a bullet is searched for; a ball has entered the arm
and been found on the opposite side of the body, ow¬
ing to the horizontal posture of the limb when wounded.
In many instances balls pass immediately under the
skin to a considerable distance, their course being
marked by a red line extending from the spot where it
68
ELEMENTS OF SURGERY.
entered, to that at which it escaped or is lodged.
Where bullets are lodged superficially under the skin,
they may ivith great safety and propriety be cut out, and
no mischief in general arise from this new opening.
The propriety however of extracting balls thus situated
has been questioned, and Mr. Hunter remarks, that it
the skin over it be quite sound, he would u in that case
advise letting it alone, until the wound made by the en¬
trance of the ball had inflamed and was suppurating/*
His reasons for this direction are, " 1st. We find that
most wounds get well when the ball is left in (except¬
ing it has done other mischief than simply passing
through the soft parts) and that very little inflammation
attends the wound where the ball lodges, only that
where it enters, the inflammation not arising so much
from the injury done by the bail, as from the parts be¬
ing there exposed to the suppurative inflammation, if it
is immediately removed. There is always a greater
chance of a slough where the ball enters than where it
•rests, arising from the greater velocity of the ball, for
beyond where the slough is, the parts unite by the first
intention."
" 2dly. In those cases where the ball passes through
and through, we have two inflammations, one at each
orifice, instead of the one at the entrance, or a continued
inflammation through and through, if the ball has pass¬
ed with great velocity. Where the ball makes its exit,
the inflammation passes further along the passage of
the ball, than when the wound has been healed up to
the ball and then cut out afterwards, so that by open¬
ing immediately the irritation will be extended further,
and of course the disposition for healing will be pre¬
vented. If this is the case, I think that two wounds
should not be made at the same time, and what con¬
vinces me more of it is, that I have seen cases where
ELEMENTS OF SURGERY.
69
the balls were not found at first, nor even till after the
patients had got well of their wounds, and these balls
were found very near the skin. They gave no trou¬
ble (or else they would have been found sooner) no
inflammation came upon the parts, and afterwards they
were extracted and did well."
" Again I have seen cases where the balls were found
at first, and cut out immediately, which were similar to
balls passing through and through : the same inflam¬
mation came on the cut wounds that came on the
wounds made by the entrance of the ball."
On these remarks of Mr. Hunter, I beg leave to offer
a few observations. A musket or pistol bullet will,
doubtless, in a majority of cases, excite no unpleasant
symptoms, the parts will heal around it, forming a sac;
but a bu.Uet is always extraneous matter, and in a ma¬
jority of cases, carries with it other extraneous matter,
cloth, linen, &c. which cannot fail to irritate the flesh
in which they lodge; they act like setons in keeping up
suppuration, and preventing the union of the wound,
effects which I have witnessed in several cases; in one
a very large abscess was formed on the back in conse¬
quence of a ball being suffered to remain nineteen days
under the skin, near the angle of the scapula.
It is with great diffidence that I would venture to op¬
pose, on a practical point, the authority of Mr. Hunter,
but I cannot but believe it right, whenever a ball pre¬
sents itself in such a situation as that it may be extract¬
ed with facility, and without risque of injuring any im¬
portant part, to remove it immediately, without waiting
for suppuration. The wound made by the knife may
commonly be healed by the first intention. The ball
should be suffered to remain whenever it is deeply bu¬
ried in the flesh. All other extraneous matter, if easily
removed, should be extracted, but probing or other via-
70 ELEMENTS OF SURGERY.
lence, must be avoided ; the finger is to be preferred
to all instruments in examining gunshot wounds.
Sometimes bullets are lodged in the substance of the
bones; all violent attempts to remove them are wrong .
the bone will exfoliate, and when suppuration takes
place, the ball will be discharged. In some cases, balls,
and other extraneous matter, have remained in bones,
or in the soft parts, during life, without exciting any
unpleasant effects, but sometimes they produce suppu¬
ration, and are evacuated long after the wound has
healed. A very remarkable instance of this kind, I
shall quote from a letter with which I have been fa¬
voured by Mr. John Randolph, of Roanoke. Major S.
was wounded in the arm at the battle of Germantown:
<4 the wound healed, but was occasionally painful, and
once or twice suppurated and healed again. At length,
about twenty-five years after the injury had been re¬
ceived, the wound broke out for the last time, when a
small shred of woollen cloth, recognized by the patient
as a portion of his coat, and another of linen, were dis¬
charged; they seemed to have undergone no sensible
alteration, except saturation with the pus and sanies,
in which they were immersed."
For the removal of musket balls, a variety of forceps
have been constructed. A prize was given by the
French Academy of Surgery to Mr. Percy for one
which appears to answer extremely well. The instru¬
ment is represented in PI. II. When a leaden ball is
lodged in a bone, the screw, which is contained in one
of the handles, may be easily made to enter it, and it
can be extracted. This screw, however, is so seldom
needed, that it is omitted in the bullet forceps used in
the service of the United States.
When an extremity has been shattered by a cannon
ball, the extent of injury is, in some instances, so great
Pin v*i > hn/Jr> 1 Tnr
' c fn j / /^> t /- >>
ft"revs Millet Forceps.
v
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.
. • |
.
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ELEMENTS OF SURGERY.
71
as to require the immediate removal of the member;
we shall mention the circumstances which call for this
operation, when we treat of amputation.
The best local application to a gunshot wound, is a
soft poultice of bread and milk, or linseed, to be con¬
tinued until the sloughs separate, and suppuration is
established. The treatment is to be similar to that of
any other contused wound. The state of the constitu¬
tion must be very carefully attended to.
When there is reason to apprehend that the parietes
of any considerable blood-vessel has been killed by the
ball, great care should be taken to attend to the sepa¬
ration of the sloughs, as serious and fatal hemorrhages
have sometimes resulted from neglecting this caution.
When bones are injured, the soft parts, in some
cases, heal up; and, when the injured bone exfoliates,
an abscess forms, and the wound must be opened afresh.
72
ELEMENTS OF SURGERY.
CHAPTER XII.
Of Poisoned Wounds.
Poisoned wounds .are those attended with an intro¬
duction of certain healthy or morbid secretions of ani¬
mals or vegetables, capable of producing disease and
death; as the bite of a venomous reptile, of a rabid ani¬
mal, or a wound with a poisoned arrow.*
The sting of a bee, wasp, or hornet, the bite of a
musquitoe, and certain other insects, although in de¬
gree very moderate, probably partake somewhat of the
nature of poisoned wounds. It is unnecessary to say
much of these. Although frequent in their occurrence,
they are generally not so severe as to require medical
aid. The sting of a bee, wasp, or hornet, is always ex¬
tremely painful, and is followed by inflammation, and
sometimes by great tumefaction. Cold applications
afford great relief. Cold water or lead water may be
used. When the patient has been attacked by a swarm
of these insects, and his head and face (which gene¬
rally, in these cases, suffer) are much swelled, bleeding
and a purge become necessary.
The bite of the musquitoe is, in some parts of our
country, extremely annoying, and excites considerable
inflammation, attended with intolerable itching. In
some rare instances, owing, probably, to peculiarity of
constitution, gangrene has resulted from the bite of this
insect. I once knew a case of it fatal in a lady of this
city, whose health, previously, was very good. Cam-
• With respect to the manner in which poisons act in producing death,
the reader is referred to Fontana; the late experiments of Mr. Magendie
upon the " upas tieute," and also to the interesting experiments of my
friend, Mr. Brodie, related in the Transactions of the ltoyal Society of
London.
ELEMENTS OF SURGERY. 73
phorated spirits, brandy, or vinegar, generally afford
relief of the itching, and the inflammation, in a few
hours, commonly subsides. Violent rubbing, to allay
the itching, should be avoided.
The rattlesnake, one of the most venomous reptiles
in the world, is found in many parts of our country.*
Like the cobra de capello in India, the bite proves
speedily fatal, and we have very few histories of the ef¬
fects of the poison.
Professor Barton, whose indefatigable labours have
thrown light on every branch of physical science, has
published in the 3d vol. of American Philosophical
Transactions, a valuable paper on the subject, to which
the reader is referred for much interesting information.
It appears from Dr. Barton's remarks, and from the
observation of others, that " in the season of superven¬
ing langour and torpidity, the rattlesnake in particular
bites with seeming reluctance, and without any or with
but little ill consequence arising from the wound;" and
" even in those seasons when the sun powerfully exerts
its influence, at which times these animals are best qua¬
lified to strike and to injure, individuals of the species
must be often found, the cavities of whose venomous
fangs are entirely or nearly destitute of their active poi¬
son, from the introduction of which into their body
those alarming symptoms which characterise the suc¬
cessful bite of this animal arise." Three chickens
were bit by a rattlesnake kept in a cagej on three suc¬
cessive days. The first died in a few hours; the second
survived much longer than the first; the third swelled
much, but nevertheless recovered. On the fourth day
several chickens were bitten, without receiving any in¬
jury. These circumstances are mentioned by Dr. Bar-
* There are several species of crotalus. I refer to the w crotalus horri-
dus," which is the most common species.
VOL. I.—K
74
ELEMENTS OF SURGERY.
ton, to show that the various supposed vegetable speci~
fics for the bite of the rattlesnake owe their reputation
to their having been used in cases where no bad effects
would have resulted.
As the poison of the rattlesnake " exerts its principal
effects on the sanguiferous system," immediate care
should be taken to cut off the circulation of blood
through the wounded part. When the poison enters a
considerable vein or artery, death in general speedily
ensues; often in the space of two minutes. Of this Dr.
Barton has been assured from a variety of sources, al¬
though he is unwilling to believe the wound necessarily
mortal. The wound being generally in the lower ex¬
tremities, he recommends the immediate application of
a tight ligature round the limb, to prevent the access of
the poison to the circulation either by the veins or ab¬
sorbents. " As poisons of various kinds are liable to be
detained for some time in the glandular appendages of
the absorbent system, it would perhaps be of use to sca¬
rify these parts, and apply a blister to them, in order to
promote the discharge of the poison." When the
glands in the groin swell, as they speedily do after a
bite in the foot, the scarifications are to be made there,
and a prompt vesication excited by the bark of the
Daphne Gnidium.
I think there can be no doubt of the propriety of ex¬
tirpating immediately the wounded part, as this will ef¬
fectually cut off all communication with the circulating
blood. The use of the numerous vegetable remedies
which have been employed in these cases appears en¬
titled to but little attention. The internal administra¬
tion of volatile alkali has been very often employed, but
probably its virtues are much overrated.
" When the poison of the rattlesnake has actually
been introduced into the general mass of Wood, it be-
ELEMENTS OF SURGERY.
75
gius to exert its most alarming and characteristic effects.
A considerable degree of nausea is a very common
symptom. We now discover an evident alteration in
the pulse; it becomes full, strong, and greatly agitated;
the whole body begins to swell; the eyes become so en¬
tirely suffused, that it is difficult to discover the smallest
portion of the adnata that is not painted with blood.
In many instances there is an hemorrhage from the eyes,
and likewise from the nose and ears; and so great is
the change induced in the mass of blood, that large quan¬
tities of it are sometimes thrown out on the surface of
the body in form of sweat. The teeth vacillate in
their sockets, whilst the pains and groans of the un¬
happy sufferer too plainly inform us that the extinction
of life is near at hand."
" In this stage of its action, and even before it has
induced the most alarming of the symptoms which I
have mentioned, the powers of medicine can do little to
check the rapid and violent progress of this poison.
The employment of the ligature, the use of the blister,
and of the other modes of treatment which I recom¬
mended in the local stage, it is obvious to remark, will
be of little, if any benefit here." (Barton.)
Perhaps the same remarks will be found applicable
in cases of bites from the other venomous serpents of
America, but my own experience does not warrant me
in offering any thing on this subject.*
* Within a few years arsenic, in large doses, has been highly recommend¬
ed by Mr. Ireland, a British military surgeon, as an antidote against the
poison of venomous serpents. He states that he has succeeded in effecting
a cure with it in five cases.
He directs a mixture composed of two drachms of Fowler's solution, ten
drops of laudanum, and one ounce and a half of peppermint water, to be
added to half an ounce of lime juice, and taken in its effervescing state, and
this to be repeated every half hour for four successive hours. The parts,
in the mean time, are to be fomented with common fomentations* and rub¬
bed with a liniment composed of
76
ELEMENTS OF SURGERY.
The bite of rabid animals is in all instances to be
treated by extirpation with the knife, and when any
dpubt exists as to the removal of all the injured parts,
caustic should be applied, so as to render their separa¬
tion absolutely certain. This is to be done even if
months have elapsed after the healing of the wound,
upon the principle of leaving nothing undone which can
possibly be instrumental in preventing so terrible a dis¬
ease as hydrophobia.
Inoculation with morbid poisons is foreign from our
present subject, and with respect to poisoned arrows,
and the effects of the "upas tieute/' i refer to the ex¬
periments of Mr. Magendie.
01. Terebinth, gss.
Liquor Amnion. 3SS.
Ol. Olivar. ^iss.
Cathartic glysters are to be used at the same time until the bowels are
freely opened.—Ed.
See Med. Chir. Trans, vol. ii. p. 393, &c.
ELEMENTS OF SURGERY.
77
CHAPTER XIII.
Of Particular Wounds.
The Scalp is liable to all the varieties of incised
and contused wounds; they are often accompanied with
injuries of the brain. A mere wound of the scalp is
to be treated as a similar wound in any other part. The
hair is to be carefully shaved, the extraneous matter
removed, the divided parts replaced in contact, and se¬
cured so by adhesive plaster, or if necessary, by stitches.
The vessels of the scalp seldom bleed so as to require
the use of a ligature. When a large artery, however,
is opened, as the occipital, or one of the principal
branches of the temporal, it must be taken up: the
needle is found more convenient for tying up arteries
in the scalp than the tenaculum.
Punctured wounds of the scalp often occasion violent
inflammations, in consequence of the parts underneath
the tendon of the occipito frontalis muscle being injur¬
ed. The usual remedies for inflammation relieve it.
In extensive lacerated wounds great portions of the
scalp are separated, leaving the pericranium,, and in
some places, the borle bare. It was the practice for¬
merly to remove all such detached portions by the knife,
than which nothing can be more absurd. The doc¬
trines of adhesion, taught by Mr. Hunter, have in this?
as in many other important instances, triumphed over
the barbarisms of former ages, and demonstrated the
propriety of preserving, in every instance, the separated
scalp. The parts are to be cleansed and placed in con¬
tact, and they will generally unite by adhesive inflam¬
mation; and if suppuration should even take place, gra~
78 ELEMENTS OF SURGERY.
nutations will form, and the union, though more tardy,,
will be equally certain. I have seen nearly one half
the scalp torn off, and covered with dirt and splinters of
wood, which, when carefully cleansed and replaced,
united in a few days with very little suppuration.
wounds of the face.
The face is liable to the various kinds of wounds
which have, been described, and they require no parti¬
cular mode of treatment from their situation, except
that it is of peculiar importance to make the cicatrix as
small and as smooth as possible, to prevent deformity.
Sutures are of course to be avoided, and sticking plas¬
ter to be used. In wounds of the eyelid, however, it
sometimes happens that a stitch or two is necessary.
In these cases care must be taken not to pass the liga¬
ture through the adnata, as in that case great irritation
will be the consequence.
In the treatment of wounds of the eye, the great
objects are to extract all foreign matter, and to make
use of very powerful measures to prevent and relieve
the inflammation of this important organ. The va¬
rious remedies for inflammation of the eye will be de¬
tailed when we speak of ophthalmia.
Where the lip is cut through, if the wound be small,
sticking plaster will be found sufficient to keep its sides
together; but if it be half an inch or more in extent,
the interrupted or twisted suture will be necessary.
When the tongue is cut, stitches must be used. In
children we often find the tongue wounded by the teeth
in consequence of falls. A hook is in these cases ge¬
nerally necessary to keep the tongue sufficiently for¬
ward to enable the surgeon to perform the operation.
A piece of soft wood should be placed between the teeth
to prevent the child from biting the surgeon. In the
ELEMENTS OF SURGERY. 79
course of six or eight days the stitches may be remov¬
ed. During the cure the child should not be allowed
to chew any solid food, but must be nourished entirely
on fluids.
When the ears are wounded, if a portion is nearly
detached, stitches are necessary, but in many cases the
adhesive plaster is found equally effectual, and should
therefore be preferred.
Contused wounds of the face are to be poulticed un¬
til suppuration commences and granulations form, and
then the adhesive strips are to be applied.
WOUNDS OF THE THROAT.
Prom the important parts which are here situated,
and from the magnitude of the blood-vessels generally
divided, wounds of the throat are among the most dan¬
gerous to which the. surgeon is called.
Superficial wounds*of the throat require no particu¬
lar treatment, but generally heal as readily as wounds
of other parts. Sometimes, however, the trachea is di¬
vided, together with large veins and arteries, even the
oesophagus, and carotid artery, without immediate death.
Whenever the carotid artery is opened freely by a
sharp instrument, fatal hemorrhage very promptly takes
place: but Mr. Abernethy has recorded an instance in
which a lacerated wound of this vessel was occasioned
by the horn of a cow, and the bleeding was not attend¬
ed with fatal consequences.* Wounds of the throat
most frequently occur in attempts to commit suicide;
and as the instrument is commonly a razor or very
* Baron Larrey has seen two cases, and Dr. Hennen one case, of bleeding
from the carotid arteries, occasioned by gunshot wounds, permanently stop¬
ped by pressure.
We should consider it safest in all cases of bleeding from the carotids,
to secure the vessels at once by means of a ligature .—Ed,
80
ELEMENTS OF SURGERY.
sharp knife, the hemorrhage is profuse, and is always
the first thing demanding attention.
Every bleeding vessel should be immediately secured
by a ligature. The external jugular veins are generally
opened, and these, as well as the divided arteries, are
to be tied. The carotid itself should be tied up, if the
surgeon arrive in time to effect it. Mr. Abernethy, in
the instance just noticed, secured this vessel by a liga¬
ture, and his patient survived thirty hours. He re¬
marks that, " should it become necessary at any time
to tie the carotid artery, it may be done without much
difficulty or danger, even without an accurate dissec¬
tion of the part. If the incision be made on that side
of the artery which is next the trachea where no im¬
portant parts can be injured, as was done in the present
instance, the finger can then be passed behind the ar¬
tery so as to compress it. The vessel being sufficiently
bulky and firm to make its form afld outline distinctly
perceptible, a needle may then be passed behind the
artery as near'as possible to that edge of it which is
next to the internal jugular vein; there can be little
risk of wounding that vessel, or of including in the li¬
gature the eighth pair of nerves which lies between
them. In attempting to secure the carotid artery, I
passed behind it in the manner described, a blunt hook
with an eye in the point, and having previously intro¬
duced a ligature into it, I drew back the instrument and
thus enclosed the artery.
In an incised wound of the carotid artery a very dif¬
ferent and much more expeditious method would be ne¬
cessary. The operation has hitherto never been done,
but a case may possibly occur in which the surgeon may
be present. In such a case I can see no impropriety in
passing a sharp armed needle round the carotid without
attending to nerves or any thing else. This ligature
elements of surgery.
81
being given to an assistant, a second should be instantly
passed in the same manner round the upper orifice,
The hemorrhagy could now be restrained until the
wounded vessel could be drawn out separately with a
tenaculum or forceps, and both its cut extremities tied;
after which the first ligatures which had been used as
tourniquets should be removed.
The hemorrhage being stopped, the sides of the
wound are to be brought together, if possible, without
the use of stitches. Where the trachea is only partially
divided, adhesive plaster may always be used; if it
be cut completely through, it is generally recommended
to make use of the interrupted suture; but in some cases
the stitches occasion great irritation, and are ulcerated
out before the union of the wound, leaving it in the same
state in which it had been before the use of the needle.
The interrupted suture is, however, to be used, when¬
ever the wound of the trachea cannot be approximated
without it; and whenever it is used, great care must be
taken to pass the needle merely through the cellular
texture surrounding the trachea, as the thread, if allow¬
ed to pass through the inner membrane of this canal,
would add greatly to the irritation. In addition to this
the head must be bent forward so as to favour the ap¬
proximation of the sides of the wound, and it is to be
kept so by bolsters and bandages: care, however, is ne¬
cessary in all such cases, to guard against a collection
of blood or mucus in the trachea, as death has been
occasioned by a neglect of this caution. Whenever
blood flows in this way into the trachea, and is not rea¬
dily coughed up, the wound should be opened, in order
that it may be discharged.
Where the oesophagus is also opened, it is difficult,
unless the external wound be very extensive, to make
any application to it. Desault, in these cases, recom-
vol. i.—l
s2 ELEMENTS OF SURGERY.
mends the introduction of an elastic catheter oi large
size, through which the necessary food may be inject¬
ed into the stomach, and this practice has been found
extremely useful in a number of cases. It should be
suffered to remain during the cure, and will produce
no ill effect, but on the contrary will preclude all that
irritation which would arise from the action of the mus¬
cles in attempts to swallow. The tube may be passed
either through the mouth or nostril, according to cir¬
cumstances. The oesophagus is sometimes punctured
by a sword, bayonet, or knife, without any wound of
the trachea. In this case, if the blood-vessels escape,
the wound generally heals readily.
The great contraction of the parts in large wounds
of the throat, produces a very unpleasant appearance
of loss of substance. I have seen several cases in which
scarcely any soft parts intervened between the lower
jaw and the sternum; the throat seemed to have sunk
into the thorax, or to have been cut away and removed.
In the Medical Commentaries a case is related by Mr.
Stark, in which this retraction was so great that " be¬
tween the clavicles and os hyoides there was only one
continued gash, which looked as if the windpipe and
gullet had been cut out entirely." In these cases, great
attention must be paid to keeping the head close to the
top of the chest.
Longitudinal wounds of the trachea heal, in general,
without difficulty, by the application of sticking plaster.
It has been doubted by some surgeons, " whether the
oesophagus can ever be wounded without destroying, at
the same time, the large blood-vessels and nerves, so
that the patient must instantly die."* There is no
doubt that the escape of food and liquids, through the
external opening, has been considered a proof of a
• Latta, Vol, III, p. 184.
ELEMENTS OF SURGERY.
83
wound in the oesophagus in cases where the knife or
razor has passed above the os hyoides and entered the
mouth; but it is equally certain that, in many cases,
the trachea has been completely divided, and the oeso¬
phagus not merely opened, but cut nearly asunder, the
wound extending almost to the cervical vertebrae, with¬
out injuring the carotid arteries. Mr. Stark's case was
of this kind. " The pharynx was cut through, except
about a finger's breadth of the back part." I have
seen a case nearly similar, in which the trachea was
cut completely asunder, and the oesophagus opened,
without any wound of the carotid arteries.
84
ELEMENTS OF SURGERY.
CHAPTER XIV.
Of Wounds penetrating Cavities.
The thorax and abdomen are sometimes opened, and
very dangerous consequences often result, especially it
any of the viscera contained in these cavities be in¬
jured.
wounds of the thorax.
When the thorax is wounded to a depth sufficient to
open the cavity of the pleura, the admission of air pro¬
duces an immediate collapse of the lung, and breathing
is performed with great difficulty. The lung so com¬
pletely fills the cavity of the chest that it is generally
injured in gunshot wounds, and in stabs with a dirk or
sword. When this is the case, blood is coughed up.
If a considerable blood-vessel is opened, either in the
parietes of the thorax, or in the lung, blood collects in
the cavity of the chest, produces great oppression, and
increases the difficulty of breathing.
When the wound is a simple incision through the pa*
rietes of the thorax, it should be dressed with adhesive
plaster, its sides being accurately brought in contact.
A compress should be next applied, and over this a
roller, moderately tight round the chest. The patient
should be kept at rest, and observe a strict antiphlogis¬
tic regimen, and be bled to prevent the accession of
inflammation. Treated in this way, incised wounds of
the thorax very generally heal without difficulty. The
great object of the surgeon in every such case is to
effect as speedily as possible the union of the wound,
because whenever the cavity of the thorax is opened,
unless union by the first intention, or by adhesive in-
ELEMENTS OF SURGERY.
85
flammation takes place, violent inflammation comes on,
frequently followed by fatal consequences.
The practice of closing the external wound, after a
violent effort to force out the air from the pleura, and,
indeed, all attempts to draw the air out from it, are un¬
necessary; the wound may be closed without attend¬
ing to the state of respiration, and the air left in the
cavity of the chest will be absorbed without occasion¬
ing any ill effects.
The great anxiety which has been shewn to evacuate
the air, originated in an opinion that the air of the at¬
mosphere is a violent irritant, capable of exciting great
inflammation : an opinion not at all founded in truth.
In the year 1790, Dr. Physick injected air into one side
of the thorax of a kitten, through a small puncture be¬
tween the ribs. The wound healed by the first inten¬
tion, and appeared to occasion very little inconvenience
to the animal. On the fourth day, the kitten was kill¬
ed, and not a vestige of inflammation was observable.
Many cases have occurred in the human subject, in
which the cavity of the pleura has been filled with air
in consequence of a wound, and the wound being
speedily healed, no inflammation has resulted. I once
saw an officer who had been wounded with a dirk; the
air entered and passed out of the wound freely, during
respiration; this wound united by the first intention,
and in a week he was completely well, not having ex¬
perienced a single symptom of thoracic inflammation.*
It happens, in many cases, that the existence of pul¬
monary disease occasions adhesions between the pleura
costalis and pleura pulmonalis, in such a manner as
* It is remarkable that the French surgeons, and indeed many others, re¬
tain this strange notion of the irritating nature of atmospheric air. The
principal case in which it irritates, is when it occasions fermentation in the
cavity of an abscess.
86
ELEMENTS OF SURGERY.
partially, or even totally, to obliterate the cavity of the
pleura. When a wound is received in the chest, under
these circumstances, the danger of inflammation is much
diminished.
Whenever inflammation comes on in consequence of
a wound in the chest, bleedings, copious and repeated,
must be employed; all the remedies for inflammation
are to be vigorously administered, and in general they
are successful.
When the lung is wounded, the patient will cough
up blood, and if a large vessel be opened, (and a great
number exist in the thorax of the largest size) fatal he-
morrhagy will in general quickly ensue, and yet the
heart itself has in some cases been wounded, and also
the aorta, without immediate death.
There is reason to believe that the heart has often
been slightly wounded without fatal consequences, and
Dr. Babington has related a very interesting case in
which the heart was wounded by a bayonet without im¬
mediate death. The patient was a marine on board a
ship of war, and acting as sentinel at the gangway, fell
through to the lower deck, and caught upon the point
of his bayonet. " It entered his side a little below the
false ribs, nearly in a perpendicular direction, and had
penetrated to its hilt, having sustained the weight of his
whole body. The poor man at the time did not feel
himself much wounded. He drew out the bayonet
without assistance, rose, lifted his musket, said he was
not much hurt, and, as if he thought himself still fit to
continue sentinel, walked eight or ten steps, then dropt
down suddenly in a faint. On being laid in a horizon¬
tal posture he soon recovered, and was brought to the
hospital (at Haslar) about 7 o'clock in the evening,
which was about two hours after the accident. He then
made very little complaint of pain, but lay constantly
ELEMENTS OF SURGERY.
8?
on the side opposite to that which was wounded, was in¬
clined to sleep, and when asked a question, spoke
slowly, as if in great distress. The wound was in the
left side, about two inches above the hip bone, and pe¬
netrated into the cavity of the belly, but neither its di¬
rection nor depth could be ascertained. He did not
seem to have bled much, but was very faint, his body-
cold, and the pulse scarcely perceptible. The circu¬
lation was so languid, that, though a vein was opened
in both arms, no blood could be obtained." He soon
after his admission into the hospital began to breathe
with difficulty, (which at first he had not done.) A
great sense of weight was experienced about the chest.
He felt some pain in the breast. A swelling next took
place, proceeding from the breast all over the body. A
little after two o'clock in the morning, (nine hours after
the wound was received,) a sudden strangulation in the
throat put a period to his life.
Upon dissection it was found that the bayonet had
penetrated through the integuments, the abdominal mus¬
cles and peritoneum, had pierced the colon, the stomach,
the left lobe of the liver, the diaphragm, and entered
the thorax at its centre. Immediately within the breast
the pericardium had presented and yielded the instru¬
ment a ready passage to the heart. The right ventricle
there received it. The point was thrust in at the lower
part of the ventricle, and had forced its way out near
the valve. From the heart, again passing the pericar¬
dium, it pierced through both the upper and middle
lobes of the lungs, but even these were insufficient to
detain it. It forced a passage on the right side near
the sternum, between the cartilages of the second and
third ribs, and had sheathed its point beneath the pec¬
toral muscle. That muscle was slightly wounded, but
the integuments above it were unhurt. A little bloody
83
ELEMENTS OF SURGERY.
serum was found in the cavity of the belly, but scarcely
any pure blood. The pericardium contained a little
blood. The right side of the breast contained above
two quarts of blood, partly in a fluid and partly in a
coagulated state.
I have quoted this abridgment of the case, because,
although so terrible a wound as that here described
must be considered necessarily fatal, yet, during the
time the patient lived, a simple puncture of one of the
cavities of the heart might have united.
Mr. Pelletan, has lately published a case in which
the aorta was punctured by a small sword in a duel.
The weapon entered above the right pap, and from his
"bent posture, passed through his body and out of the
left side near the lumbar region. The young man det-
clared the wounds to have been made by the same
thrust, (which was doubted at first from the strange
course of the sword) and said he had himself pulled it
out. The most dangerous consequences were expect¬
ed, but many days passed without any. He complain¬
ed of pain in the lumbar region, but the warm bath,
two bleedings, and a low diet relieved this, and he lived
two months after the accident, at which time he ex¬
pired in great pain, a tumour having formed opposite
to the eiglith dorsal vertebra. Upon dissection the right
side of the chest was found filled with blood coagulated
in different degrees. This blood led to an opening as
large as a writing quill, with which the aorta was
pierced, above the crura of the diaphragm. These
crura and the surrounding cellular texture were inject¬
ed with extravasated blood. No viscus of the abdomen
or thorax had any mark of injury (the sword having
ELEMENTS OF SURGERY.
89
probably passed behind them) and there was no reason
to expect a priori a wound of the aorta.*
Hemorrhage from wounds of the chest cannot be
commanded by ligature, unless it proceeds from an in¬
tercostal artery. The intercostal arteries are sometimes
wounded, and although not very large, bleed freely. It
has been proposed to secure the vessel by passing a
ligature round the rib, and tying a piece of lint upon it.
As this operation, however, would leave a foreign sub¬
stance in the cavity of the thorax (a portion of the li¬
gature) much inflammation would result from it; and
although I have never seen such a case, I cannot but
express my opinion that a safer measure would be to
make a free external incision, and secure the vessel in
the usual way, pulling it out with a tenaculum, which
could with common dexterity be performed.f
Wounds of the larger vessels of the lungs generally
terminate the existence of the patient in a few minutes.
If the lungs be wounded, without injury to any of the
great vessels, abscesses frequently form in the chest, at
tended with hectic fever, night sweats, great exhaustion,
diarrhoea, and eventually death. In some cases, how¬
ever, bullets and also small swords, have passed through
the chest, and still the patients have recovered.
Mr. Hunter remarks, " it is pretty well known that
wounds of the lungs (abstracted from other mischief)
* Chinique Chirurgicale, torn. i. p. 92.
A case of ruptured aorta is described by Mr. Linn, jun. in which the pa¬
tient survived two weeks. Medical Records.
j- " Unfortunately," says Dr. Hennen in his Military Surgery, " we but
too often are disappointed in finding the source of the hemorrhage, and
here judicious pressure is our only resource. In some very slight cases, I
have used the graduated compress with success; but if the sloughing is ex¬
tensive, nothing but the finger of an assistant, relieved as often as occasion
may require, and pressure direct upon a compress placed along the course
of the vessel, or so disposed as to operate upon its bleeding orifice, will be
of any avail."—Ed.
VOL. I.—M
90
ELEMENTS OF SURGERY.
are not mortal. I have seen several cases where the
patient has got well after being shot quite through the
body and lungs, while from a very small wound made
by a sword or bayonet into the lungs the patients have
died, from whieh I should readily suppose that a wound
in the lungs from a ball would in general do better than
a wound in the same part with a pointed instrument,
and this difference in effects would in many cases ap¬
pear to arise from the difference in the quantity of
blood extravasated, because the bleeding from a ball is
very inconsiderable in comparison with that from a cuty
and there is therefore a less chance of extravasated
blood, either in the cavity of the thorax or the cells of the
lungs. Another circumstance that favours the gunshot
wounds in these parts is, that they seldom heal up ex¬
ternally by the first intention, on account of the slough,
especially at the wound made by the entrance of the
ball, so that the external wound remains open a con¬
siderable time, by which means any extravasated matter
may escape; but even this has often its disadvantages,
for by keeping open the external wound which leads
into the cavity, we give a chance to produce the sup¬
purative inflammation through the whole surface of that
cavity, which would most probably prove fatal.w
When the quantity of blood poured out into the
cavity of the pleura is small, if it do not readily escape
at the external wound, the absorbents take it up; but
if the wounded lung continue to bleed into the cavity of
the pleura, symptoms of an alarming kind are produc¬
ed. Great prostration of strength, which proceeds
from the nature of the parts wounded, and perhaps a
fainting from the quantity of blood lost to the circula¬
tion. A great heaviness will be felt in the breast, and
considerable difficulty of breathing. The causes of
this difficult respiration will be the pain which the pa-
ELEiMENTS OF SURGERY.
91
tient will have in expanding the lungs in inspiration;
the injury of some of those muscles which move the
ribs; and also the diminution of the capacity of the
thorax, from the effusion of blood into the cavity of the
pleura which prevents the complete expansion of the
lungs.
The patient will not be able to lie down, but must
sit upright, because this posture throws the weight of
the effused blood upon the diaphragm, and forcing this
downwards, somewhat enlarges the thorax. Wherever
a large extravasation of blood into the cavity of the
pleura exists, an opening for its evacuation must be
made, and this should be done if possible before it co¬
agulates, in order that it may the more readily escape
through a small wound.
In some cases it may be convenient to enlarge the
original wound, but it is often necessary to make a new
opening, which may be done with a scalpel, just above
the upper edge of any of the ribs. If a small open¬
ing suffice to evacuate all the blood, it will be more
apt to heal by the first intention, but if the blood be
found coagulated, a larger aperture will be necessary.
When the contents are evacuated the wound must be
accurately closed with adhesive plaster.
Sabatier takes notice that many writers recommend
this operation, but that very few have performed it. He
relates, however, one case in which it became necessary
from a bleeding from the internal mammary artery after
a gunshot wound. Mr. Saucerotte performed it, and
his patient recovered.*
The treatment of gunshot wounds penetrating the
thorax, is to be extremely simple; superficial dressings
are to be applied, a soft poultice enclosed in a bag of
* Medicine Operatoire.
92
elements of surgery.
gauze oi>muslin, or a pledgit of linen rag spread with
simple cerate may be used. Great care is necessary to
prevent the dressing from being drawn into the chest
during inspiration, as much irritation would be the con¬
sequence of any foreign substance being introduced
into the cavity of the chest.
Gunshot wounds through the chest, when the sloughs
separate, leave very considerable openings into the
cavity of the pleura, and although it is a fact that these
wounds are less generally fatal than stabs with sharp
instruments, from their bleeding less freely, yet they
are much more complicated, and often attended with
fractures of the ribs, and with extraneous matter in
the thorax, as the clothing of the patient and the ball.
They are followed by tedious exfoliations of the ribs;
by long continued suppurations and hectic fever, which
however are not always fatal. In some instances the
suppuration takes' place from the whole cavity of the
pleura, and immense quantities of pus are discharged.
In some the lung gradually wastes away, and nothing
remains of it but a hard diminutive tubercle at its root.
" When a man is shot through the lungs, if death be
very near, it must be from suffocation, and you will find
him with a bloody foam at his mouth, his face pale at
the cheeks, and livid round the lips and eyes, heaving
the breast with intolerable anguish, tossing from side
to side in bed, the bloody foam increasing, the breath¬
ing becoming more difficult, and the blood and air rat¬
tling in the throat; then the pulse flutters, and the ex¬
tremities continually grow colder, till struggling in some¬
thing like a convulsion he expires." John Cell.
In this manner soldiers frequently perish on the field
of battle, their cases admitting of no relief. But many
cases, as we have already stated, do admit of relief, and
as the primary danger depends on suffocation from the
ELEMENTS OF SURGERY.
93
air cells of the lungs being filled with blood, the remedy-
must be an immediate evacuation of blood by venae-
section, and this is to be carried to a greater length than
in almost any other accident or disease, first with a view
to unload the lungs and prevent suffocation, and after¬
wards to prevent and cure the succeeding inflamma¬
tion. The French surgeons have been famous for
the quantities of blood which they direct to be drawn
in such cases. They have been censured for it,
but I believe with Mr. John Bell, that it is hardly
possible to carry the practice too far. Sabatier relates
a successful case in which the patient was bled twenty-
six times, and I have myself known a young man to lose
one hundred and eighty ounces of blood in twelve days,
in consequence of a gunshot wound in the chest. He
recovered rapidly, although a very large opening had
been made by a load of small shot.
In some cases emphysema occurs from wounds of
the lungs. It commonly happens from the wound be¬
ing of small size, and not entering in a direct line. " It
is less frequent in large wounds with a knife or broad
sword, because there the air has an open and unim¬
peded issue;" and "more frequent in deep stabs with
the bayonet or small sword;" and " it is peculiarly fre¬
quent in gunshot wounds, because the orifice in the
skin inflames and swells while the wound is wider with¬
in."
This singular affection consists in an escape of air
from the lung into the cavity of the pleura, and from
thence into the cellular texture over the wound, its es¬
cape being prevented by a closure of the external open¬
ing, the wound through the skin not corresponding with
that in the pleura; sometimes it occurs without the lung
being wounded from the air which entered the thorax
by the external wountf. In common it confines itself to
9 4
ELEMENTS OF SURGERY.
the vicinity of the wound, but sometimes it extends very
rapidly, swells the whole figure, closes the eyelids, oblite¬
rates every appearance of the neck, which has the same
diameter as the trunk. The extent to which the body
swells in emphysema may he judged of from a case re¬
lated by Mr. Littre in the Memoirs of the French Aca¬
demy, in which the skin over the chest was distended
to the distance of eleven inches from the ribs. The
palms of the hand and soles of the feet are the only
parts which do not partake of the tumefaction.
The treatment consists in making punctures through
the skin with a lancet opposite to the wound in the
thorax, by which the air may be allowed to escape. If
small punctures through the skin be found ineffectual,
a free incision is to be made into the thorax, through
the skin and muscles, which puts an immediate stop to
the progress of the complaint, care being taken to avoid
the intercostal artery. *
In many instances it is not easy to ascertain whether
the difficulty of respiration depends upon air or blood
confined in the pleura. The incision is equally effec¬
tual in both cases. It is not by compressing the lung
of the wounded side that the oppression is occasioned,
for this lung must be in a collapsed state from the mo¬
ment when the air was admitted into the thorax, and of
course respiration is entirely performed by the opposite
lung. The oppression proceeds from the pressure of
air or blood upon this sound lung, its freedom of mo¬
tion being thereby impeded.
A protrusion of a portion of the lung through a wound
of the chest is an accident which has sometimes occur¬
red. Sabatier recites several cases, and in some the
surgeons appear to have treated the patient very roughly,
having cut off the protruded lung with a hot iron in
one instance, and applied stiptic powders after cutting
ELEMENTS OF SURGERY.
9 5
it off, in another.* Notwithstanding these harsh pro¬
ceedings the patients got well.
The proper plan, if we are called before the protrud¬
ed piece of lung is mortified, will be to replace it with¬
out delay; and if necessary the wound may be enlarged
to facilitate its reduction. After this the usual dress¬
ings are to be applied. If mortification have taken place,
Sabatier recommends the application of a ligature
round the part to prevent hemorrhage, and the excision
of the mortified portion, a practice which I think ought
never to be followed, because, if the ligature be applied
tight enough to command the hemorrhage, it will infal¬
libly produce gangrene and slough off'; now the morti¬
fied part will as certainly separate without the ligature,
and ought therefore in every case to be left. Until this
separation happens, it will be safest to leave the morti¬
fied portion outside, because adhesions will form con¬
necting the lung to the margin of the wound, so that
when the separation of the slough takes place, the ca¬
vity of the thorax will not be exposed, whereas if a por¬
tion of mortified lung be returned into this cavity and
there separate, it will undoubtedly occasion as great in¬
flammation as other foreign matter, and render it ne¬
cessary to keep open the external wound.
When foreign substances, as fractured bone, pieces
of cloth, &,c. are lodged in the thorax, they must if prac¬
ticable, be immediately ren^pved. Pieces of the rib are
frequently broken oif in such a manner as to project in¬
ward and irritate the lungs. In this case a pair of for¬
ceps must be introduced, and the splinter separated. A
musket ball sometimes lodges in or about the thorax,
and, in general, it is "irrecoverably lost;" but the cloth¬
ing carried in with it may commonly be found, and
should be then carefully extracted, for every thing of
* Medicine Operatoire, torn. ii. p. 272.
96
ELEMENTS OF SURGERY
this kind has a tendency, like the setons of the French
surgeons, to keep up inflammation and suppuration. I
was called to visit a carpenter wounded in the back by
falling on a chisel; the wound penetrated into the chest,
and as the muscular flesh through which the chisel had
passed bled freely, an old lady emptied her snufT box
into the wound. At every inspiration some of the snuff
entered into the thorax, and the consequence was a
general suppuration from the cavity of the pleura, ex¬
posing the life of the patient to great hazard.
Care should be taken to extract every foreign body
within our reach, and to prevent our dressings, &c. from
being drawn into the chest.
ELEMENTS OF SURGERY.
97
CHAPTER XV.
Wounds penetrating the Abdomen.
In consequence of the great variety and importance
of the viscera contained within the abdomen, wounds
penetrating this cavity must differ essentially in their
nature and consequences according to the parts injured.
In a wound through the parietes of the abdomen, ill
which none of these viscera are implicated, the great
object of the surgeon is to produce a speedy union of
the wound, in order to prevent the inflammation of the
peritoneum. There is no reason for believing that this
inflammation arises from the admission of air into the
cavity* neither is the diminution of its temperature the
cause,f as the application of ice in cases of hernia fre¬
quently reduces the heat of the abdomen much below
that of the atmosphere, without any such effect, and pe¬
ritoneal inflammation is as apt to occur in the hottest
summer weather when the thermometer rises nearly to
the heat of the blood, as in the depth of winter. The
real cause of this inflammation in wounded cavities, it
is by no means easy to ascertain, it is much easier to
ascertain that none of the alleged causes can explain it.
The fact is all we have to state. Whenever a large
cavity, as the thorax, abdomen, or a large joint, is cut
open, unless the wound be promptly healed, violent in¬
flammation occurs throughout the surface of that ca-
* The cavity of the abdomen is a plenum, every part of it occupied with
something, and no space exists for the admission of air. Into the thorax,
when wounded, air finds a ready entrance, but not so in wounds of the ab¬
domen.
fThis opinion has been maintained by Dr. James Cocke in his Inaugural
Essay, published in this city in 1804,
VOL. I.——N
08
ELEMENTS OF SURGERY.
vity. The imperfection of the cavity appears to be
the only circumstance necessary to the production of
this inflammation, but how it effects it I am not pre¬
pared to say.
If the wound be made by a sharp instrument, it is to
be closed by the interrupted suture, care being taken
to pass the needle from within outwards, about half an
inch from the wound; it is most readily effected by hav¬
ing a needle at each end of the ligature; none of the
strings are to be tied until all the stitches are made.*
In this case I should not use leather ligatures. The
various antiphlogistic remedies are to be used in order
to prevent inflammation, and also to relieve it, if it su¬
pervene.
It is always of extreme importance to ascertain
whether any of the viscera of the abdomen be injured,
because the danger of the case, and the remedies to be
employed, depend greatly upon this circumstance. If
any part of the bowels protrude, it should be examined
carefully before it is replaced. If the wound be a small
incision or a puncture, it is more difficult to ascertain
the extent and nature of the mischief. Some informa-
i
tion is to be gained by examining the instrument with
which the wound was inflicted, and by observing how
much of it had entered, and in what direction. If a
large quantity of blood escape at the wound, there is
reason to apprehend the injury of some of the viscera
(unless the wound be in the course of the epigastric ar¬
tery.) If bile, faeces, or any of the usual contents of
the viscera, make their appearance, there can be no
doubt of a wound in an intestine. Very little is to be
learned by examinations with probes, or even by pass¬
ing the finger into the wound, and therefore unless some
real good can result from it, it should be omitted.
Adhesive plaster is also to be used, and oyer it a compress and bandage
elements of surgery.
99
When a large blood-vessel is opened, and the blood
does not find a ready exit through the external wound,
gre at debility comes on, fainting, a weak faltering
pulse, cold sweats, swelling of the abdomen, and, if the
bleeding should not stop, death.
Gunshot wounds of the abdomen, in general occa¬
sion complicated mischief, the ball passing through the
viscera, and wounding them in several places. If the
ball pass with considerable velocity, sloughs must take
place, and greatly enlarge the various openings it has
made. " If the ball pass with less velocity, there will
be less sloughing, and the parts will in some degree
heal by the first intention similar to those made by a
cutting instrument; but although the ball has passed
with such velocity as to produce a slough, yet that
wound shall do well, for the adhesive inflammation will
take place on the peritoneum all round the wound,
which will exclude the general cavity from taking part
in the inflammation, although the ball has not only pe¬
netrated, but has wounded, parts which are not imme¬
diately essential to life; such as the epiploon, mesentery,
&c. and perhaps gone quite through the body; yet it is
to be observed that, wherever there is a wound, and
whatever solid viscus may be penetrated, the surfaces
in contact, surrounding every orifice, will unite by the
adhesive inflammation, so as to exclude entirely the
general cavity, by which means there is one continued
canal, wherever the ball or instrument has passed; or
if any extraneous body should have been carried in,
such as clothes, &.c. they will be included in these ad¬
hesions, and both these and the slough will be con¬
ducted to the external surface by either orifice/'
This quotation from Mr. Hunter, explains the rea¬
son why so many patients get well of wounds in the
viscera, and affords a wonderful proof of the resources
100
ELEMENTS OF SURGERY.
of nature, in providing against danger and death. Un¬
less adhesive inflammation arise and agglutinate the in¬
jured bowels together, at the circumference of every
aperture made into them, death must inevitably result,
from the escape of the contents of these viscera into the
general cavity of the abdomen.
From this view of the subject, and from repeated
experience, we learn that most of the viscera of the ab¬
domen may be wounded without fatal consequences.
The gall-bladder is, perhaps, an exception, because the
acrid nature of its contents, and the facility with which
the bile escapes whenever this viscus is punctured, can¬
not fail to occasion peritoneal inflammation ; and we
find no case recorded of a recovery after a wound pe¬
netrating the gall-bladder. If any acrid substance
escape from the stomach into the general cavity of the
belly, as ardent spirit, &.c. the same fatal consequences
will result, of which I once saw a striking instance in
a man whose stomach was wounded after drinking
porter. The wound of the stomach was found on dis¬
section completely healed; the patient died on the fourth
day of peritoneal inflammation.
The inflammation of the cavity of the belly, which
occurs whether the viscera be wounded or not, (unless
the external wound be promptly united) calls for copi¬
ous and active measures; bleeding, purging, low diet,
and blisters over the abdomen. In general these reme¬
dies, if commenced early, and pursued actively, are
fouud successful, and the inflammatory symptoms sub¬
side. In others it terminates in adhesions, connecting
together the different viscera, coagulating lymph being
poured out, on various parts of the peritoneal surface.
In others suppuration takes place, and large quantities
of matter are formed in the abdomen. Mortification,
also, sometimes occurs, and consequently death.
ELEMENTS OF SURGERY. 101
If the remedies for inflammation do not succeed in
reducing it, and suppuration takes place, when its ex¬
istence is clearly ascertained, a lancet may be intro¬
duced, and afterwards a canula, through which this
matter may be evacuated. If no particular spot appear
elevated more than the rest, the puncture may be made
at the usual place where tapping for dropsy is perform¬
ed, about two inches below the umbilicus.
In some wounds of the abdomen, a protrusion of
some of the abdominal vicera takes place ; where the
protruded parts are uninjured, it is always best to re¬
place them as speedily as possible within the cavity.
If they be wounded, or if, from long exposure and the
stricture made upon them by the wound, they are in a
mortified state, other measures are necessary. Pre¬
viously to replacing them all extraneous matter should
be carefully removed. Dirt, clots of blood, and every
foreign substance, must be washed off with warm wa¬
ter. I- have seen a large portion of the colon, together
with the omentum, covered with sand and dirt mixed
with blood; protruding from a large wound in the ab¬
domen ; great care was, in this instance, necessary to
prevent the introduction of these irritating matters into
the abdomen.
It often happens, that a considerable stricture is
made upon the protruded parts, and, of course, diffi¬
culty is experienced in reducing them. To facilitate
it, the patient should be placed in such a posture as to
relax the muscles of the abdomen. If the difficulty
arise from distention with faeces or flatus, the contents
may often be squeezed out, and the bulk of the intes¬
tine thus reduced. If, however, the reduction be still
difficult, it is highly improper to use any violence in
attempting it; it is better to enlarge, very carefully, the
wound with a bistoury.
102 ELEMENTS OF SURGERY.
The treatment of the case, when a portion of the in¬
testine is mortified, will be described in the chapter on
hernia, as it forms a very important variety of that com¬
plaint.
Blood is sometimes poured out in considerable quan¬
tities by some large vessel within the abdomen. If the
quantity be very great, swooning, and the usual debili¬
tating effects of hemorrhage quickly ensue. If the pa¬
tient survive these symptoms, the collection of blood is
easily perceived forming a tumour in some part of the
abdomen. The abdominal viscera are so closely in
contact, that a general diffusion of this blood among
them seldom happens; it is found, on the contrary, col¬
lected into one spot; and this, according to Sabatier, is
in the lower and anterior part of the abdomen, just
above the pubis.* He remarks that, in general, upon
opening bodies in which these extravasations have hap¬
pened, the blood is found in every part of the cavity,
but that this is entirely owing to carelessness in the
dissection, and that a cautious proceeding discovers
that it is collected in one mass, and that, after a time, it
becomes firmly surrounded by the matter of adhesions,
in consequence of inflammation, forming a kind of sac
or pouch.
The changes which the extravasated blood under¬
goes, coagulating and irritating the surrounding parts,
occasion very distressing symptoms. In the first place
pain, and tension of the part, followed by hiccough,
costiveness, vomiting, and sometimes suppression of
urine. Sometimes, by great weakness, a small feeble
pulse, and cold sweats.
To relieve these symptoms, it becomes necessary to
make an opening for the discharge of the blood. A
puncture is to be made with a lancet, or trochar, and
* Medecine Operatoire, torn. i. p. 35.
ELEMENTS OF SURGERY.
103
a canula introduced; if the blood be fluid it will readily
flow through it; when it is found coagulated, it has been
recommended to inject warm water into the wound, in
order to wash it out; from the fact that injections of
warm water, in cases of hydrocele, effect a radical cure
by exciting inflammation, I have strong doubts of the
propriety of this practice.
When the contents of the viscera are extravasated,
the only remedies which can be employed are the re¬
medies for inflammation; rest, a low diet, bleeding,
purging, &c. They sometimes form abscesses, and are
discharged externally. I have known a piece of cheese
which escaped from a wounded stomach, discharged
after the wound had healed, by an abscess in the groin.
, V, . s
i WOUNDS OP THE ABDOMINAL VISCERA.
The symptoms denoting wounds of the particular vis¬
cera of the abdomen are not always strongly marked,
but in general we are able, from a careful investigation,
to ascertain with some degree of accuracy the parts in¬
jured.
" From a wound in the liver there will be a pain in
the part of the sickly or depressing kind; and if it is in
the right lobe there will be a delusive pain in the right
shoulder, or in the left shoulder from a wound in the
left lobe.
" A wound in the stomach will produce great sick¬
ness and vomiting of blood, and sometimes a delirium.
" Blood in the stools will arise from a wound in the
intestine, and according to the intestine wounded it will
be more or less pure; if the blood is from a high part
of an intestine, it will be mixed with faeces and of a
dark colour; if low, as the colon, the blood will be less
mixed and give the tinge of blood; and the pain or sen¬
sation will be more or less acute, according to the in-
104
ELEMENTS OF SURGERY.
testine wounded, more of the sickly pain the higher the
intestine, and more acute the lower.
" There will be bloody urine from a wound of the
kidneys or bladder, and if made by a shot or ball and a
lodgment made, these bodies will sometimes become the
cause of a stone. The sensation will be trifling.
" A wound of the spleen will produce no particular
symptoms, excepting probably sickness, from its con¬
nexion with the nerves of the stomach." (Hunter.)
In the treatment of wounds in the stomach or intes¬
tines, it must be evident that many cases occur where
the part wounded cannot be exposed, or indeed known,
and here nothing is to be done but to combat the inflam¬
matory symptoms.* When a wound in the stomach
can be seen, a number of siitches proportioned to its
extent must be used, the ligatures cut off close, and the
parts returned. In transverse wounds of the intestine,
in which the greater part of the canal remains entire,
the experiments of Mr. Asiley Cooper and other sur¬
geons have proved the safety of closing the wound by
the interrupted suture, and returning the gut into the
belly. The stitches are separated by the actions of
the absorbents, and pass readily through the intestinal
canal, a coating of coagulating lymph being formed
over them, which prevents their falling into the cavity
of the peritoneum, and exciting inflammation there. A
single stitch is generally sufficient to close a wound not
extending more than half round the intestine, and it
should be made with a common round sewing needle
armed with waxed thread. Longitudinal wounds of the
intestine, it has been believed, do not heal so readily
* The propriety of dilating the external wound to search for the wound¬
ed intestine is very doubtful; 1st, from the danger attending an enlarge¬
ment of the wound, and 2dly, from the uncertainty of finding the injured
viscus.
ELEMENTS OF SURGERY.
105
as those which are transverse. There is probably
more danger of the escape of fa3ces from them, and
they are not so readily closed. From some experi¬
ments of Dr. T. Smith, performed in this city, and pub¬
lished in his inaugural thesis in 1805, it appears that in
dogs even extensive longitudinal wounds may be re¬
united.
It is proper in many such cases to cutout completely
the wounded portion and unite the cut extremities to¬
gether, because the longitudinal is thus converted into
a transverse wound,
When the intestine is cut completely through, either
by a removal ot a mortified portion, or by the original
wound, the divided extremities are to be secured by
four stitches; the ligatures are to be left out at the ex¬
ternal wound, and in a short time they unite, and an
adhesion takes place connecting the intestine to the pe¬
ritoneum at the wounded part. After five or six days,
the threads, if loose, may be removed, as they become
useless after adhesions take place. The practice of
Mr. John Bell in these cases, of trusting to a single
stitch, is full of danger, and ought never to be adopted.
Mr. Cooper's remarks on the treatment of mortified in¬
testine in his work on hernia, are entirely applicable
to the present subject.
In most instances of wounded intestine the canal is
diminished at the injured part, and colicky pains are
an occasional consequence. A great degree of con¬
striction has in some cases resulted and terminated fa¬
tally, but in general the bowel regains its usual volume,
and performs its functions as well as before the injury.
In all cases where there is reason to believe that the
bowels are wounded, it ig important to prohibit the use
of solid food, and confine the patient to barley water
exclusively, or some mild drink.
vol. i.—o
106
ELEMENTS OF SURGERY.
Wounds of the omentum or mesentery seldom occa¬
sion trouble, except from their bleeding; when practi¬
cable, the bleeding vessels are to be secured by liga¬
ture, and the ligature in every instance left out at the
external wound.
Wounds of the gall-bladder are, in the opinion of
most surgeons, necessarily fatal. A case is related in
the Edinburgh Medical Essays, in which the patient
survived this accident a week. Before death the abdo¬
men became extremely tense; a rumbling noise was
heard in it. The patient had no stools, notwithstand¬
ing the use of purgatives and glysters. Sleep could not
be procured, although anodynes were exhibited. No
fever appeared. The pulse was natural till the last
day, when it became intermittent. Upon dissection
the intestines were found much distended, the gall-blad¬
der quite empty, and a large quantity of bile, extrava-
sated in the abdomen. Sabatier relates a case in which
bile was drawn off by a trochar from the cavity of the
belly; but no advantage resulted, and the patient died
a few hours after it was performed, viz. on the third
day.
Wounds of the liver call for no particular treatment.
They are generally, when extensive, fatal from he¬
morrhage, owing to its great vascularity; and if any
of the branches of its excretory duct are punctured, the
bile escapes and occasions inflammation of the perito¬
neum. Small incised wounds of the liver often heal
without difficulty.
Wounds of the kidneys are not fatal unless the urine
escapes into the cavity of the abdomen. They call for
no particular treatment. The patient generally voids
bloody urine at first, but the part soon heals.
ELEMENTS OF SURGERY.
107
CHAPTER XVI.
Wounds of Joints.
In these, as in other wounds penetrating cavities, it
is of great importance to guard against inflammation,
as the effects of violent inflammation in the larger joints,
upon the constitution, are very serious.
In all cases of wounded joints, it is important to place
the limb in such a posture as to favour the approxima¬
tion of the sides of the wound. Absolute rest is to be
enjoined, and a rigid adherence to the antiphlogistic
treatment. Sutures are never to be used in these cases,
if it be possible to dispense with them; and when it is
not, they must never be passed into the cavity of the
joint, but only through the cellular membrane, on the
outside of it, for very obvious reasons. Treated in this
manner, incised wounds of the larger joints very readily
heal by the first intention, even when the articulating
extremity of the bones are injured.
When inflammation supervenes in consequence of a
wound in a large joint, the constitution suffers severely:
fever comes on, generally ushered in with a great de¬
gree of nausea. Violent pain takes place in the joint,
and an increased secretion of synovia, which is thinner
and more watery than usual. The ligaments swell, and
become thickened, by effusions of coagulating lymph.
At length, suppuration takes place, and pus is secreted
from the whole surface of the synovial membrane; ul¬
ceration comes on, and openings are formed in various
parts of the skin covering the joint.
The formation of an abscess, in a large joint, as the
knee or hip, never takes place without great danger to
108
ELEMENTS OF SURGERY.
the life of the patient. I have seen death occur in a very
few days from inflammation of the knee, terminating
in suppuration. Extreme pain, fever and delirium, ge¬
nerally precede the fatal event.
In those cases where the symptoms of inflammation
do not terminate so speedily, ulceration of the ligaments
is followed by inflammation of the bone; the cartilage
is absorbed, and the whole joint destroyed; granulations
arise from the inflamed bones; they unite, and anchy¬
losis is effected; but these processes require a great
length of time, and during this time the patient is af¬
fected with hectic fever, and great exhaustion from the
continued discharge. Abscesses also form in the vici¬
nity of the joint, and portions of carious bone or de¬
tached cartilage, are evacuated through them. Before
anchylosis can in this manner be accomplished, the pa¬
tient must inevitably suffer a tedious, painful confine¬
ment, under which the constitution often sinks, and a
lingering death eventually concludes his sufferings.
These terrible consequences sometimes result from
simple incisions or punctures into joints, as well as
from the more aggravated mischief of lacerated or gun¬
shot wounds. They are only to be prevented by a most
active employment of the remedies for inflammation
already enumerated.
On the first approach of inflammation, bleeding is to
be performed, and carried to as great an extent as the
patient's strength will warrant. Topical bleeding, by
cupping or leeches, is next to be employed, and after
this, a blister should be applied large enough to cover
the skin over the joint. The blister, in these cases,
should be applied earlier than is recommended by au¬
thors. I have seen the best effects from a speedy ap¬
plication of this remedy.
In chronic inflammations of joints, either from
ELEMENTS OF SURGERY.
109
wounds or other causes, the repeated use of blisters is
never to b,e omitted. Purging is also to be actively em¬
ployed.
In order more effectually to procure absolute rest of
the joints, it is advantageous, in some cases, to apply
carved splints to fit the parts, and these being lined
with soft materials, occasion no inconvenience. In
wounds of the knee, ankle, or elbow, these splints are
particularly useful.
When, in consequence of the violence and continu¬
ance of the inflammation, there is reason to apprehend
a stiff joint from anchylosis, it is necessary to choose
the position of the limb, in which this stiffness will be
least inconvenient to the patient, and to preserve that
posture during the cure. If, for example, the elbow
were to heal with the arm permanently extended, the
limb would be almost useless, whereas an arm flexed
at the elbow, even when the joint allows no motion, is
extremely useful. In the lower extremity, on the conp
trary. a flexed posture would preclude the patient from
walking, while an extended leg, with a stiff knee, would
be attended with comparatively little inconvenience.
Lacerated and gunshot >
wounds, because in them the parts cannot unite so
speedily, and the cavity remains longer imperfect. So
great is the danger to the life of the patient, that it al¬
ways becomes a serious question with his surgeon in
such wounds of the elbow, knee, or ankle, whether an
amputation ought not to be immediately performed. In
addition to the dangers already enumerated, gangrene
from the disorganization of the parts may occur, or life
may be destroyed by tetanus.
It is not easy to give any general rules by which to
guide our decision of the momentous question of ampu-
ways attended with more
110
ELEMENTS OF SURGERY.
tation in wounds of joints. Undoubtedly many cases oc¬
cur, in which the destruction of the surrounding parts,
arteries, nerves, tendons, &c. together with the shat¬
tered state of the bones forming the articulation, espe¬
cially when this complicated injury has occurred in the
hot weather of summer, leaves no doubt of the propri¬
ety of immediately removing the limb; but other cases
occur in which the main artery of the limb is not de¬
stroyed, and in which there is a prospect of saving the
limb, provided the patient escape the dangers of gan¬
grene, of tetanus, of inflammatory fever, of extensive
suppurations, of hectic fever, &c. In cases of this
kind the surgeon feels his responsibility to be great, and
it requires an attentive consideration of every circum¬
stance connected with the particular case to confirm
his decision. All these circumstances should be stated
to the patient and his friends, and they should assume
the responsibility, and conclude whether to attempt the
saving of a limb, by incurring the dangers which must
]>e encountered, or by an amputation to avoid them.
The cartilages of a joint never either inflame, suppu¬
rate or ulcerate; they are incapable of restoring them¬
selves when injured, and although flesh, in some cases,
grows over them, they never adhere to it. Mr. John
Bell observes, " we amputate a toe at the joint, and
the flaps unite in two days, but still they have united
with each other only, and not with the cartilage at the
joint; and in a luxated limb we find that the bone con¬
tinues displaced, the cartilage never inflames, nor ever
unites with the lacerated parts."
ELEMENTS OF SURGERY. Ill
CHAPTER XVII.,
Wounds of JYerves and Tendons.
In most of the systems of surgery which have been
published, wounds of the nerves have been consider¬
ed as a subject of great importance, and many terrible
consequences are attributed to punctures or partial
divisions of them.
The first symptom indicating a wound of a considera¬
ble nerve is severe pain, and afterwards a numbness, or
diminution in the sensation and powers of the part to
which the injured nerve was distributed. These symp¬
toms in general gradually subside, and no particularly
bad consequence results from the wound.
The inflammatory symptoms sometimes consequent
to the operation of phlebotomy have been ascribed by
many surgeons to punctures of a nerve or tendon.
The true explanation of these effects we shall presently
offer.
The operation of cutting down to the nerve and di¬
viding it entirely, is very seldom to be performed. The
only case in which it is to be recommended is when,
after venisection, the patient experiences violent pain,
followed by numbness of the arm, and where these
symptoms, instead of subsiding after a few days, in¬
crease in severity. Under such circumstances an in¬
cision should be made through the wound, and carried
a little below it, by which in all probability any partially
divided nerve would be completely cut through, and the
symptoms, if derived from this source, would speedily
cease.
The necessity for this operation is, however, extremely
112 ELEMENTS OF SURGERY.
rare. I have never seen or heard of a case in this city
(where blood-letting is a very frequent operation) in
which the symptoms have been such as to warrant any
surgical operation for the division of a nerve.
Tendons, when wounded, occasion no pain. There
are many proofs that tendons in a healthy.state possess
little or no sensibility; when inflamed, they are often ex¬
quisitely sensible. It occasionally happens, however,
in punctured wounds, that certain tendinous fasciae are
pierced, and the soft parts below the expansion are also
injured; when these inflame, the stricture formed by
the tendon occasions very severe pain, and greatly ag¬
gravates the inflammatory symptoms. In these cases
a division of the tendinous fasciae procures immediate
relief. As the fasciae attached to the tendon of the
biceps flexor cubiti is situated in the vicinity of those
veins from which blood is generally drawn, there is
reason to believe that in some rare cases this accident
has happened in phlebotomy; in such cases a small in¬
cision through the fasciae could very readily be made.
Wounds of tendons are to be treated as wounds in
other parts, by keeping them at rest with their divided
surfaces in contact. It happens to carpenters and ship
joiners, occasionally to divide with a foot adze the tendo
Achillis. When this accident happens, the foot is to
be kept extended by a spiint secured by means of a
roller in front of the leg, extending from just below the
knee to the point of the toe; compresses being applied
to fill up the inequalities of the limb, the divided sur¬
faces of the tendon are to be accurately placed in con¬
tact, and kept so six or eight weeks, when union will
be effected; but several months must elapse before the
patient attempts to support the weight of the body upon
this tendon. The same mode of treatment is to be
used in ruptures of the tendon. In wounds, however.
ELEMENTS OF SURGERY. US
- « .
the skin js apt to fall into folds, and insinuate itself be¬
tween the cut surfaces of the tendon. To prevent this
inconvenience, adhesive plaster should be applied in
such a manner as to keep it pulled back from the wound.
D. Monroes plan of dressing such an accident is
equally successful. It consists in having a strap fas¬
tened to the heel of a slipper, and this strap buckled
to a bandage fixed round the leg just below the knee.
The roller on the leg prevents the action of the gas-
trocnemii muscles, by which the superior portion of the
tendon would be pulled up, and the strap on the slip¬
per keeps the foot in an extended position, by which
•the lower portion is prevented from being drawn down.*
WOUNDS OF VEINS.f
These generally occasion very little trouble; the he*
inorrhage may be commonly stopped by compression.
In some cases, however, the cavities of veins, like the
other cavities of the body, take on inflammation, in con¬
sequence of the external opening not being united by
the first intention. Mr. Hunter has published a very
valuable paper on the inflammation of veins in the Me-
dico-Chirurgical Transactions; from this paper it ap¬
pears that the swelling of the arm consequent to venas-
section is generally occasioned by the inflammation of
the inner coat of the vein. He has dissected the arm
in some cases where patients have died from this dis-
* An accident of frequent occurrence, is a rupture of some muscular as
tendinous fibres of the gastrocnemius muscle, attended with severe pain-,
ecchymosis and subsequent inflammation ; the treatment is the same, but
patients rarely submit to the confinement, in which case a tight roller ap*
plied so as to cover the leg affords great relief, and generally effects a cure.
A paper on this subject may be seen in the 7th vol. of the Medico-Chirur-
gical Transactions by Mr. Wardrop.—The author having tried his plan of
treatment was compelled to lay it aside as inefficient; the roller being the
only useful part of it.
■{•The principal circumstances demanding attention in cases of wounds
of the ahteries have been already noticed in the chapter on hemorrhage^.
VOL. I*—P
114. ELEMENTS OF SURGERY.
ease, and has found in some parts of the vein adhesion,
in others suppuration, and in other cases ulceration.
In most cases when pus forms in a vein thus circum¬
stanced, adhesive inflammation having preceded the
suppurative stage, is found to have cutoff all communi¬
cation between the general circulation and the inflamed
vein. In other cases, however, the pus is not thus ex¬
cluded from the mass of blood, but is carried along with
it to the heart, and occasions death.
After an abscess is formed by adhesions closing up a
portion of the vein, absorption takes place, and the coats
of the vein are removed. The abscess then points, and
matter appears under the cuticle. Mr. Hunter has seen
instances of pus contained in the cavities of veins in
many patients who have died after amputation, com¬
pound fracture, and mortification. Itr happens as fre¬
quently in healthy constitutions as in others, a proof of
which is that if a patient with an inflamed vein be bled
in the other arm, the wound heals without any such
consequence.
In some cases a considerable portion of the vein takes
on inflammation; generally that portion between the
wound and the he&rt, but sometimes the portion next
the extremity; a string of abscesses existing throughout
its extent. When the parts get well, it is found that
the cavity of the vein at the inflamed part has been ob¬
literated, and the patient can never afterwards be bled
in that place.
Inflammation of a vein is sometimes an effect after
bleeding horses, which is usually done in the neck.
" The operator on this animal does not always take suf¬
ficient care to close up the external wound, for although
the method usually employed would at first sight appear
a good one, that is by a pin passed through the wound
from side to side, as in the hare-lip, and overtied by a
ELEMENTS OF SURGERY.
115
thread or hair; yet if not executed with sufficient atten¬
tion, i am inclined to believe that it is the very worst,
as it very readily promotes inflammation in the cavity
of the vein, either of the adhesive or suppurative kind,
according as the ligature does or does not communicate
with the cavity." (Hunter.)
Mr. Hunter has seen iu some of these inflammations
of horses the jugular vein inflamed through its whole
length, the head greatly swelled, and the inflammation
carried along the vein quite into the chest. Many
horses die of this disease, but what is the particular cir¬
cumstance which occasions their death is not ascertain¬
ed. " ft may be either that the inflammation extends
itself to the heart, or that ttie matter secreted from the
inside of the vein passes along that tube in considera¬
ble quantity to the heart, and mixes with the blood."
In many instances the constitution is affected with
violent fever, and in some cases in the human subject
death has resulted. Pus passing into the circulation
adds, in Mr. Hunter's opinion, to the general disorder,
and renders it fatal.
" Although the operation, which is the most frequent
cause of this complaint, is in appearance trifling, yet,
as it is very often of serious consequence both to the
life of the patient and the character of the surgeon, it
requires particular attention in the operator to prevent
as much as possible an evil of such magnitude; with this
view he will be particularly attentive to the mode of
closing the wound and binding up the arm: this is to be
done by bringing the two sides of the wound together,
that they may unite by the first intention. To accom¬
plish this let the surgeon with the thumb of that hand
which holds the arm push the skin towards the orifice,
while he draws it on the other side to the same point
with the compress; thus the skin will be thrown into
116
ELEMENTS OF SURGERY.
folds at the wound, over which he is immediately to
apply the compress, which should be broad to keep the
skin better together, and thick to make the compres¬
sion more certain."
Mr. Hunter recommends a " compress of linen or
lint, in preference to sticking plaster, for the blood dry¬
ing over the orifice is a kind of bond of union more na¬
tural and effectual than any other application, and this
conclusion is drawn from practice,'' more sore arms be¬
ing a consequence of bleeding where plasters have been
used than when the arm has been dressed in any other
way.
"When inflammation takes place beyond the orifice,
so as to alarm the surgeon, he should immediately make
a compress upon the vein at the inflamed part, to make
the two sides adhere together; or if they do not adhere,
yet simple contact will be sufficient to prevent suppu¬
ration in this part; or if inflammation has gone so far
as to make the surgeon suspect that suppuration has
taken place, then the compress must be put upon that
part of the vein just above the suppuration."
The remedy for inflammation of the veins consequent
to venassection, which answers best, is the application
of a blister over the inflamed part. As soon as the in¬
flammation commences, a small plaster of simple ce¬
rate, spread on linen, should be applied on the orifice,
and over this a blister large enough to cover the whole
inflamed part, extending three or four inches from the
orifice in every direction. This remedy, I believe, was
first introduced by Dr Physick. It has been used by
him for many years with constant success, and I have
myself employed it repeatedly, and never without ad¬
vantage.
Should fever attend, purging and low diet should be
ordered, and bleeding, if the inflammatory symptoms
ELEMENTS OF SURGERY.
117
run high. A splint is sometimes useful to keep the arm
at rest.
The inflammation of a vein consequent to venaesec-
tion sometimes assumes a chronic form, and continues
with a hard swelling and some pain for many weeks.
Repeated blisters have been found extremely service¬
able in these cases.
It is unnecessary particularly to describe the appear¬
ance of the inflamed arm consequent to venaesection,
because it is generally known to medical men. In its
commencement it resembles somewhat an erysipelatous
affection, extending above and below the orifice made
by the lancet, a tumor existing, however, at the part
which is hard and painful; the arm cannot be bent or
extended without great pain. In this state the blister
very generally prevents the further progress of the in-
flammation.
118
ELEMENTS OF SURGERY.
CHAPTER XVIII.
Of Fractures.
A fracture is a breach in a bone, (or as it is gene¬
rally defined, a solution of continuity) produced by ex¬
ternal violence, or by muscular action, or by the conjoint
operation of both.
The bones most frequently broken are those of the
extremities. Bones are broken in one or in several
places ; when broken in more than one place, the frac¬
ture is said to be comminuted.
Fractures may occur in the vicinity of joints, or in
the middle of the bones of an extremity. In the fore
arm and leg,*one or both bones may be fractured. The
fracture may be directly across the bone in a transverse
direction, or it may be oblique, antf the degree of ob¬
liquity may vary very much.*
Fractures differ in relation to the form of the bone,
its importance, and uses. The broad flat bones, as the
scapula or ilium, are rarely fractured. The bones of
the scull, however, are more frequently broken than any
other flat bones, and the importance of this accident
transcends that of most others, from the effects of the
* There is still another direction in which a bone may sometimes be frac¬
tured, viz. longitudinally. Although the existence of this kind of fracture
for a long time was denied, it is now completely established by several well
authenticated cases; one of which is related by Leveille.
The tibia of a soldier was fractured in consequence of being struck by a
ball; upon examination after amputation, a longitudinal fracture was found,
extending from the lower third, nearly up to the head of the tibia. This
was admitted to be a real longitudinal fracture by a committee appointed
by the Ecole de M^decine to inquire into the fact. Dr. Physick informs
me he has seen two cases where the jaw bone had been fractured in thedi
rection of its basis.—Ed.
ELEMENTS OF SURGERY.
119
injury upon the brain. The long bones are by far the
most frequently fractured. !
When the long bones are broken, the place of frac¬
ture is a subject of some importance to be attended to
in judging of the effects of the accident and of the
mode of treatment. In a fracture of the middle of a
bone, the broken surfaces are less extensive, and there¬
fore they move more widely 'one from the other, yet
this kind of fracture is the least dangerous, because in
such cases the cause is seldom applied to the part frac¬
tured, and for that reason the surrounding soft parts are
injured equally seldom. A less force suffices to break
the bone in its middle than at any other part. It is
also certain that inflammation, stiffness, and anchylosis
are less likely to happen than when the bone is fractur¬
ed near the articulation.
Bones are sometimes broken within a joint; the frac¬
tured patella is always an example of this. I have seen
a fracture through tfoe head of the thigh bone, and also
through the head of the humerus.
The relative situation of the fractured extremities it
is of great importance to ascertain. In some cases of
transverse fracture no derangement at all takes place,
the parts supporting each other as though they were
not fractured. I had one patient with a transverse frac¬
ture of the tibia, who could stand up and bear some of
the weight of his body upon the injured leg; and Dr.
Physick had a patient who, although the grating of the
bones was distinctly heard, before his limb was dressed,
took off all the bandages and splints, under an idea that
the doctor was mistaken. After walking, however,
once or twice over the floor, and being confirmed in
his opinion, an unwary motion of his leg occasioned a
twist, and it bent under him at the place of fracture.
Sometimes the fragments in a transverse fracture are
120
MOMENTS OF SURGERY.
partially separated, and in the tibia we often find one
fragment projecting a quarter of an inch or more above
the other, and yet a great part of the fractured surfaces
remain in contact. This is less apt to happen when
both bones of the leg or fore arm are broken, as in
these cases a total separation and distortion of the limb
generally take place, in fractures of the thigh and ai m
the muscles generally draw up the inferior fragment,
and thus shorten the limb, even when the fracture is
transverse.
In some cases a bone is broken in such a manner as
to form an angle at the place of fracture.
The principal causes of the derangement of the frag¬
ments are the force which produced the fracture, the
weight of the body, or of the fractured limb, and (lie
action of muscles. The force which produced the
fracture will often occasion great derangement of the
limb, as the kick of a horse. The weight of the arm
in fractures of the humerus, and of the leg in fractures
of the thigh bone, occasion a separation of the frag¬
ments. The weight of the foot, when the patient lies
on his back, will occasion a rotation in a broken thiqh
or leg; but the most powerful of these causes is mus¬
cular action.
" Of the muscles which surround a fractured bone
some are attached to that bone in a great part of its
length, and therefore in many cases to both portions of
the fractured bone. Others extend from the bone
which is superior to that fractured, to that which arti¬
culates with the lower portion, or to the lower fragment
itself; there are still others which terminate in the up¬
per fragment, the other extremity of which may be
more or less distant. The muscles of the thigh offer
examples of these three different dispositions. The
triceps is attached to the whole length of the femur.;
ELEMENTS OF SURGERY.
121
the biceps, semimembranosus and semitendinosus, de¬
scend from the pelvis to the leg, to which the lower
part of the femur is articulated, and all the movements
of which it obeys; the great adductor muscle has its
insertion in the lower part of the femur itself; finally
the psoas, iliacus, pectineus, &c. descend from the loins
and the pelvis, and have their insertion near the supe¬
rior extremity of the femur.
"The muscles which are attached to both portions
of the fractured bone, contribute very little to their
change of situation, but may, however, draw them both
to the side on which they are inserted, and thus change
the direction of the limb. The triceps, and more par¬
ticularly its middle part, acts thus on the fractured fe¬
mur, and renders the thigh convex anteriorly. The
brachialis anterior tends to produce the same effect
when the humerus is broken below its middle part, but
the change from the natural situation is principally
owing to the muscles which are inserted into the lower
portion of the fractured bone, or the limb with which
it articulates. Let us suppose the fracture of the hu¬
merus between its superior extremity, and the insertion
of the great pectoral muscle, this muscle aided by the
latissimus dorsi and teres major, draws the inferior por¬
tion inward and upward, and causes it to ascend on the
interior side of the upper fragment which rests motion¬
less, on account of its shortness, and because the mus¬
cles which are inserted into it are not acted on by any
cause that excites them to action. In the fracture of
the neck of the femur, the superior fragment has no
muscles inserted into it, and remains motionless in the
articulating cavity; those muscles which, on the con¬
trary, are attached to the lower portion, draw it up¬
ward and backward, and render its being displaced in
that direction inevitable.
vol. I.—Q
122
ELEMENTS OF SURGERY.
" The lower portion being acted on by the limb to
which it is articulated, follows all its motions, and is
liable to be displaced by the action of the muscles which
are inserted into it. Thus, in fractures of the body ol
the femur, the biceps, semitendinosus, and other mus¬
cles, draw the leg, and with it the inferior portion, up¬
ward, inward, and backward, and cause it to ascend
on the internal, and a little on the posterior side of the
superior portion, the inferior extremity of which pro¬
jects, in that case, on the anterior and external side.
" In the fracture of the leg, the gastrocnemii muscles.
&c. draw the inferior portion upward and backward,
with the foot; for in this, as in every similar case, the
stronger muscles displace the lower portion of the frac¬
tured bone, and draw it in their direction: hence it is,
that in this case the portion is drawn backward as well
as upward, because the muscles are more numerous
and larger on the back part of the leg than on any other.
Therefore, when a fracture takes place in any part of
a bone, it is easy to determine, from a knowledge of the
muscles, what species of derangement will follow, if
there be no counteracting cause. Finally, the muscles
which have their insertion in a superior fragment, may
produce its separation from the inferior. When the
femur is fractured immediately below the small trochan¬
ter, the iliac and psoas muscles draw forward the infe¬
rior extremity of the superior fragment, which raises
the skin, and projects more or less. It is to be observ¬
ed, however, that the displacing of this fragment is very
rare, whilst the inferior fragment is displaced in almost
every case."—(Boyer.)
Fractures are more or less accompanied with lace¬
ration and injury of the surrounding soft parts. When
the integuments covering the fractured bone remain
entire, even although there be a great degree of lacera
ELEMENTS OF SURGERY.
m
tion underneath it, the fracture is called simple. A
compound fracture is that in which an external open¬
ing is formed, communicating with the space between
the broken extremities of the bone, or as it is com¬
monly called, the cavity of the fracture. Mr. Hunter
has applied the appellation of compound simple frac¬
tures to those in which a fracture originally compound
becomes simple by the immediate healing of the exter¬
nal wound.
It sometimes happens that fractures are accompanied
with dislocation, the dislocation probably in every case
preceding the fracture.
The causes of fracture are the endless varieties of
ac<^3ental force applied to bones. Certain circum¬
stances of constitution, however, may be considered as
predisposing causes, such as old age, in which the bones
are more brittle than in youth. Any morbid state of
the system which occasions absorption of parts of the
bony structure. The French surgeons* have record¬
ed cases where bones have been broken by simply
turning in bed. Cold weather has been supposed to
predispose to fractures. Boyer observes, that if these
accidents are more frequent in winter than in summer,
it is because persons are then more liable to injuries
from falling. Dr. Physick has offered a much more
plausible explanation of the fact, which is, that in walk¬
ing over frozen pavements and other slippery places,
great exertions are often made to prevent falling, and
this muscular exertion, added to the force of the fall,
occasions the fracture. The bones are too well cover¬
ed to feel much influence from the cold.
The symptoms of fractures it is very important to be
acquainted with. They are severe sudden pain—an
alteration in the form of the part—sometimes a shorten-
* Louis and Saviard»
124
ELEMENTS OF SURGERY.
ing of the limb, if the fracture be in an extremity—an
inability to move the limb without severe pain at the
injured part—an inequality of the skin covering the
bone; which renders a fracture of the clavicle, or ot
the tibia, generally easy to be discovered; crepitation is
the most certain of all the sjmptoms—a grating noise,
not to be mistaken for any other sound, which is some¬
times very audible. The surgeon should take hold of
the limb above and below the fracture, and by moving
the fractured extremities of the bone, he produces this
noise, and decides, beyond doubt, the existence of the
fracture.
If, however, the surgeon be not called till swelling
from ecchymosis, and inflammation have come on,|jt is
not easy always to judge whether a fracture exists; in
this case he must wait until these symptoms subside.
In judging of the probable event of a fracture, a great
variety of circumstances influence the surgeon. The
age of the patient is of great consequence; in young
persons they heal much more speedily and certainly
than in the aged. I have seen several fatal cases of
simple fracture in old persons. A healthy constitution,
not debilitated by intemperance, is favourable for the
healing of broken bones. Drunkards often become de¬
lirious and die, in consequence of fractures and other
severe accidents. The nature of the accident, the de¬
gree of violence applied, and the mode of its applica¬
tion, greatly influence the prognosis. Fractures from
gunshot are always dangerous, a portion of bone being
destroyed by the force of the ball, which must exfoliate
(be separated by the absorbents) before the sound bone
can granulate and unite: a compound is always more
dangerous than a simple fracture. A fracture attended
with great ecchymosis, and extensive injury of the ad¬
jacent flesh, is more dangerous than one unattended
ELEMENTS OF SURGERY.
125
with these circumstances. An oblique is more difficult
to manage than a transverse fracture. Fractures of
the lower extremities have more serious consequences
than those of the upper. In general those of superfi¬
cial bones are less important than those in which the
fracture is covered by large strong muscles. Fractures
in the middle of a bone are less dangerous than at its
extremities in the vicinity of joints. The season of the
year, and many other circumstances, will no doubt affect
the healing of broken bones.
The reunion of fractured bones is effected nearly in
the same manner as the restoration of soft parts. The
inflamed vessels pouring out coagulating lymph, which
becomes vascular, and is gradually by a deposition of
bony matter and an absorption of the unnecessary parts,
converted into a bone.
The uniting medium is called callus; it is at first soft,
but gradually becomes firmer, and at length completely
ossifies.
In some cases the bond of union is very slow in form¬
ing, and then the inflammatory action must be increas¬
ed by stimulating remedies. In other cases too much
inflammation exists, and then, unless prevented by de¬
pletion, suppuration takes place.
OF THE TREATMENT OF FRACTURES.
To place the fragments as nearly as possible in their
original position, and to keep them so until union is ef¬
fected, are the important indications in the treatment
of fractures.
To effect the replacement of the fragments, exten¬
sion and counter-extension are generally necessary,
though in some cases, as in fractures of the olecranon
and patella, the fragments are to be pushed together.
After the parts are placed in their proper position, the
126
ELEMENTS OF SURGERY.
application of bandages and splints becomes necessary
to retain them so. Extension signifies the force ex¬
erted on the fragment of a limb most remote from the
body. Counter-extension is the power by which the
opposite fragment is prevented from moving with it.
The various modes of applying these forces will be
most properly considered, when the treatment of par¬
ticular fractures is described.
The constitutional treatment must be regulated by
various circumstances. Inflammation frequently attends
a fracture, and is an essential part of the process of
restoration. If it be too violent, the surgeon must re¬
strain it by the usual remedies. Purging in many cases
of fracture is extremely inconvenient in consequence
of the motion to which it gives occasion. Blood-letting
is to be preferred, as this mode of evacuation is not lia¬
ble to any objection, and the bowels are to be kept from
costiveness, but no cathartics should be administered,
unless in those fractures in which absolute rest is not
enjoined, and the patient on the contrary is permitted
to walk, as fractures of the arm, clavicle, &c. A low
diet should be observed.
When the soft parts are much injured, the antiphlo¬
gistic measures are to be carried further than where
the only injury is the broken bone. In many cases, by
their powerful application, we prevent ulceration, which
would convert a simple into a compound fracture. In
cases of extensive ecchymosis, where no large artery
is wounded, cold applications and copious depletion are
generally successful in preventing the formation of an
abscess.
If any particular artery of considerable magnitude
is wounded, it becomes necessary to cut down to it and
tie it up; and if possible without cutting into the cavity
of fracture.
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ELEMENTS OF SURGERY.
127
In every case of fracture in which it is necessary for
the patient to remain in bed during the cure (and there
are very few in which it is not) a proper bed is an ob¬
ject of great convenience. Sir James Earle has pub¬
lished an account of a bedstead and mattress invented
by his son, which in fractures and various other acci¬
dents and diseases, adds so greatly to the comforts of the
patient, that I think the medical world are under great
obligations to the inventor.'*! In private practice, how¬
ever, and especially in the country, it is extremely diffi¬
cult to procure such a convenience, and then a firm
common mattress of hair is to be substituted, or if this
cannot be obtained, a few blankets folded and applied
over boards. A feather bed and sacking bottom afford
so very unequal and unsteady a surface, that it is ex¬
tremely difficult to keep the patient who lies on them
in a proper posture.
* Eahle's Double Bed. " The contrivance consists of a double bed; the
upper one has an opening in the sacking, in a suitable place and of the
proper size, to which a thin mattress, blanket and sheet are made to corre¬
spond with a similar aperture: this, by a very simple piece of mechanism,
may be elevated to a sufficient height for the nurse to introduce a proper
receptacle between that and the fixed bed. The patient being relieved,
the bed is gently let down again upon the under one, a thin cushion being
placed on the under bed to fill up the opening, and make the upper bed
level."
The apparatus for elevating the upper bed may be varied according to cir¬
cumstances: or the hands of several assistants may be substituted, especially
in cases where the accommodation is not likely to be long wanted. In the
adjoining plate, Fig. 1. represents the original bed contrived by Mr. Henry
Earle, at St. Bartholomew's Hospital.
Fig. 2. Shews the improved plan in which the upper bed is made of suffi¬
cient width for one person, but is intended to be placed on, and fixed to,
any bed, of any breadth.
In both figures "the upper bed is seen lying on the lower one; and also,
as it appears when raised up." The mode of elevating the patient is evi¬
dent, without a description.
f In the Pennsylvania Hospital, I have constantly used this bed in cases
of fracture for several years, and have found it extremely convenient in the
treatment of a variety of other accidents. An improvement on this appa¬
ratus by Dr. J. R. Barton, is described in the 4th vol. of the F.clectic Re¬
pertory.
128
ELEMENTS OF SURGERY.
OF COMPOUND FRACTURES.
These have an external wound communicating with
the cavity of the fracture. Mr. Pott very judiciously re¬
marks, that, " In this kind of case the first object of
consideration is, whether the preservation of the frac¬
tured limb can, with safety to the patient's life, be at¬
tempted ; or, in other words, whether the probable
chance of destruction, from the nature and circum¬
stances of the accident, is not greater than it would be
from the operation of amputation. Many things may
occur to make this the case ; the bone or bones being
broken into many different pieces, and that for a consi¬
derable extent, as happens from broad wheels or other
heavy bodies passing over, or falling on such limbs, the
skin, tendons, muscles, &c. being so torn, lacerated and
destroyed, as to render gangrene and mortification the
most probable and most immediate consequence; the
extremities of the bones forming a joint being crushed,
or as it were, comminuted, and the ligaments connect¬
ing such bones being torn and spoiled, are, among
others, sufficient reasons tor proposing and for perform¬
ing immediate amputation; reasons which, notwith¬
standing any thing that may have been said to the con¬
trary, long and reiterated experience has approved."
"When a surgeon says that a limb which has just
suffered a particular kind of compound fracture ought
rather to be immediately cut off than that any attempt
should be made for its preservation, he does not mean
by so saying, that it is absolutely impossible for such a
limb to be saved at all events; he is not to be supposed
to mean so much in general, though sometimes even
that will be obvious; all that he can truly and justly
mean is, that from the experience of time it has been
found that the attempts to preserve limbs so circum-
elements of surgery.
129
stanced have most frequently been frustrated by the
death of the patients in consequence of such injury,
and that from the same experience it has been found
that the chance of death from amputation is by no
means equal to that arising from such kind of fracture.
" Every man knows that apparently desperate cases
are sometimes cured, and that limbs so shattered and
wounded as to render amputation the only probable
means, are sometimes saved. This is an uncontrovert-
ed fact, but a fact which proves very little against the
common opinion, because every man of experience also
knows that such escapes are very rare, much too rare
to admit of being made precedents, and that the majo¬
rity of such attempts fail. This consideration relative
to amputation is of the more importance, because it re¬
quires immediate determination; every minute of delay
is in many instances to the patient's disadvantage, and
a very short space of time indeed makes all the differ¬
ence between probable safety and fatality."
It is not easy to give general rules for practice in
these cases, or else Mr. Pott, and other writers of great
practical experience, would certainly have expressed
themselves with more precision. One evades the ques¬
tion, another gives it very little attention, and Boyer
(inferior to none in a knowledge of the subject) says,
" It is impossible to establish any general rule for cases
of this kind. The surgeon must be directed by his own
talents and sagacity in each particular case." There
are, however, some cases of compound fracture which
so evidently call for amputation that no doubt need ex¬
ist as to the propriety of performing it immediately, if
the surgeon is called within a few hours after the acci¬
dent has happened, and before inflammation has com¬
menced. These are, when a luxation of a large joint,
as the knee, ankle, elbow or wrist, accompany thefrac-
vol. i.—It
130 ELEMENTS OF SURGERY.
ture, forming what has been called a compound dislo¬
cation; when the principal blood-vessels of the part are
destroyed, and thus the danger of gangrene augmented;
when a large lacerated wound exists, the bone being
greatly comminuted, part of its substance destroyed,
and the weather very hot. In such cases, the dangers
are to be stated, and the patient and his friends advised
to submit to the operation; a mere compound fracture
never calls for it; it is the additional injuries which may
require so terrible a resource.
Mr. John Bell remarks, " I am sorry to observe this
the most important question perhaps in surgery, treated
as if it were no question, but rather a rule of practice,
which might be established on the most absolute grounds.
When a surgeon condemns a limb, he does not say that
if amputation be not instantly performed the patient will
die, nor is he disappointed if the limb be saved; ho
thinks both more sensibly and more humanely; he
knows that there is great danger of losing the patient's
life in attempting to save his limb, and reckons it his
appointed duty to advise amputation; but he is still sen¬
sible that the limb may possibly be saved, and often af¬
ter his honest opinion is rejected, contributes, by his
attention and kindness, to that most desirable object
Sometimes he feels it his duty to advise amputation, and
to represent very strongly the manifold dangers of at¬
tempting to save the limb, while yet he rejoices to find
his patient willing to hazard all those dangers in favour
of an object which it must be the chief honour of the
surgeon to accomplish."
The wound communicating with the fracture is some¬
times made by the protrusion of the bone, at other times
by the same force which caused the fracture; the latter
cases are generally accompanied with the greatest mis¬
chief. If, however, the injury be not so great as to in
ELEMENTS OF SURGERY.
131
Uuce amputation, the bone is to be reduced, and proper
dressings ire to be applied.
Sometimes a considerable portion of bone protrudes
through the external wound and cannot readily be re¬
duced. It has been the custom in these cases, to cut off
the sharp ends and projecting pieces of bone, but this
is almost in every insiancc unnecessary, and therefore
improper. By carefully attending to the posture of the
limb, and by dilating the wound when the bone becomes
girded in it, and embraced tightly, we may always suc¬
ceed in the reduction. The enlargement of the wound
thus occasioned, does much less mischief than violent
attempts to reduce the bone, which always occasion
bruising and great pain ; an incision down upon the
bone with a scalpel, or from the bone outward, with a
narrow bistoury (whichever may in the particular case
be found easiest) is to be performed; this incision
readily heals, and leaves the wound no larger than it
would have been if this had been omitted. Any loose
splinters of bone may be removed, and the fragments
carefully placed in contact. The wound, if an incision,
may be closed with adhesive plaster. Mr. Hunter pre¬
fers, however, the application of a superficial dry com¬
press, in order to allow the blood to coagulate and form
a kind of scab, shutting up the cavity of the fracture.
I have found both methods successful, and prefer the
latter in all cases except where the wound of the in¬
teguments is somewhat extensive, in which case a strip
of adhesive plaster should be applied over the middle
of the wound, leaving an opening at each end for the
evacuation of effused fluids. We are always to keep
in mind the great importance of uniting the wound by
the first intention, and thereby converting the accident
to the state of a simple fracture, by which much danger
and suffering will be prevented. Whatever circum-
132 ELEMENTS OF SURGERY:
stances, therefore, can keep the parts in a situation la
vourable for union by the first intention, are to be strict¬
ly observed, of course whatever can prevent the inflam¬
matory action from transcending the adhesive grade;
copious blood-letting is often necessary in these cases.
In fractures occasioned by gunshot, and in others
where union by the first intention is impracticable, and
suppuration must take place, from the extensive contu¬
sion and injury of the surrounding flesh, a soft poultice
of bread and milk should be applied.
The wound being dressed, the accident is to be treat¬
ed as a simple fracture, and of the proper dressings we
shall speak after describing the fractures of particular
bones.
When extensive suppurations come on, and exfolia¬
tions of bone, the state of the patient's constitution will
direct the general remedies. If debility be occasioned,
bark and tonics must be administered, and a generous
diet with fermented liquors allowed.
The length of time necessary for the reunion of a
broken bone varies at different ages and in different
bones. In a healthy adult a broken leg will generally
heal in six weeks, a broken rib or clavicle in four. In
children they heal in a shorter time. In old persons not
so soon.
Notwithstanding the use of the proper remedies, cases
sometimes occur in which fractures do not heal by
forming bone, but by a ligamentous union. The patella
generally heals in this manner, and no inconvenience
results from a deficiency of bone between the fragments
in that particular instance; but whenever this happens
in one of the long bones, motion is allowed at the place
of fracture, and a joint is formed, which destroys in a
great measure the use of the limb, and exposes the
patient to great inconvenience. In order to obviate this
ELEMENTS OF SURGERY. *
133
inconvenience, and to occasion bony union, a variety
of measures have been resorted to.
The physiological account of the formation of cal¬
lus is a subject foreign from our present purpose; it is
still, however, necessary to keep in view, that inflam¬
mation is essential to the restoration of a fractured bone,
as well as of a wounded muscle. Whenever, therefore,
two months or more have elapsed, without solid union
being effected, it becomes necessary to excite inflam¬
mation by rubbing forcibly the fractured ends against
each other; after which the dressings are to be reap¬
plied, and the part kept still. If this fail of procuring
the desired event (and it sometimes does fail) other
measures of a much more active nature become neces¬
sary. Mr. Boyer, and other writers who have preced¬
ed him, recommend the cutting off of the extremities of
the bone, and placing them again in contact. " This
operation," he observes, " is painful, terrifying, and of
dubious event. Its success, however, has been frequent
enough to warrant the trial. It would be impractica¬
ble in fractures of the leg or fore arm, on account of
the difficulty of separating from the integuments the
two bones of which each of these parts is formed, and
on account of the numerous nerves and arteries which
would be in danger of being wounded by the large in¬
cisions, it is therefore practicable only in the femur and
humerus, especially in the latter/'
Mr. Boyer describes an operation of this kind which
he once performed in the middle of the humerus; the
limb mortified, and the patient died on the sixth day!
In many other cases amputation has been performed. I
saw an arm cut off in one of the largest hospitals in
Europe in consequence of an u artificial joint," in the
middle of the radius. It must be stated, however, that
in this case there was a great deal of pain experienced
134
ELEMENTS OF SURGERY.
in the part, but I do not consider this by any means an
excuse for such an operation, because there is every
reason to believe that had the firm reunion of the frag¬
ments been effected, this pain would have subsided.
Mr. John Hunter suggested the propriety of expos¬
ing the cavity by an incision, under an idea that the
" stimulus of imperfection" would excite a sufficiency
oi inflammation to effect a union of the fragments.
Dr. Physick has the credit of having proposed and
practiced a mode of cure in these cases more eligible
and successful than any heretofore in use, and one
which promises to supersede the cruel and fatal opera¬
tions which have been mentioned. It consists in pass¬
ing a seton between the fragments, and suffering it to
remain until bony union commences. The first case
in which this plan was carried into effect, occurred in
the year 1802. The os humeri had been fractured
man) months before, and a joint was formed in its mid¬
dle, which rendered the arm useless. A sefon needle
armed with a skein of silk was passed through the limb
(extension being made at the time by two assistants)
between the fractured ends of the bone, a pledget was
applied on each orifice made by the needle, which was
cut off, leaving the silk in the wound. The operation
occasioned very little pa in, and the subsequent inflam¬
mation was by no means violent, and was followed by
moderate suppuration; the arm was in a few days after
the operation placed in splints; the dressings were re¬
newed daily for twelve weeks, during which time no
amendment was perceived; but soon after, the bending
of the arm at the fracture was observed to be more
difficult, and the patient complained of more pain when
it was moved. From this time the bony union went
on gradually, and in about five months the cure was
completed, leaving the arm as well and strong as it
ever had been-
ELEMENTS OF SURGERY.
135
Several cures of the os humeri and tibia have since
been made in the same manner. It is important to be
recollected that a long continued inflammation must be
kept up in these cases, and therefore the seton should
not be withdrawn for four or five months unless bony
union is found commencing. I am sorry to state that
the remedy has been applied to two cases of fractured
os femoris without effect; the occasion of the failure was,
however, very obvious in both cases; it was found im¬
possible to place the fractured extremities nearly to¬
gether. They had passed each other to a considerable
distance, and the adjacent lacerated flesh had healed
around them in such a manner, that a great interven¬
tion of soft parts existed, and precluded completely all
contact of the fragments.* My friend Mr. Brodie of
London, has succeeded completely in a case of fractur¬
ed os femoris, by means of the seton, and believes it
applicable to that as to other cases. Mr. Wardrop
found it useful in diminishing the mobility of the arti¬
ficial joint, but the ill health of his patient prevented it
from effecting a complete cure. (See Medico-Chirur-
gical Transactions, vols. 5 and 7.)
It is probable that the remedy will be found effectual
in most other cases of artificial joints, but not often in
those situated in the os femoris.
Much of the substance of the bone is absorbed in
cases of artificial joints, so that the fragments are
rounded, or rather pointed, and terminate in a kind of
cartilage or ligament.f
* See plate VI. fig. 6.
f In a thesis published at Paris, by J. B. La Roche, in 1805, the seton, as
proposed by Dr. P. S. Physick, is recommended as preferable to all other
means heretofore used in such cases; but the writer being unacquainted
with the English language, has supposed the family name of Dr. Physick to
be that of his profession, and consequently ascribes the honour of the in-
vention to Monsieur F S. , Physician. The writer of the thesis allud¬
ed to, having seen setons used after gunshot fractures to facilitate the dis¬
charge of dead bone, wonders that the thought never occurred to himself
nor his master, of applying the remedy to cure artificial joints.
136
ELEMENTS OF SURGERY.
CHAPTER XIX.
Particular Fractures.
FRACTURES OF THE OSSA NAST.
The ossa nasi, in consequence of their exposed si¬
tuation, are often fractured. " The cause of the fracture
is always applied to that part immediately where the
solution of continuity takes place, and the fracture may
be oblique, longitudinal, or transverse, without derange¬
ment of the fragments; but it more frequently happens
that the bones are splintered and crushed into the ca¬
vity of the nostril: the nose loses its natural form, and
the neighbouring soft parts are much bruised by being
crushed between the bones and the cause of the frac¬
ture, whether this be a body against which the nose has
been forcibly struck, or one which may have been
strongly impelled against it.
" If the soft parts have suffered no solution of conti¬
nuity, and if the fragments have not been displaced, the
fracture may not be discovered, because the form of the
nose does not change. An oversight in this case is not
dangerous, as the use of emollients and resolvents is all
that is required. If the fracture be comminutive, not
only the inflammatory symptoms ought to be combatted
by blood-letting and other antiphlogistic means, but fur¬
ther, the fragments ought to be replaced, as they strain
and irritate the soft parts, already contused, by their
unnatural situation. For that purpose the surgeon
takes a grooved sound, a female catheter, a ringhan-
dled forceps, or any such instrument, introduces it into
the nostrils, and by using it as a lever, pushes the frag¬
ments outwards; at the same time with the index of the
ELEMENTS OF SURGERY.
137
left hand applied to the ring of the nose, he prevents
them from being pushed out too far, and from lacerat¬
ing the integuments. Sometimes the bones continue in
the situation in which they have been thus placed; but
it may happen, that from being much fractured, and
badly supported by the soft parts, they fall again in¬
wards: in which case a canula of elastic gum should be
directed along the inferior surface of each nostril, which
ought then to be stuffed with lint, and gently thrust in,
lest the pituitary membrane should be hurt.
" In cases of comminuted fracture, with depression
of the splinters, it would be imprudent to wait the dis¬
appearance of the inflammatory symptoms, before mak¬
ing an 'attempt to raise and adjust the fragments; be¬
cause, during the interval, the portions of bone might
reunite in an unnatural situation, and produce deformity
of the nose.
" Fracture of the nasal bones is sometimes attended
with very dangerous symptoms, whether produced by
a violent commotion given to the head, by the cause of
the fracture, or by a co-existing fracture of the bones
of the skull; or, as some authors think, by the concus¬
sion communicated to the perpendicular part of the eth¬
moidal bone, and thence to its cribriform part, which
would, in that case, be fractured, on account of its great
tenuity. The laceration of the dura mater and its ves¬
sels, caused by the fractureof the cribriform lamella of
the ethmoidal bone, would produce effusion, and thus
give rise to all the symptoms. It is certain that cases
have occurred where blows on the root of the nose have
produced coma, convulsions and death; particularly
when the nasal bones were not fractured." (Boyer.)
A piece of leather spread with adhesive plaster as¬
sists, by gentle compression, in preventing the displace¬
ment of the fragments, and as there is no danger of dis-
vol. i.—s
138
ELEMENTS OF SURGERY.
placement from muscular action, no other dressing is
necessary. I have seen a fracture of these bones in
which one of the fragments punctured the facial artery
as it passes over the nose. The hemorrhage at first
was very profuse, but ceased after the fragments were
reduced.
elements of suruery.
139
CHAPTER XX.
Fractures of the Lower Jaw.
This bone, from its moving freely when struck, and
also from its strength of texture, is not very often frac¬
tured. It sometimes however is broken, and no part
of it is secure from fracture. Mr. Boyer declares that
its "symphysis at the chin is very rarely fractured,
though it is not impossible." I once saw an instance
of fracture at this place. Sometimes it is broken in
several places. I have known the jaw bone broken by
a fall, into five different fragments. The middle piece
in these cases is most difficult to be kept fixed, because
of the muscles inserted into it which tend to draw it
downwards.
It is liable to fracture in every part, from the con¬
dyles, to the chin. The coronoid process is not often
fractured except by gunshot wounds. The condyles
are oftener broken. The fracture may vary greatly in
its direction; it is sometimes transverse, sometimes ob¬
lique, sometimes in the direction of the bone, or longi¬
tudinal, separating the alveolar portion from the basis.
It is generally simple, but sometimes compound.
The symptoms of a fractured jaw are very obvious;
a severe pain at the part is felt at the time of the acci¬
dent, and an inequality is perceived on passing the fin¬
gers along the basis of the jaw; upon examining the
teeth they are found unequal, those situated upon one
fragment being elevated above those of the other; when
the two sides are taken in the hands it is easy to re¬
duce the teeth to their proper level, and in doing so
crepitation is perceived. These symptoms exist when
I... V .. •
y y
140
ELEMENTS OF SURGERY.
the fracture is situated anteriorly to the angle of the
jaw; when the condyles are broken, the fracture is not
so very obvious, but may be ascertained by pain near
the ear when the jaw is moved, and by crepitation oc¬
casioned by these motions. If considerable swelling
occur before the surgeon is called, greater ^difficulty is
experienced in determining the nature of the accident,
and in these cases it becomes necessary to wait until
the inflammatory symptoms subside.
The greatest danger attending a simple fracture of
the lower jaw is that of consequent deformity, and this
is very readily obviated by proper arrangement. Com¬
pound fractures, however, are more dangerous, and are
often followed by tedious exfoliations, and in some in"
stances do not unite.
To reduce the fracture, nothing more is necessary
than to shut the mouth, and forcibly push upwards the
inferior fragment, until the teeth contained in it come
in contact with those in the upper jaw. When all
the teeth are upon a level, the fragments are to be. sup¬
posed in apposition. It is not easy in all cases to kedp
them at rest in this position:—A variety of means have
been contrived to effect this purpose, such as fastening
the pieces together by passing wire around some of the
teeth in each—forming a mould of moistened paste¬
board to fit the chin, and binding this fast upon it. The
simplest and best plan is to avail ourselves of the sup¬
port given by the teeth in the upper jaw, by binding
the fragments firmly against them, and this can be very
conveniently done by means of a simple roller of mus¬
lin passed repeatedly round the topvof the head and
under the chin. It may be further secured by passing
a few turns of it round the back of the neck and in
front of the chin. The four-headed and double-head-
ELEMENTS OF SURGERY. 141
ed bandages formerly used for this purpose, have no
advantage over the roller, and it is by no means so easy
to apply them neatly.
The patient should be nourished fifteen or twenty
days on spoon victuals, sucked between the teeth, for
which there is generally space enough, and this space
is often augmented by the want of a tooth at some part
of one of the jaws.—It has been proposed in commi¬
nuted and compound fractures, where the slightest mo¬
tion is productive of great pain, to pass a catheter
through the nostril, and inject the fluid aliment through
it. If a case requiring such treatment should occur, no
difficulty would be found in effecting it.
In fractures of the condyles of the jaw, that process
is drawn forwards by the pterigoideus externus muscle;
as it is very short there is no means of obviating this,
and it becomes necessary therefore to push forward and
keep in that situation the inferior fragment; in order to
effect which, before applying, the bandage as has been
directed, a compress is to be applied behind the angle
of the jaw extending nearly up to the ear, this com¬
press when the roller presses tightly on it will keep the
inferior fragment advanced sufficiently to come and re¬
main in contact with the upper. In fractures of the
condyles it is particularly necessary for the parts to re¬
main at rest, as motion has sometimes prevented the
reunion of the fragments and the condyle has exfolia¬
ted. Boyer relates a case in which this unpleasant
event occurred: he extracted the condyle seven months
after the accident through a fistulous ulcer.
Compound fractures of the lower jaw, are very fre¬
quently attended with exfoliation, by which the cure is
much protracted.
It often happens that one or more of the teeth are
142 ELEMENTS OF SURGERY.
loosened at the fractured part; it has been advised to
extract all loosened teeth, as extraneous matter. It is
a fact, however, that the teeth under these circum¬
stances very readily become fixed, and it is extremely
imprpper to remove them, because the accident is thus
converted into a compound fracture. .
ELEMENTS OF SURGERY.
143
CHAPTER XXI.
Fractures of the Vertebrce.
{ * ' ' ,
* v
The spinal column moves readily in every direction,
and being composed of a great number of separate
pieces, of small size, is not very liable to fracture.
The spinous processes are sometimes broken, because
they are more slender and brittle than the other parts
of the bone, project considerably backwards, and are
more superficial. Whenever the vertebra© are fractur¬
ed, the force which produces this effect occasions also
concussion of the spinal marrow, which./s the only cir¬
cumstance rendering, the accident important, for the
mere facture of the vertebrae would heal as readily
as that of any other bone. A palsy of all those parts
which derive their nerves from below the fractured
spot is the immediate consequence of every fracture of
the spine which produces compression on the spinal
marrow, whether this be by the pressure of bone or
effused fluids. When this happens, therefore, in either
of the three superior cervical vertebrae, immediate death
ensues, from palsy of the fonrth and fifth pair of cervi¬
cal nerves, which chiefly supply the diaphragm, and
which originate in the spinal marrow, a little higher
than the place of their exit. Although death does not
instantaneously follow the fracture of the fourth cervi¬
cal vertebra, yet it very soon occurs.*
* a very remarkable case occurred in Jarmary 1816, which seems to form
an exception to this general rule—a gentleman was shot by a pistol present¬
ed close to his face—the ball entered his mouth and shattered the atlas ver¬
tebra, notwithstanding which he survived the accident three weeks, and no
symptoms of paralysis occurred, though the pus and the ball were in con¬
tact with the dura mater.
144
ELEMENTS OF SURGERY.
" The variety of causes which may give rise to symp¬
toms analogous to those <>f fracture of the .vertebrae ren¬
der it* difficult to establish a diagnosis. Yet when
person has fallen on his back from an elevated situa¬
tion, or when a body very forcibly impelled, as a bullet
discharged from a musket, has struck that part, if a
fracture has taken place, some derangement of the
spinal process of the fractured vertebrae may be ob¬
served, by an attentive examination^ the part affected.
Much pain is caused by pressing on that process; the
inferior extremities are paralyzed, as also the rectum and
bladder; the patient is afflicted with a retention of urine
and faeces, or with an involuntary discharge of the latter.
" This paralysis of the inferior extremities, the neces¬
sary concomitant of the fracture of the vertebrae, is not
in itself a moital affection; but the patient losing the
power of locomotion, and being obliged to lie perpetu¬
ally on his back, soon feels a troublesome itching in the
region of the sacrum on which the pressure of the
body is principally concentrated. The skin of this part
becomes inflamed and gangrene to a greater or less de¬
gree ensues, because the pressure on that part inter¬
cepts the course of the humours. The bone is quickly
denuded, the ulcer extends rapidly and consumes the
patient's strength, the dissolution is accelerated by the
retention of excrements, from the paralysis of the rec¬
tum and bladder. The catheter which must be intro¬
duced into this latter organ for the purpose of evacuat¬
ing the urine gives admission to the air * " Its mucous
secretion becomes more abundant and its substance
thickened. A slimy matter flows out with the urine,
and the penis and scrotum become (edematous, a slow
* The inflammation thus occasioned, is probably not excited, as Mr. Boj er
supposes, by the admission of air, since there is no reason for supposing
this fluid a powerful irritant, except when it produces fermentation, in the
contents of a cavity.
ELEMENTS OF SURGERY.
145
fever succeeds these symptoms, and the patient, how¬
ever robust he may be, falls in a few weeks. We have
known, however, a man of very vigorous constitution to
have survived for six months an accident of this nature.
Examples of recovery are recorded, but they are ex¬
tremely rare, and to be ascribed to the secret opera¬
tions of nature rather than to the efforts of art, and
we repeat that scarcely one in thirty recovers; almost
all die from the exhaustion of their strength, by slow
fever, colliquative diarrhoea, &c.
"Any attempt at setting these fractures would be not
only useless but dangerous, by the straining which it
would occasion. General treatment alone can be had
•recourse to/' (Boyer.)
In all cases of injury of the spine it is of extreme im¬
portance to introduce a catheter into the bladder, and
to leave it in with a cork in the orifice, or to introduce
it and evacuate the urine three or four times every
twenty-four hours. As the patient in these cases feels
no pain and is not conscious of the distention of his
bladder, it is necessary for the surgeon to be aware of
the importance of attending to this circumstance. A
patient was brought into the Pennsylvania hospital in
the summer of 1812, who had been wounded in the
spine, by a musket-ball two weeks before in a naval
engagement. He had received very little attention af¬
ter the accident; immediately on his admission I order¬
ed the catheter to be introduced, when nearly three
quarts of urine were drawn off; he had voided none for
two weeks.
It has been recommended to trepan the spine in
cases of paralysis from fracture, and to remove the de¬
pressed bone or effused fluids, as in cases of fractured
cranium. This operation could not be performed with¬
out extreme difficulty, and the greatest uncertainty of
vol. I.—T
i
146
ELEMENTS OF SURGERY.
relieving the compression. The inflammation likely to
follow the operation, would probably occasion a repeti¬
tion of the pressure from distention of the vessels
within the spinal cavity.
Dr. Physick has attempted to relieve the effects of
fractures of the vertebrae, by making extension and
counter-extension from the head and feet of the patient,
the head being secured to the upper and the feet to the
lower part of the bedstead. In the first case in which
it was used, the fracture was situated in the fifth and
sixth cervical vertebrae; the patient regained after the
extension, the use of his arms which had been para¬
lytic, but expired shortly after, apparently from a col¬
lection of mucus in the trachea which he was unable-
to cough up, from palsy of the expiratory muscles.
Perhaps as some relief was in this case experienced the
remedy may be worthy of trial.*
In examining patients with fractures of the spine it
is of extreme importance not to turn them on their
faces, but to conduct the examination whilst they lie on
one side—suffocation has resulted and instant death
from neglecting this caution.
* An account of this case may be seen in Dr. Hartshorne's edition of Boyef.
ELEMENTS OF SURGERY.
147
CHAPTER XXII.
Fractures of the Ribs.
• ' ' * 1 ' J •' ' _•
The ribs, in consequence of the elastic cartilages in
which they terminate, and of the strength derived from
their arched form, are not very often fractured. The
first rib is very seldom broken, as the shoulder and
clavicle protect it greatly from accidental violence.
The ribs are most commonly broken by falls from a
considerable height, and sometimes by violent blows.
They are generally broken near their middle, by a
transverse fracture; sometimes the fracture is oblique,
and inconveniences result from the sharp extremities
of the fragments; sometimes these penetrate the exter¬
nal integuments, forming a compound fracture, and
sometimes they pierce the pleura and lung, and thus
occasion emphysema.
The fracture is ascertained by an acute pain in
breathing and by careful examination with the hand,
and by pressing the rib in different parts a crepitus
may sometimes be felt. To assist in the investigation
the patient should be desired to cough whilst the sur¬
geon's hand is kept on the part injured, if any fracture
exist the act of coughing will generally produce crepi¬
tation.
In many cases, especially in very corpulent subjects,
tliere is great difficulty in ascertaining the existence of
the accident, and in all these cases the dressings should
be applied as if a rib actually were fractured.
From the articulation of the ribs to the sternum be¬
fore, and the vertebrae behind, no diminution of length
can take place; no lateral derangement of the frag-
148 ELEMENTS OF SURGERY.
t ♦ A,
ments can happen, because the intercostal muscles act
equally on both fragments, and tie them to the unin¬
jured ribs above and below. The only derangement
which can happen, is by an angular projection inter¬
nally at the place of fracture.
The only treatment necessary in simple fractures of
the ribs, whether one or several be broken, is to keep
the parts at rest as much as possible during their re¬
union, and this is done by counteracting in great mea¬
sure their motions in respiration. To effect this, a
bandage six inches wide is to be passed repeatedly
round the chest as tight as the patient can suffer it to
be drawn. Its descent may be prevented by a shoul¬
der-strap. When this is done respiration is performed,
principally by the action of the diaphragm, and the ribs
remain, comparatively at rest. Instead of the roller, a
jacket of strong linen may be used capable of being
laced very tight by means of tapes.
When the lungs have been wounded by a fragment
of the bone, the patient generally spits blood and coughs
violently—the lungs inflame, and violent fever comes
oi), attended with difficult respiration and other symp¬
toms of pneumonia. Copious blood-letting, and the
usual remedies for inflammation must in such cases be
employed.
When emphysema occurs from a fractured rib, it is
to be treated in the same manner as has been recom¬
mended when this affection is consequent to a wound
of the thorax. If the complaint proceed to any consi¬
derable extent an incision is to be made into the tho¬
rax; it is, however, a very rare occurrence: to prevent
it, it has been recommended to bind a compress very
firmly over the fracture.
When the cartilages of the ribs become ossified, as
they often do in advanced life, they are also liable to frac¬
ture, the accident is to be treated just as a broken rib
ELEMENTS OF SURGERY. 149
CHAPTER XXIII.
Fractures of the Sternum*
This bone, in consequence of its spongy texture, and
the manner in which it is connected with the elastic
cartilages of the ribs, is not so liable to be fractured as
most of the other bones.
Cases, however, sometimes occur from gunshot vio¬
lence, heavy blows upon the chest, and similar causes.
Where a fracture exists, it may, in general, be easily
ascertained by making careful pressure on the surface
of the bone with the fingers, which readily detect any
elevation or depression of the broken fragments, and
by the crepitation. A fracture of the sternum is some¬
times accompanied with palpitations, cough, and spit¬
ting of blood. The only treatment necessary in a sim¬
ple fracture of this bone, is the application of some
adhesive plaster over the injured parts, together with a
roller round the chest, in order to prevent, as far as
possible, any motion of the ribs. Rest, bleeding, and
low diet must be prescribed, with the view of prevent¬
ing inflammation of the contents of the thorax.
The principal danger to be apprehended from a frac¬
ture of the sternum, arises from the liability of the im¬
portant vital organs contained within the chest, being
contused or lacerated by any splinters or depression of
one or more of the fragments.
When this is the case, the most dangerous conse¬
quences are to be looked for, and every exertion is ac¬
cordingly to be made to prevent them.—Ed.
* Fractures of the sternum having been omitted altogether by the au¬
thor of this work, it was thought best to introduce the following observa¬
tions under the head of a distinct chapter.—Ed.
150
ELEMENTS OF SURGERY.
CHAPTER XXIV.
Fractures of the bones of the Pelvis.
The os sacrum is not often fractured—a carriage
passing over it, or a heavy weight falling on it, may oc¬
casion a fracture: no muscles are inserted into it which
have any agency in moving the fragments, and the only
remedy is rest in a horizontal posture. If extensive in¬
flammation result from the contusion accompanying the
fracture, it is to be treated as usual. If suppuration
take place, and abscesses form, they must be opened as
soon as possible, to prevent the formation of fistulous
ulcers. When large extravasation takes place within
the pelvis, bleeding and low diet are to be ordered, with
a view to prevent suppuration; which in this situation
would prove a very serious evil.
The os coccygis is sometimes broken, though very
rarely—the existence of this fracture is ascertained by
pain in the part, and in every attempt to walk this pain
is augmented: by introducing the finger into the anus,
the fragments may be felt. The only remedy neces¬
sary is rest and gentle compression, by means of a com¬
press supported by a T bandage.
The ossa innominata are occasionally broken by a
variety of accidents; the fracture occurs in different si¬
tuations. Mr. S. Cooper has seen instances of fracture
in the ilium, the ischium, and the os pubis. I have seen
the acetabulum fractured in such a manner as to occa¬
sion incurable lameness. The ilium, however, is more
frequently broken than either the ischium or pubis.
The fracture of these bones, is in itself of less conse¬
quence than the mischief occasioned by the force which
ELEMENTS OF SURGERY. 151
produced it. The contents of the pelvis must be con¬
tused severely by any force great enough to fracture
the bones which form it, and generally extravasations
of blood take place into the cellular texture, which in¬
tervenes between the viscera of the pelvis.
A fracture of the os innominatum, is to be known by
the usual symptoms of pain and crepitation upon mov¬
ing the fragments; an inability to walk also occurs, but
any severe injury to the pelvis produces this: fractures
of these bones have often been found after death, when
their existence has been unsuspected.
The treatment consists chiefly in obviating inflamma¬
tion by the usual remedies, as no displacement of the
fragments is likely to occur. The inconveniences of
discharging the urine and faeces, are sometimes very
great in these accidents, but they are much diminished
by the use of Sir James Earle's bed. In some cases
suppuration takes place, notwithstanding the free use
of evacuating remedies, and large abscesses form: splin¬
ters of bone have been found to occasion these collec¬
tions of matter. " Desault, in giving an exit to a col¬
lection of urine which had taken place from a fracture
of the pelvis, found a splinter which he extracted from
the bottom of the wound. It the bladder be perforat¬
ed by a splinter, this should be extracted, and a cathe¬
ter introduced, in order to prevent the accumulation of
urine and its consequent effusion into the cavity of the
abdomen;" an accident which has occurred.
152
ELEMENTS OF SURGERY.
CHAPTER XXV.
Fractures of the Scapula.
The mass of muscular flesh which surrounds the sca¬
pula, and its great mobility, protect it in great measure
from fracture; some parts of it, however, are more ex¬
posed than others. The acromion process forms the
most projecting part of the shoulder, and is oftener frac¬
tured than any other part of the scapula; the inferior
angle is the part next in frequency found broken. The
coracoid process has seldom been known fractured: a
gunshot wound, and the falling of a heavy body directly
upon it, have sometimes, however, occasioned this ac¬
cident.
The force which produces the fracture generally oc¬
casions much contusion of the adjacent flesh. When
the scapula is broken longitudinally, the muscles on its
surfaces prevent a displacement of the fragments, trans¬
verse fractures are more apt to be accompanied with a
derangement of them. The serratus major anticus
muscle, draws forward the lower portion to which it is
principally attached. The inequality is evidently per¬
ceived by passing the fingers along the base of the
scapula.
To ascertain the existence of the fracture, it is ne¬
cessary to examine particularly whether any derange¬
ment is evident, and whether any crepitation can be
produced by pressing the bone in different places. The
only fractures which are not easily discoverable in this
way are the longitudinal. The lower angle when bro¬
ken off moves easily under the fingers, whilst the rest
of the bone is stationary.
ELEMENTS OF SURGERY,
153
When the fracture is longitudinal, or transverse
through the scapula, a roller is to be applied round the
chest and arm, so as to confine the arm close to the
side; this roller should cover the arm down to the el¬
bow.
" As the inferior angle, when separated by fracture
from the rest of the bone, is like the condyloid process
of the jaw, little susceptible of being acted 011 by any
means in our power, it will be necessary to act on the
scapula itself, to push it downwards and forwards, to¬
wards the inferior fragment which the serratus major
anticus has drawn in that direction. In this case too,
it is on the arm that it will be necessary to act, in order
to move the scapula. The arm is to be pushed inward,
forward, and downward, the fore arm being half bent.
It must be kept in this position by a circular bandage
seven yards long. It will be proper at the same time
to act on the angular detached portion by means of
compresses, which may be pressed backwards by some
rounds of a bandage, and thus brought in contact with
the rest of the bone. The arm may be supported in a
sling tied on the opposite shoulder." (Boyer.)
" The acromion when fractured is drawn outward
and downward by the action of the deltoid muscle, at
the same time that the rest of the bone is drawn up¬
ward and backward by the trapezius and levator sca¬
pulas. This fracture is set, by raising the arm in such
a manner as that the head of the humerus may push
upward the acromion, which has descended, and which
naturally covers it like an arched roof, at the same time
an assistant pushes the scapula forward and downward,
in a direction opposed to that which is given to the
arm"—in order that the parts may remain in this situa¬
tion, bandages are to be applied—" a circular bandage is
to be applied round the trunk and arm, and afterwards
vol. 1.—u
154
ELEMENTS OF SURGERY.
made to ascend from the elbow to the shoulder, and vice
versa." 14 This bandage, like all those of the thorax,
is very liable to be displaced, and therefore to be fre¬
quently reapplied, never forgetting on these occasions,
to have the elbow raised and the shoulder pressed
down." (Boyer.)
Although fractures of the scapula consolidate in the
ordinary time of thirty-five or forty days, yet in those of
the acromion it will be necessary to continue the
bandage a little longer; not that the generation of cal¬
lus is slower in that part than in any other, but because
the acromion is acted on by strong muscles, which
might rupture the callus if exposed to their action be¬
fore it had acquired a great degree of solidity.
elements of surgery.
155
CHAPTER XXVI.
Fractures of the Clavicle.
The clavicle is perhaps as often broken as any bone
of the body. Its exposed situation at the upper part of
the trunk, its long slender shape, and its being covered
only by the common integuments, expose it to frequent
accidents.
The fracture commonly occurs near the middle of
the bone, as it is here most prominent, it is also occa¬
sionally broken near the sternal, and humeral extremi¬
ties. When fractured by the falling upon it of a heavy
body, the nerves of the arm become paralyzed by the
contusion.
In general the fragments are displaced, unless it is
broken near the shoulder, in which case its firm con¬
nexion by ligaments with the scapula prevent the dis¬
placement. The external fragment, or that nearest
the shoulder, is drawn downwards by the weight of the
arm, and the action of those fibres of the deltoid mus¬
cle, which are inserted into it, and also by the pectora-
lis major, which when it is depressed draws it forwards,
or inwards towards the sternum; so that the sternal
portion is always found riding over the humeral; the
arm of the affected side falls over upon the breast, and
the patient is unable to rotate the humerus, so that it is
impossible for him to raise his hand upon his head. He
leans to the fractured side, and the attitude is so re¬
markable, that the celebrated Desault, it is said, was
never deceived in deciding, from this circumstance
alone, the existence of the fracture. Crepitation may
easily be produced by moving the arm, and the finger
156 ELEMENTS OF SURGERY.
• 4
passed over the clavicle readily detects the place of
fracture.
This accident in itself is not dangerous, but becomes
so when accompanied with great contusion or laceration
of the neighbouring soft parts.
The treatment of this fracture has been the source
of much difficulty among surgeons, a vast variety of ma¬
chinery has been contrived for the purpose of keeping
the fragments together, and lately a surgeon of great
and deserved celebrity* has renounced all applications
and trusts to rest in a horizontal posture, as the only
necessary remedy. I refer to Mr. Boyer for a concise
aecount of the discarded apparatus of the older sur¬
geons. Mr. Desault was the first who properly con¬
templated the difficulties to be surmounted, and con¬
structed an apparatus, which, better than any before in
use, removes them. His plan with different modifica¬
tions has been very generally used in this country, and
continues to be preferred to all others, I shall therefore
describe it. It is not the smallest advantage of his
dressings that they are always at hand.
" The pieces of which this apparatus is composed
are, 1st, Three rollers three inches broad; the two first
six, the other eight ells long, each one rolled up sepa¬
rately.
2d, A bolster or pad (Fig. 1. a b) made in the form
of a wedge, out of pieces of old linen. Its length should
be equal to that of the humerus, its breadth four or
five inches, and its thickness at the base about three
inches.
3d, Two or three long compresses.
4th, A small sling for the arm.
5th, A piece of linen large enough to cover the
whole bandage.
* Mr. Pelletan, surgeon in chief io the Hotel Dieu, &c, &c. 8cc
JJL.\ TB Jr.
ELEMENTS OF SURGERY.
157
Every thing being properly arranged, the following
is the mode of applying the apparatus, which of itself
reduces the fracture.
The patient being placed in a standing position, or
if his case render that impracticable, on a seat without
a back, an assistant elevates the arm of the affected
side, and supports it at nearly a right angle with the
body, (Fig. 2.) whilst the surgeon places under the arm¬
pit the head of the bolster, which descends along the
side of the thorax, and which another assistant situated
at the patient's sound side holds by two upper corners.
The surgeon now takes one of the first rollers, ap¬
plies the end of it on the middle of the bolster, fixes it
there by two circular turns round the body, and passes
a turn obliquely (a a) along the fore part of the tho¬
rax ascending to the sound shoulder. The roller then
descends behind, passes under the arm, and returning
in front of the thorax, makes a circular turn and a half
horizontally. Having reached the hind part of the tho¬
rax it reascends obliquely by the cast (b) as it had done
before, and passes over, before, and under the sound
shoulder; having thus crossed the turn (a a) the roller
again passes across the hind part of the thorax, and
finishes by circular turns which completely cover the
bolster. A pin is now to be fixed in the place of cross¬
ing of the roller on the sound shoulder, to prevent the
turn (a) from slipping downward.
The application of this first roller is intended for no
other purpose than firmly to fix the bolster, which is
held up by the two oblique turns before and behind,
and secured against the body by the subsequent circu¬
lar turns.
The bolster being fixed, the surgeon applying one
hand to its external surface pushes it upwards, and with
the other, taking hold of the elbow, after having half
158
ELEMENTS OF SURGERY.
bent the fore arm, lowers the arm till it is laid along (he
bolster. He then presses its lower extremity forcibly
against the side of the thorax, pushing it upwards at
the same time and directing its upper extremity a little
backwards.
The application of the bandage constitutes a part of
the process of reduction. The humerus, now convert¬
ed into a lever of the first kind, is drawn at its upper
end from the shoulder, in proportion as its lower end is
approximated to the thorax. The scapulary fragment
being drawn along with it, and directed at the same
time upwards and backward, comes into contact w7ith
the sternal fragment, and in an instant the deformity of
the part disappears.
The arm being thus situated is given in charge to an
assistant, who retains it in the same position in which
he received it from the surgeon, by pressing on it with
one hand, and with the other supporting the fore arm
half bent, and placed horizontally across the breast.
The second roller is next to be applied. The end of
this is carried under the arm-pit of the sound side. It
is then brought across the breast, over the superior
part of the diseased arm, and extends across the thorax
behind till it passes under the arm-pit. Two circular
turns cover the first. The roller must then ascend to
the lower part of the shoulder by oblique turns (c c Fig.
3.) each of which must be overlapped by the succeed¬
ing one to the extent of about the third part of its
breadth. It is necessary that these turns be applied in
such a way as to bind but very gently above, and to in¬
crease in tightness, as they descend nearer to the lower
extremity of the humerus.
The use of the second roller is to supply the place
of the hand of the assistant in pressing the arm against
the side of the thorax, its effect evidently is to draw
ELEMENTS OF SURGERY.
159
t he upper extremity of the arm outwards, and as it ig
already directed backwards, to retain it in that position.
The compression of the circular turns on the arm,
being thus gradually augmented, becomes on the one
hand more efficacious, because it acts on a greater sur¬
face ; and on the other less troublesome, because being
more divided it is less felt at the lower extremity of the
arm, where it bears with most force.
A third indication remains to be fulfilled, namely, to
retain the shoulder in its elevated position, and by that
means to assist in the extension of the fragments, which
already has some effect in preventing a depression.
To fulfil this indication, an assistant sustains the
elbow in its elevated position with one hand, and with
the other supports the patient's hand before his breast,
whilst the surgeon fills with lint the hollow spaces
around the clavicle. He then applies on the clavicle
at the place where it is fractured, the two long com¬
presses, wet with vegeto mineral water, a solution of
sugar of lead, or some other cooling liquid. Taking
now the last roller, he fixes the end of it under the
sound shoulder, from thence he brings it obliquely
across the breast, over the long compresses, and carries
it down behind the shoulder along the posterior part of
the arm, till it passes under the elbow. From this point
he again carries it obliquely upwards across the breast
to the arm-pit, then across the back over the com¬
presses, and brings it down again before the shoulder
along the front of the humerus, till it again reaches the
elbow. From thence the roller again ascends obliquely
behind the thorax, passing under the arm-pit where the
first coat of the roller is covered, and from whence it
again starts to run the same course we have just describ¬
ed. This constitutes a second round, which covers in
part the first, and forms a kind of double triangle, e,f}
160
ELEMENTS OF SURGERY.
d, situated before the breast, and over the circular turns
of the other rollers (c c Fig. 4.). The remaining part
of the roller brought from behind forward, is employ¬
ed in circular turns over the arm, and round the thorax
for the purpose of preventing the displacement of the
first part. To make it the more secure it is fastened
with pins or stitches at its different places of crossing.
The sling (Fig. 4.), is next passed under the hand,
and fastened above to the ascending turns (d) and not to
the circular (c c), which the weight of the hand would
be likely to draw downward.
It is only necessary to examine the course of this
third roller to see that united to the sling; it is well cal¬
culated to support the external fragment, which the
weight of the shoulder has a tendency to depress, on a
level with the internal one. It supplies the place of
the assistant who raises the elbow, and supports the
hand of the patient, in like manner as the second roller
performs the office of the assistant who presses the
lower part of the humerus against the side of the tho¬
rax.
On the other hand, the circular turns by which the
application of the third roller is finished, being direct¬
ed from before backwards, push in the same direction
the arm and shoulder, which have been already carried
that way, by the process of reduction, and thus retain
them in their proper places." (Desault.)
By this apparatus the shoulder is kept, upward, back¬
ward, and outward; the weight of the arm and the ac¬
tion of the muscles, are thus effectually prevented from
drawing the humeral fragment inward and downwards.
" The coats of the rollers thus surrounding the tho¬
rax, however well they may be secured, are yet liable
to be displaced, particularly when the patient is in bed.
This inconvenience may be obviated by surrounding the
PLATE, T".
ELEMENTS OF SURGERY.
161
whole with a piece of linen, leaving nothing uncover¬
ed but the sound arm, which is at liberty to perform its
usual motions."
It is better, however, to add to the firmness of the
dressings by connecting them together with several
rows of stitches in different places.
This mode of treating fractured clavicle has been
found extremely successful, but it has its inconveni¬
ences; the principal one that I have experienced in its
use, is the numbness of the arm, and stoppage of the
circulation, which occur in consequence of the pres¬
sure of the bolster in the axilla, upon the vessels and
nerves of the arm- Great attention is necessary to
obviate this by diminishing when it occurs, the tight¬
ness of the bandage, which passes round the arm near
the elbow; to judge whether the pressure be too great,
the pulsations of the radial artery at the wrist should
be attended to; if they be interrupted the bandage must
be loosened. Another inconvenience results from the
slipping down of the pad in the axilla; I have in some
cases, with advantage, attached a piece of tape to it,
and tied this on the opposite shoulder. Whenever the
dressings become slack they must be tightened; with¬
out attending to this circumstance they are useless.
Mr. Boyer, availing himself of the principles of De-
sault, has constructed a very simple apparatus which acts
in the same manner, and is very easily applied.
It consists of a girdle of linen cloth quilted, and six
inches broad, which passes round the trunk on a level
with the elbow. It is fixed on by three straps, and as
many buckles fastened to its extremities. At an equal
distance from its extremities, on each side, are placed
two buckles, that is, two anterior, and two posterior to
the arm. A bracelet of quilted linen cloth five or six
fingers broad, is placed on the lower part of the arm
vol. i.—x
m
ELEMENTS OF SURGERY.
of the side affected, and laced on the outside of the arm;
four straps fixed to this bracelet, that is, two behind and
two before, correspond to the buckles on the outside of
the girdle already described, and answer the purpose
of drawing the lower part of the arm close.to the trunk,
the more so, as the straps, by being two before and two
behind, prevent the arm from moving either backwards
or forwards. With this apparatus, as well as the pre¬
ceding, the cushion must be applied under the arm.
I have never seen this plan used, but have no doubt
it would answer very well. It cannot, however, be free
from those inconveniences of Desault's which result
from pressure in the axilla, and the weight of the arm
appears to be less completely supported.
In about four or five weeks the fracture will gene¬
rally unite, and no particular attention is necessary to
diet or regimen; the patient may be allowed to walk
about during the cure.
ELEMENTS OF SURGERY. 163
CHAPTER XXVII.
Fractures of the Os Humeri.
The os humeri is fractured most frequently near its
middle; occasionally, however, in all its parts. I have
known it fractured in one case within the capsular liga¬
ment, the fracture extending through the head of the
bone. Fractures above the insertion of the pectoral and
latissimus dorsi muscles, are called fractures of the neck
of the bone. The lower extremity is also broken, and
in some instances the condyles are detached from the
rest of the bone, and from each other.
When the fracture is tranverse, and is situated near
the middle of the bone, no great derangement takes
place, the fragments supporting each other, and the
limb preserving its length, and unless moved, its form.
In oblique fractures, the limb is shortened by the action
of the muscles, and considerable alteration in its shape
is perceived.
When the bone is fractured at its upper end or neck,
there is some difficulty in distinguishing the accident
from a dislocation of the head of the bone into the axilla.
It can always, however, be known, by a depression at
the upper and external side of the arm, very different
from that depression which occurs in dislocations, and
which is situated immediately under the acromion
scapulae. In the present instance, the shoulder retains
its natural rotundity, and no depression exists directly
under the acromion. The axilla being examined with
the fingers, the fractured unequal surface is readily felt;
whereas, in dislocations, the round head of the bone is
felt high up in the arm-pit. By moving the arm the
164
ELEMENTS OF SURGERY.
grating of the fractured surfaces can be distinctly per¬
ceived. The best manner of treating this accident, is
that described by Desault.
" The patient is to be seated on a chair, or on the
side of a bed, the arm is slightly separated from the
body and carried a little forward. One assistant is di¬
rected to fix and secure the trunk in a proper manner;
this he does by pulling the arm of the sound side, tak¬
ing hold of it near to the hand, and extending it in a
direction perpendicular to the axis of the body. This
mode of counter-extension, is preferable to that com¬
monly employed, which consists in applying the hands
to the upper part of the patient's shoulder; because on
the one hand, the power being further removed from
the resisting force need not be so great, and on the
other, the body being entirely unincumbered renders it
easy for the surgeon to apply the roller, without discon¬
tinuing, or in any way disturbing the extension. Ano¬
ther assistant makes extension on the fore arm, which
serves him as a lever, where one hand being placed
behind, or on the back of the wrist, forms the point of
support, or fulcrum, while the other applied to the an¬
terior and middle part of the fore arm, on which it
makes pressure from above downward, constitutes the
power, and the fragments to be brought into contact,
the resistance.
The relaxation of the muscles produced by this semi¬
flexion of the fore arm, and the separation of the arm
from the trunk, greatly favours this mode of extension;
a mode, recommended by the ancients, adhered to by
the English, and which possesses the advantage of leav¬
ing uncovered all that portion of the limb on which the
apparatus is to be applied, and by that means of allow¬
ing the hands of the assistant to keep the same position
during the whole time of the application. A small do-
ELEMENTS OF SURGERY. 165
gree of force directed according as the displacement is
inward or outward, is sufficient to effect the reduction,
which even takes place of its own accord under this
process. If the surgeon lays his hands on the place of
fracture, it is rather to examine the state of the frag¬
ments, than to assist in bringing them into apposition."
In order to keep the parts in this state of reduction,
the surgeon takes a roller, fixes one end of it by two
circular turns, on the upper part of the fore arm, and
carries it up along the arm by oblique turns moderately
tight, and overlapping each other about two-thirds of
their breadth. Having reached the upper part of the
limb, he makes some reversed turns to prevent the
wrinkles, which would otherwise be caused by the un-
evenness at this place. He then passes two casts of
the roller under the opposite arm-pit, and brings it to
the top of the shoulder again; a splint* is then placed
before, which reaches from the fold of the arm to a
level with the acromion; another on the outside reach¬
ing from the external condyle to the same level; a third
reaching from the olecranon to the fold of the arm-pit.f
These splints are to be secured in their situation'by the
roller brought down over them and secured at the el¬
bow. A bolster is now applied between the arm and
side; Desault advises this bolster "to be made of linen
from three to four inches thick at one end, tapering
like a wedge to the other, and of a sufficient length to
reach from the arm-pit to the elbow." If the displace¬
ment be in an inward direction, the thick end is to be
placed uppermost, and if outward, which is commonly
the case, the thin end. This bolster is to be pinned to
the roller, and the arm then secured against it, by a
* Firm pasteboard answers very well for this purpose.
f Two splints, each two inches wide, axe generally sufficient in this frac¬
ture*
166 ELEMENTS OF SURGERY.
roller passed round the arm and body, (as in cases of
fractured clavicle,) sufficiently tight to keep the arm
firmly fixed against the bolster. Instead of the cushion
or bolster recommended by Desault, compresses ol fold¬
ed flannel or linen may be substituted, and they can be
made thicker at one place than another, according as
the displacement inward or outward, may require. The
fore arm is to be suspended in a sling. From twenty-
six to thirty days are required for the reunion of the
fragments. It is of consequence in this accident, from
the vicinity to the joint, to prevent any displacement of
the fragments, as their union under such circumstances
would greatly impede the motions of the limb. The
apparatus just described, which varies in nothing im¬
portant from that of Desault, will effectually prevent
this inconvenience.
Fractures occurring in the middle of the bone, or in
any situation between the immediate vicinity of the el¬
bow and shoulder joints, are very easily dressed. Coun¬
ter-extension is to be made by an assistant with his arms
round the chest; extension is to be made by another
assistant who draws down the arm, taking hold below
the elbow. The surgeon readily places the fragments
in contact, when the arm will be found to have its pro¬
per length and shape; the external condyle correspond¬
ing with the most prominent part of the shoulder. A
roller is now to be applied, extending from the wrist to
the shoulder (to prevent tumefaction of the fore arm);
the fore arm is to be bent to a right angle with the arm:
when the roller reaches the elbow, three or four splints,
according to the bulk of the arm, (I have never, how¬
ever, seen more than three necessary,) are to be applied
to the outer, inner, and back part of the arm, and se¬
cured by bringing down the roller over them: these
splints should be two and a half inches broad, long;
ELEMENTS OF SURGERY. 167
enough to extend from the shoulder to the elbow, the
inner one will be several inches shorter than the two
others, to allow the flexion of the fore arm, and to pre¬
vent excoriation at the axilla. They may be made of
thin wood, or strips of wood glued upon leather, or tin,
or what I have always preferred to every other material,
thick pasteboard, such as is employed for the covers of
books. When pasteboard is used in this case, it need
not be soaked in water, but bent so as to fit the arm.
The roller must never be bound so tight as to cause
pain. The arm must be supported in a sling, and the
patient, in general, walks about during the cure, which
is commonly completed in four weeks. At the expira¬
tion of a week (and in most other fractures the same
thing should be done) the dressings are to be removed
and the part examined, and any displacement rectified
before they are reapplied.
When the fracture is situated near the condyles, or at
the condyles, a very different mode of treatment is to
be adopted. A deformity is extremely apt to occur af¬
ter this accident, and the motion of the elbow is much
impeded. To obviate this, Dr. Physick has for many
years been in the habit of applying two angular splints,
which keep the fore arm flexed at a right angle upon
the arm. The fracture being reduced, and the parts
placed in their proper situation, a roller is to be applied
as usual, from the wrist to the shoulder, and brought
down over the angular splints: these splints are made
of pasteboard or wood, an inch and a half wide; the
part applied to the arm, extends from near the shoulder
to the elbow, and the part applied to the fore arm,
should be long enough to reach to the ends of the
fingers, to obviate the motions of the hand; a handker¬
chief passed round the neck, supports the weight of the
arm.
168
ELEMENTS OF SURGERY.
After a week has elapsed, the dressings are to be re¬
moved, and the joint carefully and gently flexed, and
extended several times to prevent stitfness; after which
they are to be carefully reapplied, and this is to be re¬
peated once in every forty-eight hours, increasing, as
the cure advances, the motion of the joint. At the end
of three weeks the mode of dressing is to be altered,
and splints forming an obtuse angle are to be substitut¬
ed for the rectangular, which had been first employed.
The object of this change is to prevent a kind of de¬
formity, which though not very important in man, as it
does not interfere with the motions of the joint, is, how¬
ever, of more consequence to females. The deformity
alluded to, consists, in an angular projection of the el¬
bowi, outwards. it is most evident when the whole arm
is placed at right angles to the body, with the thumb
upwards, the patient standing erect. In that case, in¬
stead of a gentle curve downwards at the elbow, which
is natural, the curve is directly reversed. I have at¬
tempted to represent it in the annexed sketch, in which
the natural and the deformed appearances are contrast¬
ed. The effect is particularly ^ipt to occur, when the
condyles are broken off directly at the joint, and when
in addition to this transverse fracture they are also se¬
parated from each other, which sometimes happens,
from the extreme thinness of the bone between the two
condyles, occasioned by the space for receiving the ole¬
cranon behind, and the coronoid process of the ulna
before. The mode of treatment just described has, in
several instances, been completely successful in prevent¬
ing deformity, and preserving the perfect motions of
the elbow.
Dr. Physick has since ascertained that the same end
may be answered by keeping the patient in bed, with
the arm flexed at th<* elbow, and lying on its outside,
with rectangular splints, supported by a pillow.
elements of surgery.
169
CHAPTER XXVIII.
Fractures of the Fore Arm.
These are very frequent accidents, and are produc¬
ed by a variety of causes. Sometimes both bones are
broken, sometimes the radius only, and sometimes the
ulna. When both bones of the fore arm are fractured,
by the same force, the fracture in each bone is gene¬
rally on the same level; but sometimes one bone is bro¬
ken higher up than the other. The interosseous liga¬
ment which connects the bones of the fore arm to¬
gether, generally prevents a separation of the fragments
in the longitudinal direction; the derangement is most
commonly in a transverse direction, the four fragments
approaching each other at the injured part, and a con¬
siderable change in the shape of the arm is perceived.
The symptoms of the fracture are very obvious; great
pain at the time of the accident, which is augmented
by every motion of the hand; an inability to pronate or
supinate the hand; mobility at the place of fracture;
crepitus when the fragments are moved, and deformity
of the member. These symptoms are not so obvious
when the fracture occurs near the wrist; the accident
has, in such ca^s, been mistaken for a dislocation.
Boyer mentions as line best diagnostic symptom that,
when the fracture exists, the styloid processes of the
radius and ulna follow the motion of the hand when
the wrist is flexed; whereas in cases of dislocation they
remain fixed. The dislocation is a very rare accident,
and the fracture a very frequent one; in most cases,
the crepitus when the fragments are moved decides the
nature of the injury.
vol. i.—y
17(3
ELEMENTS OF SURGERY.
To reduce the fracture, the fore arm is bent to a
right angle with the os humeri. An assistant takes
firm hold of the arm just above the elbow, another
grasps the patient's hand, and the necessary extension
is then made. The surgeon very readily adjusts the
fragments.
To dress the fracture a roller is applied, commencing
at the hand and extending a little above the elbow; two
firm splints of pasteboard (not soaked in water), are to
be next applied; compresses of linen, flannel, or tow,
being interposed, to fill up the spaces between the splint
and arm: the roller being brought down over these
splints secures them in their situation; the thumb being
uppermost may be left projecting out between the
splints, as an indication that no rotatory motion has dis¬
placed the fragments. The splints used in dressing all
fractures of the fore arm, should be long enough to ex¬
tend from the elbow to the extremities of the fingers,
and a little wider than the broadest part of the arm.
They should be long, in order to confine the fingers
from moving, by which irritation would be occasioned,
and possibly a displacement of the fragments, because
the muscles moving the fingers, are situated on the fore
arm; and they should be broad, because the roller pass¬
ed round narrow splints would press the fragments to¬
gether, and thus by diminishing the interosseous space,
greatly impede the motions of the li»ifr: for the same
reason the roller first passed rou»d the arm should not
be drawn tight over the place of fracture. The com¬
presses placed on each side of the arm, being pressed
by the splints upon the soft parts situated between the
bones, force them between the two bones and thus ob¬
viate the inconvenience alluded to: all that remains, is
to place the arm in a sling. After a week or ten days,
the dressings should be removed and the part examin-
ELEiMENTS OF SURGERY.
171
ed; any deviation from the proper position can at this
period be remedied. In thirty or forty days the cure
will generally be completed. Whenever the fracture
occurs near the elbow or wrist, the dressings should be
removed every forty-eight hours after the tenth day,
and the joint gently flexed and extended before they
are reapplied.
If much contusion be occasioned by the cause of the
accident, the patient is to be confined to his bed, and
the inflammation combatted by the usual remedies.
A compound fracture requires the confinement of the
arm upon a pillow, and instead of the roller a bandage
of strips is to be applied (called Scullets, from its in¬
ventor Scultetus;) the wound is to be dressed in such
a manner as to promote its speedy union: if it be small
and not greatly contused, it may be allowed to scab,
and dry lint is to be applied over it: if great lacera¬
tion exist, a poultice will be found necessary.
2. When the Radius only, is broken, which is most
frequently the case in fractures of the fore arm, the
member cannot be bent at the place of fracture, as the
ulna being uninjured, preserves its firmness. The ex¬
istence of the accident is discovered by drawing the
hand along the edge of the radius firmly, when the
fracture can be felt by the angle of one of the frag¬
ments; great pain is experienced in attempts to rotate
the hand, and the crepitus can generally be heard.
When the radius is broken near its upper extremity,
the depth of muscle in which it is imbedded, renders
the diagnosis more difficult. In these cases Mr. Boyer
recommends that " the thumb be placed under the ex¬
ternal condyle of the os humeri, and on the superior
extremity of the radius, and at the same time, the hand
is to be brought to the prone and supine positions. If
hi these trials, always painful, the head of the bone
172
ELEMENTS OF SURGERY.
rests motionless, there can be no doubt of its being
fractured." There can be no derangement of the frag¬
ments in fractures of the radius, except what the mus¬
cles occasion by drawing one or both fragments to¬
wards the ulna ; and the pronators principally effect
this. • 1
The treatment of this acccident is similar to that re¬
commended when both bones are broken ; the ulna,
however, acts as a splint in the present case, and aids
in keeping the fragments at rest; but it has no effect
in preventing their lateral displacement, and therefore
compresses must be applied between the splints and the
fore arm, to keep up pressure upon the interosseous
muscles, and thereby preclude the approximation of the
fragments, to the ulna.
3. When the ulna is alone broken, the fracture is
easily discovered by passing the hand along it, as it is
superficial and easily felt from the olecranon to the
wrist. The treatment is the same as in a fracture of
• ' ' • ,
both bones, unless the fracture happens high up, near
the joint. ' <-•
When the olecranon is fractured, no difficulty is ex¬
perienced in detecting it. The fracture is generally
transverse, and as the triceps extensor cubiti, is insert¬
ed into it, the upper fragment is generally separated
considerably from 4he lower, and the patient loses the
power of extending the fore arm: a wide space is gene¬
rally felt and seen between the fragments, and they
readily move upon each other producing crepitus. The
proper treatment of the accident is well described by
Boyer. " The divided parts, are brought into contact
by extending the fore arm, and pushing down the ole¬
cranon from the place to which it had been drawn up
by the action of the triceps. The principal object is to
counteract the action of this muscle, which tends inces-
ELEMENTS OF SURGERY. 173
santly to separate the detached olecranon from the
ulna. To effect this purpose, a circular bandage mo¬
derately broad, is passed on the fore arm fully extend¬
ed, this being done the olecranon is pushed down into
contact with the ulna, and the middle part of a long
compress placed behind it, the extremities of which are
brought downward, and crossed on the anterior part
of the fore arm, after which several turns of the band¬
age made so as to cross one another, are carried round
the articulation of the elbow*, the bandage should then
be rolled up on the humerus, in order to diminish by
pressure the irritability of the triceps, which is relaxed
by extension of the fore arm. This bandage being
applied, the bend of the fore arm is filled with lint, and
a long splint applied on it anteriorly, by which the
flexion of the arm is prevented. The splint is fixed by
the same bandage, rolled on downward from the shoul¬
der to the wrist. The oblique casts of the roller which
cross one another on the articulation, forming a kind
of figure of 8, ought to be nicely applied and drawn
very tight; because if but slightly braced, their action,
which is oblique, will not be sufficient to confine the
olecranon in its situation. Previous to the application
of these oblique casts, the skin of the olecranon should
be drawn up by an assistant, for if this precaution be
not taken, it may sink between the divided portions and
prevent their contact.
Though the contact be exact, immediately after the
application of the bandage, yet if, as is apt to hap¬
pen, the bandage become relaxed, or if the patient in¬
advertently contract the triceps, the olecranon ascends;
because the bandage acting perpendicularly to its di¬
rection, can but feebly oppose the ascent of this process:
an interval will therefore exist between the ulna, and
olecranon; which will be filled up by granulations, and
174 ELEMENTS OF SURGERY.
by the thickening of the periosteum, or tendinous ex¬
pansion of triceps which covers that bone, and the re¬
union of the parts will be effected by means of an in¬
termediate ligamentous substance, the length of which
will depend on the careful application, and frequent
renewal of the bandage. In forty or forty-five days
the ligamentous substance acquires its greatest consis¬
tence, but the articulation should not be kept motion¬
less so long ; gentle motion may be commenced on the
twenty-fifth or thirtieth day. The object of these mo¬
tions is to prevent a false anchylosis of the articula¬
tion.
In cases of recovery obtained by these means, the
olecranon adheres to the ulna firmly enough to transmit
to it the action of the triceps muscle, and to moderate
the extension of the fore arm.
Compound fracture of the olecranon is an accident
of the most grievous nature, on account of the great
number of nerves which pass in the neighbourhood of
that part. It should therefore be treated with the great¬
est care. The inflammatory symptoms arc to be treat¬
ed by copious and repeated bleedings; the arm is to be
placed half bent on a pillow and dressed with Scultets
bandage. In these cases the intermediate ligamentous
substance is always greater than in simple fracture, and
consequently the force of the arm is much diminished.
If a false anchylosis be prevented by judiciously exer¬
cising the articulation as soon as the state of the parts
will permit, the patient may think himself fortunate.
If the inflammatory swelling, &c., be not dissipated
before the twenty-fifth or twenty-sixth day, the appli¬
cation of the apparatus we have just described will be
useless, because it will be necessary at that time to be¬
gin to exercise the articulation the formation of the li-
ELEMENTS OF SURGERY.
175
gamentous substance being then considerably advanc¬
ed." (Boyer.)
The coronoid process of the ulna, Dr. Physick has
once seen broken. The symptoms resembled a dislo¬
cation of the humerus forward, or rather a luxation of
the fore arm backward, except that when the reduction
was effected, the dislocation was repeated, and by care¬
ful examination, the crepitation was discovered. The
fore arm was kept flexed at a right angle with the hu¬
merus. The tendency of the brachieus internus to
draw up the superior fragment, was counteracted in
some measure, by the pressure of the roller above the
elbow. A perfect cure was readily obtained,
•*< t;
„• * - •
• •, ' i >*;' i ... ' ..
176 ELEMENTS OF SURGERY.
CHAPTER XXIX.
Fractures of the Wrist and Hand.
Fractures of the bones of the carpus very rarely oc¬
cur, except in gunshot wounds, or by a heavy body fall¬
ing upon them. In every case of this accident which I
have seen, the fracture has been an object of secon¬
dary importance, and amputation has in general been
necessary from the nature of the injury. Where the
limb is to preserved, the hand is to be placed in a
straight position and kept at rest by splints and band¬
ages.
The bones of the metacarpus are sometimes broken.
I have known them fractured in pugilistic contests.
The accident is readily known from the crepitation
perceived at the place of fracture by careful examina¬
tion. The treatment consists in filling the palm of the
hand with a compress, and applying a straight splint in
front, extending from just below the elbow to the ends
of the fingers.
The bones of the fingers are also sometimes broken.
All the different phalanges are liable to fracture. The
accident is known by the change of shape in the finger,
and by the motion at the fractured part, which is attend-
ed with evident crepitation. The reduction is easily
effected, and is to be maintained by a narrow roller
passed round the finger, and by two firm pasteboard
splints, one before and one behind, wider than the
finger and bent a little round it, which are to be secur¬
ed by the same roller. I have found it useful to pre¬
vent the motion of the fingers and hand by a firm splint,
long enough to reach from the middle of the fore arm
ELEMENTS OF SURGERY.
177
to the finger ends. In about four weeks the union is
generally completed.
" When a very heavy body has crushed the extremi¬
ties of the fingers, or when they have been bruised by
a folding door, the soft parts are generally lacerated,
the nail torn off, and- the last phalanx fractured and
denudated.. If in such cases, the parts hold together
by a shred of a certain thickness, and which contains
vessels enough for the nourishment of the phalanx, the
reunion of the parts should.be attempted. The pros¬
pect of success, it is true, is not great in most cases,
but if our endeavours to save the finger fail, amputa¬
tion is still as much in our power, as in the commence¬
ment.
"If the last phalanx alone is crushed, it will be bet¬
ter to amputate at once, than attempt to save the joint.
The cure would, be difficult and tedious, on account of
the exfoliation that would take place. Besides, the part
being deformed, instead of being useful, wcyild be trou¬
blesome. By amputating at the articulation with the
second phalanx, a simple wound is substituted to the
ragged and lacerated wound, produced by the cause of
fracture. This will heal in a very short time, if care
be taken to preserve a sufficiency of skin to cover the
surface of the articulation." (Boyer.)
vol. i.—£
178 ELEMENTS OF SURGERY.
. 7 •
CHAPTER XXX.
Fractures of the Thigh.
The os femoris is very frequently broken, and it is
of great importance to treat the accident in such a man¬
ner as to prevent deformity and lameness, which are
often its consequences.
The thigh bone* may be broken at the head, even
within the acetabulum; at the neck, at the condyles,
and at any part between the neck and condyles. The
great trochanter is in some cases, knocked off from the
rest of the bone. The fracture is sometimes transverse,
sometimes oblique, sometimes comminuted, sometimes
compound; but most commonly we find.it, a simple ob¬
lique fracture:
A fracture of the oS femoris is attended with a mo¬
bility at the fractured part, an inability to stand on the
limb, or to move it without extreme pain at the'fracture ;
generally with a very distinct crepitation when the frag¬
ments are moved against each other, and almost in
every instance with deformity and shortening of the
member.
Mr. Boyer observes, that " the numerous muscles of
the thigh by means of which derangement may be ef¬
fected, are divisible into three classes, relative to the
manner in which they tend to effect it. The three por¬
tions of the triceps femoris are attached to both pieces,
and tend to produce the angular derangement by draw¬
ing the two fractured portions to a salient angle on the
outside, where their*fibres are strongest and most nu¬
merous. The biceps femoris, semitendinosus, semi¬
membranosus, sartorius, rectus internus, and third ad-
ELEMENTS OF SURGERY.
179
<luctor, all those in short, which extend from the pelvis
to the inferior portion, or to the leg with which it articu¬
lates, tend to draw the inferior portion upward, on the
internal side of the superior, the extremity of which
forms a tumour on the external side of the thigh. The
inferior portion is that which is always displaced, ex¬
cept when the fracture takes place immediately under
the small, trochanter, to which process are attached, by
a common insertion, the psoas and iliacus muscles;
which muscles would, in such a case, draw the superior
portion upward and forward, producing by that means
a tumour in the groin.
When the femur is fractured immediately above the
condyles, the inferior piece is drawn backward, and its
superior surface turned downward by the action of the
gastrocnemius externus, plantaris, and popliteus mus¬
cles. When the great trochanter is detached from the
rest of the bone, it is drawn upward by the muscles
which are inserted into it, but without producing any
change in the direction or form of the thigh.
The angular derangement in which the foot inclines,
either inward or outward, is the effect of the weight of
the foot or of the bed-clothes, rather than of muscular
contraction."
Transverse fractures are less liable to displacement,
and are more easily retained in their natural position
than oblique, for very obvious reasons, the opposing sur¬
faces surporting each other to a certain extent.
Fractures of the os femoris are more difficult of cure
than those of any other limb; and such was formerly
the want of success in preventing deformity that the
ancients considered it impossible to cure them without
shortening of the thigh, and Mr. John Bell, notwith¬
standing his high notions of modern surgery, declares,
that " the machine is not yet invented, by which a frac-
180 ELEMENTS OF SURGERY.
tured thigh bone can be perfectly secured. ' A posi¬
tion which, though entirely false, proves that surgeons
consider the fracture of a very serious nature.
Before proceeding to detail the practice I wish to
recommend in the treatment of fractures of the os femo-
ris, it may not be amiss to premise, that surgeons have
been greatly divided in their opinions respecting the
posture in which the patient should be placed during
the cure.
The celebrated Mr. Percival Pott, was a warm advo¬
cate for a bent position, and recommended the thigh to
be bent upon the pelvis, and the leg upon the thigh,
and the patient to be laid upon his side, under an idea,
that in this manner the muscles would be most com¬
pletely relaxed, and thus the great cause of deformity
obviated. The British surgeons have pretty generally
followed this practice.
The late French writers, and particularly Desault
and Boyer, have strenuously recommended a contrary
practice, placing the patient on the back and extending
the lower extremity; the reasons which induced them
to reject Mr. Pott's plan, Desault states to be " the
difficulty of making extension and counter-extension,
with the limb thus situated; the necessity of making
them on the fractured bone itself, and not on a part re¬
mote from the fracture, such as the lower part the leg;
the impossibility of comparing the broken with the
sound limb; the uneasiness occasioned by this position
if long continued, though at first it may appear most
natural; the troublesome and painful pressure on the
great trochanter of the affected side; the derangements
to which the fragments are exposed when the patient
goes to stool; the difficulty of fixing the leg with sufficient
steadiness, to prevent it from affecting the os femoris
by its motions; the evident impracticability of this me-
ELEMENTS OF SURGERY.
181
thod when both thighs are broken, and finally experience,
which in France has been by no means favourable to
the position recommended by Pott."
Mr. John Bell, with all that copia verborum which
characterizes his truly peculiar style, and with all that
violence, with which he opposes every thing he fancies
wrong, has devotecf several quarto pages of his Princi¬
ples of Surgery to an abusive opposition of the practice
of Desault, whose theory he pronounces " unworthy his
high character," and asserts that " his intentions, and
indeed his very words, are anticipated not merely by
old surgeons whose works he might have neglected to
read, but by his immediate predecessors and cotempo-
raries, Petit, Sabatier, and Duverney." Mr Bell de¬
clares, thatDesault's plan " is neither original nor suc¬
cessful," and that " the napkin round the thorax pro¬
duces oppression and insufferable distress which no-
one can possibly bear." Mr. Bell in this and many
other passages proves incontestibly that he never saw
Desault's apparatus applied; that he is entirely ignorant
of it, and that in this, as in several other instances, he
writes and rails on a subject he does not comprehend.
In proof of this, I shall quote the following passage,
which strongly evinces his want of candour, and his
want of correct information.
"To judge of the merits of these methods, imagine
to yourselves the condition of a patient under Desault's
discipline \ first laid down on one side and bound to the
long splint of Duverney that the body and the limb
were as one piece; next a great napkin put round the
thorax with all the firmness of a bandage; straps going
round the thorax, passing under the arm-pits fixed to
this circular, and the patient drawn up by these straps
to the head of the bed. Next imagine, two lacs or long
bandages, fixed one round the knee the other round
182
ELEMENTS OF SURGERY.
the ankle, one tightened when the other had caused ex¬
coriation; imagine the patient, extended like a malefac¬
tor drawn by horses, bound so down to the bed, that
even a cloth or flat dish could not be slipped in under
him; the bands assiduously tightened the moment they
seemed to relax, and the thorax so bound and compress¬
ed that he could not breathe; think"of all this apparatus
of bandage if you can, without holding in your breath,
as if trying whether such oppression could be endured.
I think for my share, I could as well undertake to live
under water, as in Desault's, I might say Damien's bed."
When the reader has finished this rhapsody, let him
imagine something precisely opposite to what Mr. Bell
has imagined, and he will have some idea of Desault's
apparatus.
How far Desault is to be considered as the author of
this imaginary apparatus of Mr. Bell, a perusal of his
writings will show; .but it is truly astonishing that after
such gross perversions, Mr. Bell should have the effron¬
tery to add, that he has quoted his histories of the va¬
rious machines " in the very words of the inventors,
because it is the only fair and impartial representa¬
tion/'* Mr. Bell knew what would have been im¬
partial; and yet far from quoting Desault's " very
words," his whole object has been to misrepresent them.
I should owe an apology for this digression if the ob¬
ject were less important, but I am solicitous that stu¬
dents of surgery should not consider the sophistries of
Mr. John Bell as logical arguments.
I should next proceed to state the advantages of the
straight position in fractured thigh, but having quoted
them from Desault, I shall simply detail the mode of
treatment which I consider best adapted to the accident,
and which is a modification of that proposed by De-
• John Bell—Principles of Surgery, Vol. R,
ELEMENTS OF SURGERY. 18S
sault, just premising that although volumes have beea
written on the action of the muscles in occasioning de¬
rangements of the fragments, it is a certain truth which
has been too much overlooked by all writers, that the
muscles very speedily accommodate themselves to any
posture, and that therefore, that one should be chosen,
which is most favourable to the healing of the fracture
and the convenience of the patient, and this, for many
reasons which I shall not detail in this place, (but the
chief of which is the experience of the surgeons in the
Pennsylvania hospital and in the French hospitals,) I
believe to be the straight position.
The bed should be prepared and the dressings dis¬
posed on it before the patient is placed upon it. If Sir
James Earle's bed cannot be procured, a hair mattress
may be placed upon a common bedstead, but boards or
strips of wood should be substituted for the sacking
bottom; across this mattress, five or six pieces of tape
should be laid; over the tapes a piece of muslin a yard
in width, and a yard and a half long (if the patient be
an adult;) over this " splint cloth" a splint of pasteboard
nine inches long and two. wide is to be placed at its
upper end, and a bandage of strips long enough to ex¬
tend from the knee to the groin, is to be laid over this
splint; each strip should be of muslin, two inches wide,
and long enough .to pass round the thigh, and overlap
several inches. In arranging these strips, the one
which is to be last applied to the thigh, must be the
first laid down, and this will be the upper one, which
should be rather longer than the rest, because the thigh
is thickest at its upper part; each succeeding strip is
to cover one-third part or half of that which preceded
it. The next things to be provided, are two bags of
chaff, or finely cut straw, four inches wide and long
enough to extend from the hip to the foot; if these
184
ELEMENTS OF SURGERY.
cannot be obtained, flannel or .tow may be used as com¬
presses, in lieu of them. A silk handkerchief, or a
strong band of soft linen, is to be placed at the top of
the splint cloth for counter-extension, and a similar one
is to be provided for making extension at the ankle.
Two long splints are to be procured, made of light wood;
the first, which is that of Desault, improved by Dr.
Physick and Dr. Hutchinson, should be so long as to
extend from the axilla six inches below the foot; it is
formed like a crutch at its upper extremity, and a block
projects from near its lower end, the use of which will
be presently noticed; two holes are formed near the
upper extremity, and one near the lower, through
which the counter-extending and extending bands are
passed; the second long splint is three inches wide
above, and tapers to two and a half below, and long
enough to reach from the perineum to the end of the
longest splint; a fourth splint, of the same dimensions
and materials as the first, completes the apparatus.
The patient is now to be placed carefully on his back
on the mattress, in such a manner that the injured thigh
may be situated upon the bandage of strips. The band
for counter-extension is now passed along the perineum,
and between the scrotum (or labium pudendi) and the
affected thigh, and is delivered to an assistant. The
band for extension is passed round the ankle, tied un¬
der the foot and delivered to another assistant; by pull¬
ing these bands extension is made, and 'the surgeon re¬
places carefully the fragments in apposition, and then
applies the bandage of strips, beginning at the knee aud
proceeding upward to the groin. The two long splints
are now folded up in the splint cloth so that both splints
may apply neatly to the sides of the limb; the bags of
chaff, or compresses are interposed to fill up the spaces
occasioned by the inequalities of the leg and thigh, and
ELEMENTS OF SURGERY.
185
the two extremities of the bands for counter-extension
are passed through the two holes near the upper end of
the splint and tied firmly; care.being taken not to per¬
mit the displacement of the fragments whilst this is
done. The band for extension is next passed through
the hole at the lower end of the splint, and tied; but
great caution is to be used in this stage of the business,
to avoid, on the one hand, drawing the bandage too
tight, and on the other, relaxing it so as to suffer the
fragments to pass each other. All that now remains is
to apply the fourth splint on top of the thigh, and se¬
cure it by three tapes, which will bind all four of the
splints moderately tight upon the thigh, and to secure
the lower extremities of the two long splints by two or
three tapes between the knee and ankle. A bandage
or handkerchief may now be passed round the pelvis,
to assist in fixing the patient at rest, and this bandage
will certainly be found to exert no mischievous effects
on the organs of respiration.
The use of the posterior pasteboard splint, is chiefly
to prevent the tape passed round the thigh from irritat¬
ing the skin, and also to assist in gently compressing the
muscles of the thigh and supporting equably the frag¬
ments of the bone behind.
The principal difference between the mode of dress¬
ing a fractured thigh, just described, and that recom¬
mended by Desault, consists in the increased length of
the splint by which the permanent extension is kept
up; an improvement which was first made by Dr. Phy-
sick.
In the first of the annexed engravings, Desault's ap¬
paratus is represented, and in the second the improve¬
ments that have been introduced by Dr. Physick, which
certainly give to tlie apparatus some important advan¬
tages. In the first place, the splint of Desault being
vol. i.—A a
186 ELEMENTS OF SURGERY.
but little longer than the limb, the strap or band for
counter-extension passes over the upper part of the os
femoris at an oblique angle, and has a strong tendency
to draw the superior fragment of the bone outwards;
whereas in the splint contrived by Dr. Physick, the
mortise hole being cut high up near the axilla, the band
for counter-extension acts upon the pelvis, in a line
nearly parallel with the natural direction of the limb,
and has no tendency to any lateral displacement of
either fragment. In . the next place, by extending the
splint as high as the axilla, the pressure of the end of
the splint,does not injure the patient's hip. The crutch¬
like form is intended to prevent the extremity from rub¬
bing against the patient's side, and it is to be covered
with soft flannel or linen, to defend the axilla.
Dr. Physick having, in some cases, found that when
considerable force was applied to the extending band,
the foot was pulled outward and pressed against the
splint so as to occasion excoriation, and finding the use
of compresses and the chaff bags inefficient in prevent¬
ing this inconvenience, suggested to Dr. Hutchinson
then a student at the Pennsylvania hospital, the advan¬
tage of some contrivance to obviate it. He accordingly
attached to the lower end of the splint a block, project
ing two or three inches from the inside of the splint,
across which the band for extension is carried to the
mortise.hole at the lower end of the splint. The splint
being thus constructed, the extension is also made more
completely in the direction of the limb.
By the use of this apparatus there can be no doubt
that " permanent extension" of the thigh bone, notwith¬
standing the cavils "of Mr. J. Bell, may be kept up, and
that a. perfect cure may in most cases be effected, with¬
out the slightest evident deformity, or shortening of the
limb. I have, for twelve or fourteen years, witnessed
ELEMENTS OF SURGERY, J87
•
the effect of this mode of treatment in the Pennsylva¬
nia hospital, where more accidents are admitted than
in any other institution in America, and I am safe in
asserting, that the success of the practice has been sur¬
passed by that of no other hospital in the world. I
have never seen a crooked limb, or a shortened limb,
the consequence of a simple fracture of the thigh, un¬
attended by comminution, where Desault's apparatus,
modified as above, has been fairly applied.
It is proper, however, to remark, that some practition¬
ers have*become dissatisfied with this mode of treat
ment in consequence of the excoriation which they have
found to take place at the perineum and at the top of
the foot. In answer to this objection, it must be stated,
that the use of "permanent extension" does not imply
violent extension, nor sudden extension, but simply a
long continued resistance to the contraction of muscles
which would, if unresisted, shorten the limb. In order
to effect this, after the dressings are applied, it is pro¬
per in every instance, if any pain is experienced, either
at the foot or perineum, to loosen the extending band.
Most of the inconveniences attributed to the method of
Desault have arisen from its improper application, and
nothing is more improper, than to make violent exten¬
sion during the existence of the irritation and inflam¬
matory symptoms which succeed to a fracture of the os
femoris. The extending bandages ought always to be
very moderately tense, during the first three or four
days after the accident, and afterwards they should be
gradually tightened, the limb being examined from day
to day, and its comparative length with its uninjured
fellow, distinctly ascertained. If the patient experience
any difficulty in bearing pressure upon the top of the
foot, a piece of buckskin with holes in front may be
laced round the ankle, and straps attached to this afford
188 ELEMENTS OF SURGERY.
a very convenient substitute for the handkerchief with
which the extension is made. In warm weather, and
in emaciated persons, this gaiter of buckskin is ex¬
tremely useful.
By observing these precautions, very little difficulty
will be experienced in the treatment of fractures of the
thigh bone near its middle. Six or eight weeks are
generally necessary for the reunion of a fractured thigh
bone*
Compound fractures of the body of the os femoris
require 110 difference of treatment from other com¬
pound fractures, but the dressings necessary for the ex¬
ternal wound may be very conveniently applied, with¬
out interfering with the long splints.
When both thighs are broken, or when one thigh is
* Professor Gibson has lately suggested a very ingenious method for
treating fractures of the thigh bones. It Consists in elevating each of the
extremities upon an inclined plane, extending from the ischium to the
heel. Extension is kept up by securing each foot by gaiters to a foot
board well cushioned. Counter-extension is inade by the weight of the
body, or may be effected by fixing the pelvis to the lower end of the frame
by means of a roller or straps. Near this extremity an opening is left with
a corresponding door, for the purpose of placing a vessel beneath the pa¬
tient to receive the faeces or urine. WTe have not yet had an opportunity
of testing the utility of Dr. Gibson's new apparatus, by experience; but its
great simplicity, together with the favourable position in which the limb is
preserved for counteracting any danger of inflammation, certainly impart
to it considerable advantages.
We must, however, be permitted to observe, that we consider Desault's
apparatus, as modified by Dr. Physick, more fully competent to answer all
the indications pointed out in the cure of fractures of the thigh, than any
other we are acquainted with.
When the dressings are properly applied, we believe the danger of ulcer¬
ation from the extending bands to be comparatively trifling.
We are authorized by Dr. Physick to state, that of the numerous cases
of this accident which have fallen under his immediate observation, and
which have been treated with the above apparatus, very few indeed have
been attended with the inconvenience of excoriation so loudly complained
of by some surgeons.—Ed.
For a more particular account of Dr. Gibson's apparatus, see No. 10, of
Dr. Chapman's Medical Journal.
ELEMENTS OF SURGERY.
189
fractured in several parts, no plan of treatment is com¬
parable with that by permanent extension. I have
had occasion to apply it in the case of a miller's wife
who was caught in some machinery ; which fractured
both her thighs and one leg below the knee. She was
placed on her back, and the dressings which have been
recommended, were applied; she recovered as happily
as if only one fracture had existed, experiencing very
little more pain, fever or inconvenience, than is usual
in simple fractures of the thigh or leg.
It has been proposed, among other methods of pre¬
serving a bent position, to place the patient on his back
with an angular box under the knee. I have known
this plan used, and much difficulty was experienced in
preventing the rotation of the limb, every motion of the
pelvis, occasioned motion at the fracture, and the sur¬
geon who attempted it, laid it aside *
Fractures of the great trochanter are the ef¬
fect either of falls on that protuberance, or of the ac¬
tion of bodies striking against it. They are either ob¬
lique, or transverse, situated sometimes at its summit,
and sometimes at its base.
This accident may be distinguished, by a facility of
moving the great trochanter in every direction, while
the pelvis and the thigh remain without motion; by a
crepitation, arising from the friction of the divided sur¬
faces against each other; by there being no shortening
of the limb, when the fracture exists alone; by the frag¬
ments being brought together in abduction, and sepa¬
rated in adduction; by the position of the great trochan¬
ter being higher and more anterior than natural. The
presence of these signs are more readily perceived, be¬
cause, being superficially situated, this protuberance
* Something of this kind has been recommended by Mr. Charles Bell.
Operative Surgery, Vol. II. page 190.
190
ELEMENTS OF SURGERY.
can be easily felt, and yields to the motions impressed
on it. fe
The reduction is effected, by pushing the separated
fragment in the direction opposite to that of its displace¬
ment, by bringing it to its natural level, and, in certain
cases, by moving the thigh a little outwards; it is retain¬
ed by means of some compresses placed by its sides,
and secured by a roller directed obliquely from the
sound hip towards that part of the thigh corresponding
to the fracture.
Fractures of the neck of the os femoris are
not so frequent as those of the body of the bone, but
they do occasionally occur; the fracture is generally
transverse, occurs at every part of the neck of the
bone, sometimes completely within the capsular liga¬
ment, so that the round ligament, constitutes the only
connexion which the upper fragment has with the body.
As this accident has some symptoms in common with
certain dislocations of the os femoris, it is of great im¬
portance to discriminate this accident from all others.
Desault states the following as the best diagnostic symp¬
toms. "At the time of the fall a sharp pain is felt,
sometimes a noise is distinctly heard, a sudden inability
to move the limb occurs, and in general the patient
cannot rise, this last circumstance, however, is not uni¬
form; a case is recorded in the fourth volume of the
Mem. Acad. Surg, where the patient walked home after
the fail, and even rose up the following day." Desault
also saw examples of this peculiarity. The interlock*
ing of the fragments is the cause of it.
A shortening of the limb almost always occurs, more
or less perceptible, according as the extremity of the
fragments are retained by the capsule, or as the divi¬
sion being without the cavity, no resistance is made to
their displacement. The muscular action drawing the
ELEMENTS OF SURGERY.
191
lower fragment upwards, and the weight of the trunk,
pushing the pelvis and superior fragment downward,
are the causes of this shortening. A slight effort is in
general sufficient to remove this shortening, which,
however, soon returns when the effort ceases. A tume¬
faction appears in the anterior and upper part of the
thigh, almost always proportioned to its shortening, of
which it appears to be the effect.
The projection of the great trochanter is almost en¬
tirely removed. That protuberance being directed up¬
ward and backward, is approximated to the spine of
the ilium. But if it be pushed in the opposite direc¬
tion, it readily yields, and then returning to its proper
level, allows the patient to move the thigh.
" The knee is a little bent. A severe pain always
accompanies the motions of abduction, when they are
communicated to the limb. If. while the hand is ap¬
plied to the great trochanter, the limb be made to ro¬
tate on its axis, this bony protuberance is perceived to
turn on itself as on a pivot, instead of describing, as it
does in its natural state, the arch of a circle, of which
the neck of the os femorisis the radius. This sign,
which was first observed by Desault, is very percepti¬
ble, when the fracture is at the root of the neck; less,
when it is in the middle, and very little, when it exists
towards the head of the bone: these are circumstances
the cause of which it is unnecessary to unfold. In ro¬
tatory motions, the lower fragment, rubbing against the
upper one, produces a distinct crepitation, a phenome¬
non which does not always occur.
" The point of the foot is usually turned outwards; a
position which Sabatier, Bruningheusen, and most other
practitioners, regard as a necessary effect of the frac¬
ture ; although Ambrose Parey and Petit have borne
witness that it does not always exist. Two cases, re-
192
ELEMENTS OF SURGERY.
ported on this subject, by celebrated surgeons, have
been thought unfounded by Louis, who has attributed
them either to an error in language, or a mistake of
the transcriber. But the practice of Desault has fully
confirmed their possibility. The first patient whom
he had under his care, at the Hospital of Charity, after
he was appointed surgeon in chief, laboured under a
fracture which presented this phenomenon. Many
other examples occurred to him afterwards, and he
believed it might be laid down as an established princi¬
ple, that, in fractures of the neck of the os femoris, the
direction of the foot outwards is to that inwards as
eight to two.
" The common opinion is, that this direction out¬
wards, is to be attributed to the muscles that perform
rotation. But, were that the case, 1st, it is evident
that it would always exist: 2dly, all the muscles run¬
ning from the pelvis towards the trochanter, except the
quadratus, are in a state of relaxation, in consequence
of the approximation of the os femoris to their points
of insertion: 3dly, muscles in a state of contraction
would not allow the point "of the foot to be drawn so
easily inwards. Is it not more probale, that the weight
of the part draws it in the direction in which it is
usually found?
" From the foregoing considerations, it follows, that
none of the signs of a fracture of the neck of the os fe¬
moris, is exclusively characteristic, that the whole ol
them, taken separately, would be insufficient, and that
it is their assemblage alone, which can throw on the
diagnosis that light which is oftentimes wanting to it,
even in the view of able practitioners. But after all,
in the present case, as in every other one, should any
doubt exist, it is right to take the safe side, and apply
the apparatus, which is indeed useless, but not danger
ELEMENTS OF SURGERY. * 193
ous, if the fracture does not exist, but indispensably ne¬
cessary if it does/' (Desault.)
A concise abstract of the symptoms enumerated by
Boyer will aid the student in distinguishing this frac¬
ture. A fall or blow on the trochanter or feet, is gene¬
rally the cause; it is followed by pain in the articulation,
an impossibility to bend the thigh; shortness of the limb,
which is easily removed, but returns when the exten¬
sion is discontinued; an inclination of the foot and knee
outward, with great facility of moving these parts to
their natural situation; crepitation produced in different
movements; and the smallness of the circle in which the
great trochanter moves in a rotatory motion. We can
seldom be mistaken as to the existence of this fracture,
if we attend to all these circumstances.
Of all fractures of the os femoris, those of the neck
are most tedious in healing, and attended with most
danger of lameness and deformity. Some surgeons
imagine, that bony union never forms between the
fragments; but many proofs exist that this opinion is
erroneous, and preparations in different anatomical col¬
lections shew instances of bony reunion of the neck of
the thigh bone. It is always, however, slower in its for¬
mation, and in many instances does not at all take place,
the patient remaining incurably lame.
Instances of recovery in old persons are not frequent,
and Boyer considers the fracture " after a certain age"
incurable; but he adds " it is not in our power to mark
precisely the period beyond which a cure is not to be
hoped for. To be able to settle this, it would be neces¬
sary that the effects of old age were uniform in every
individual, and that the degree of sensibility were always
commensurate with the number of years. Lesne shewed
at the Academy of Surgery, the femur of a woman aged
vol. i.—b b
194 *
ELEMENTS OF SURGERY.
eighty-nine, with evident marks of a consolidated frac¬
ture of its neck." Buyer himself, saw a patient in
which the consolidation of a double fracture was con¬
siderably advanced in a man eighty-three years old.
Numerous facts of this nature, authorize and require
the application of the apparatus in all cases, except
where the patient reduced to the last stage of decrepi¬
tude and debility cannot support its weight, or is attack¬
ed by some mortal disease. But at the same time the
surgeon should for his own sake, acquaint the patient
and his friends with the uncertainty of the cure, in
order to ward off any imputation that might be made
in case of failure.
Many respectable surgeons have positively asserted
that a recovery without lameness and shortening is im¬
possible. Desault and Boyer, on the contrary, both re¬
late instances in which they were completely successful.
The fracture is easily reduced by making counter-ex¬
tension at the arm-pits, an assistant holding the patient
under the arms, and extension by drawing down the
foot until the limb resumes its natural length and ap¬
pearance; it is not easy, however, to secure the frag¬
ments in contact, but the apparatus of Desault promises
to be more successful than any other plan heretofore
in use for that purpose. The long splints are to be ap¬
plied precisely as in fractures of the body of the os
femoris, but no bandages of strips, or pasteboard splints
are required in this case, as the permanent extension
is alone necessary, and they would be useless as they
would act only on the inferior fragment.
The fracture healed in one case recorded by Desault,
in sixty days, but generally three months are required
for the consolidation. During this time the apparatus
should be examined daily, and tightened from time to
time, if any shortening of the limb is observed. Stiff-
ELEMENTS OF SURGERY.
195
ness of the joint is not a frequent consequence of this
accident.
When the permanent extension cannot be applied,
from the extreme age of the patient, or any other cause,
great care should be taken to prevent the motions of
the fragments, by long stiff' splints bound firmly on the
pelvis, and extending below the foot. In this manner
a cure will be effected, but probably the detached neck
of the bone will adhere to a portion, considerably below
the trochanter, and thus the limb will be shortened.
In a case of fracture of the head of the os femoris
which occurred in a gentleman of Philadelphia, perma¬
nent lameness ensued, and no union of the fragments
took place; he died some years after, and upon examin¬
ing the hip joint, a singular instance of the resources
of nature was presented to view. A ledge of bone was
observed projecting from the trochanter, and upon
this the acetabulum rested, and thus some weight was
sustained by the os femoris—it was in fact, an attempt
to regenerate a neck and head for the bone in a situa¬
tion where it would have been useful, and have enabled
the patient to walk, had he lived until it was completed.
He never was able after the accident to bear much
weight on the affected side. The bone is now in Dr.
Physick's possession.
Fractures of the lower extremity of the os femoris,
unless they are situated within the joint, call for no
peculiarity of treatment, but are to be managed just as
when they occur higher up in the bone.
Sometimes, however, the fracture detaches a portion
of one condyle from the rest of the bone (Fig. 5.) Some¬
times a fracture separates the condyles from each other,
and both from the rest of the bone by a double frac¬
ture, analogous to that which occurs in the lower end
of the humerus, as in Fig. 4.
196
ELEMENTS OF SURGERY.
The fracture in which the condyles are thus sepa¬
rated from the os femoris may be known, by a percepti¬
ble separation, increasing the width of the knee. The
patella sinking into the chasm between the condyles,
renders the part flatter than natural: if the patella be
pressed backwards the condyles are still further sepa¬
rated: if on the contrary, pressure be made on the sides
of the knee, the knee resumes its usual breadth and
appearance: by moving the fragments, crepitation ma}
be heard. Where only one condyle is detached, it can
be felt moving under the fingers, and producing crepi¬
tus when rubbed against its fellow.
Sometimes this accident is complicated with a lace
rated wound, from the bone being forced through the
skin, or from the cause of the accident penetrating to
the cavity of the fracture, and of the joint, thus pro¬
ducing a compound fracture, with an exposure of the
joint: a terrible accident, attended with all the dangers
resulting from lacerated wounds of the larger joints,
and demanding the same mode of treatment, with the
additional measures necessary for maintaining in con¬
tact the fragments of the bone.
The treatment necessary in these cases, varies ac¬
cording to their circumstances. If a fracture exist an
inch above the knee joint, and this fracture be attend¬
ed with a shortening of the limb, (which will be the
case if it be an oblique fracture,) and if in addition to
this, a second fracture separates the condyles extend¬
ing to the first, as in Fig. 4; in this case the perma¬
nent extension is to be applied, as in fractures of the
body of the thigh bone with the omission of the paste¬
board splints, this will prevent the upper fracture from
displacement, and in order to keep the condyles in con¬
tact at their fractured surfaces a roller or bandage of
strips must be applied, reaching from the ankle to ihr
ELEMENTS OF SURGERY.
19?
middle or upper part of the thigh, and applied pretty
tight at the knee.
If the upper fracture be transverse, no necessity ex¬
ists for permanent extension, and therefore simple paste¬
board splints may be applied, or the long splints as in the
preceding case, omitting to apply the extending force.
The lateral pressure is in these cases the chief indication,
and to prevent the foot and leg from swelling, a roller
should be applied from the foot to the knee. The usual
antiphlogistic remedies are to be employed if inflamma¬
tion run high, and the apparatus must be kept on eight
weeks before any motion is attempted; as soon as the
parts have united firmly, the limb must be gently and re¬
peatedly moved, to prevent false anchylosis, or stiffness
of the joint. The patella should be moved frequently,
and the posture of the leg whilst at rest, often varied.
198
ELEMENTS OF SURGERY
EXPLANATION OF THE PLATE.
Fig. 1. Represents a fracture of the head of the os fe-
moris.
Fig. 2. A fracture of its neck.
Fig. 3. A common oblique fracture near the middle of
the bone.
Fig. 4. A fracture at the lower extremity of the bone,
in which the condyles are detached from the
body of the os femoris and from each other.
Fig. 5. Suews several directions a, b, c, d, in which the
different condyles are occasionally fractured.
Fig. 6. Represents the relative situation of the fractur¬
ed ends of the bone in the cases mentioned in
page 135, in which the seton was unsuccessfully
tried for the cure of an artificial joint. The
dotted line shews the course of the seton, which
passed through an indurated mass of flesh, and
did not come in contact with the bone. From
this view it is evident, that in such cases, the
seton cannot be successfully used.
/Tiirrt/rt's or ttie i
nil ih.
flate n
Jlntp civj jL by jrJeuyt
ELEMENTS OF SURGERY.
199
explanation of the plate.
The opposite engraving represents the apparatus for
permanent extension, employed by Desault in oblique
fractures of the osfemoris.
AA. The external splint, with a notch and a mortise
at the lower end to fix the inferior extending roller.
BB. A bandage passing round the body, intended to
secure this splint against the pelvis.
CC. The anterior splint, reaching only to the knee.
d. d. d. d. The anterior bolster, extending along the
whole limb, and secured by pieces of strong tape.
EE. A portion of the bandage of strips, seen between
the anterior and the external lateral bolsters.
FF. The junk-cloth intended to be folded round the
two lateral splints.
g. g The superior extending roller, passing round the
end of the external splint, and fixed underneath on
the tuberosity of the ischium.
H. The sub-femoral roller or strap, intended to pre¬
vent the bandage BB, which passes round the body,
from slipping upwards.
K k. A roller usually passed round the foot, to prevent
it from turning.
L. The inferior extending roller, fixed in the mortise
and the notch of the external splint.
200 ELEMENTS OF SURGERY.
EXPLANATION OF THE PLATE.
Representing Dr. Physick's modification of Desault's
apparatus.
AA. Dr. Physick's long splint.
B. A block fastened near its lower end, projecting at
right angles from the splint, over which the extend¬
ing band passes and is tied at the mortise C.
D. The crutch-like extremity fitted to the axilla.
E. The edge of the inner splint which extends from
the perineum below the foot.
F. The splint cloth wrapped round the external and
internal splints.
G. The counter-extending band passing under the tu¬
berosity of the ischium, and secured at the mortise,
at the upper end of the splint.
H. The anterior splint of pasteboard (a similar one is
placed on the back part of the thigh.)
The bandage round the pelvis is omitted to prevent
confusion.
ELEMENTS OF SURGERY.
201
CHAPTER XXXI.
Fractures of the Patella.
These may be longitudinal, transverse, or oblique;
but in general they are transverse. They are occa¬
sioned by falls, blows, and accidental violence, and also
in some cases by the exclusive action of the extensor
muscles of the leg: of this many instances are record¬
ed. I have myself met with two, one of which occurred
in a rider at the circus, who in vaulting into his saddle
from the ground whilst his horse was in full speed,
suddenly fell, without knowing the cause: a sharp pain
at the knee informed him of the seat of the injury.
Upon examination, 1 found the patella fractured trans¬
versely, and the upper half, drawn to a considerable
distance from the lower.
It sometimes, though very rarely, happens that the
tendon above or below the patella is fractured, and not
the bone. The mode of treatment are in both cases
precisely similar.
A fracture of the patella is readily distinguished. If
it be transverse, the patient cannot extend the leg; he
generally falls and is unable to rise; though sometimes
he gets up, and by dragging the limb sideways, is even
able to walk, taking great care not to bend the knee.
A depression at the place of fracture is perceived, and
commonly, the superior fragment is found at a consi¬
derable distance from the inferior, which being tied
firmly to the tibia, cannot move upwards. The longi¬
tudinal and oblique fractures can be known by examina¬
tion with the fingers, as the bone is very thinly covered.
It has been a matter of doubt among surgeons whe-
VOL. i.—c c
202
ELEMENTS OF SURGERY.
ther bony reunion ever takes place between the frag*
ments of a broken patella. When the distance between
them is considerable, a firm ligamentous or tendinous
matter connects them, and the motion of the joint after
a time is regained. When, on the contrary, they are
kept in close contact, the union is hard, firm, and un¬
yielding; whether it is bone, tendon, cartilage, or liga¬
ment, is an object of more curiosity than utility.
The great object to be attended to in the treatment
of fractures of the patella, is to preserve the fragments
as nearly as possible, in apposition, so that the sub¬
stance connecting them may be rendered as short as
possible, and the motions of the joint be perfectly pre¬
served. x
Whenever the fracture is occasioned by a violent
blow, and great contusion is produced by it, there i&
reason to apprehend inflammation and swelling of the
knee, in which»case bleeding and the usual remedies
for inflammation are to be employed.* The local
treatment consists in keeping the limb at rest in an ex¬
tended posture, and by a splint and bandages preserv¬
ing the contact of the fragments. The chief obstacle
to be encountered, is the action of the extensor mus¬
cles; and this is easily overcome, by the application of
a stiff splint behind the limb secured by a roller.
A variety of machines have been constructed for the
purpose of preserving the permanent extension of the
leg, and most of them answer very well. I have always
* The inflammation of the knee joint arising from fractures of the pa¬
tella, is sometimes so violent as to cause the patient the greatest suffering
and distress. Mr. Astley Cooper, with the view of obviating this inconve¬
nience, advises that in all cases of this accident, the application of the ban¬
dages for preserving the fragments in proper contact be omitted for a few
days, until the swelling and tension have subsided. To effect this, he ele¬
vates the thigh and leg so as to make the limb form an angle with the bcily;
and directs the employment of the usual remedies for inflammation, such
as leeches, cold saturnine lotions, &c.—Ed,
ELEMENTS OF SURGERY.
203
employed a very simple one. It consists of a piece of
wood half an inch thick, two or three inches wide, and
long enough to extend from the buttock to the heel;
near the middle of this splint, two bands of strong
doubled muslin a yard long, are nailed, at a distance of
six inches from each other. Upon this splint, covered
with compresses of soft flannel or linen, so as to fill up
the inequalities of the limb, the patient's leg and thigh
are placed. An assistant now raises the heel, and the
surgeon applies a bandage, (a common muslin roller,
two inches wide, and eight or ten yards long,) com¬
mencing at the ankle, and proceeding to the knee; he
carefully draws down the upper fragment of the bone
as nearly as possible to the lower one, and places a com¬
press of folded linen above it; several turns of the ban¬
dage are now made over this compress and obliquely
under the knee, in such a manner as to cross below the
lower and above the upper fragment alternately, in the
form of the figure 8; the bandage is then carried on to
the top of the thigh and brought down over the splint,
leaving the band attached to it, free. Care must be
taken to cover every part of the skin with the roller,
because any part which is not thus supported will swell
and inflame. After the dressing has proceeded thus
far, the bands of muslin are to be used for the purpose
of more completely fixing the fragments; the lower one
is to be passed round the thigh above the upper frag¬
ment, and vice versa, the upper strap passed below the
lower and secured by a pin or knot. These bands will
thus enable the surgeon to exert any requisite compres¬
sion upon the fragments without the inconvenience of
moving the bandage or splint.
It is evident that this apparatus is in principle the
same as Boyer's. I claim no merit for its construction,
but one advantage it certainly possesses; it may always
204
ELEMENTS OF SURGERY.
be procured in a few minutes, as a shingle or a strip of
wood and a couple of nails are the only materials ne¬
cessary for its formation; and this in country practice,
is an object of no small importance. I have never em¬
ployed any other mode of treatment, in the cases of this
accident which have fallen under my care, and in all
these, it has completely answered my expectations; the
union of the fragments has taken place very quickly,
and in two cases without any perceptible interval or
motion between them. The patient must be kept lying
on his back on a mattress, and from day to day the
bands are to be examined, and tightened if necessary.
Boyer directs the joint to be moved after the twenty-
fifth day, to prevent stiffness. These motions, if com¬
menced so early, should be very gentle, but they may
safely be delayed until the fourth or fifth week. In six
or seven weeks the union is generally completed.
elements of surgery.
205
CHAPTER XXXII.
Fractures of the Leg. ,
The tibia and fibula are sometimes broken singly ^
and sometimes both are fractured. The fracture may
happen at any part between the knee ankle. The
fracture of both bones is most frequent; it may be
transverse or oblique, simple or compound, commi¬
nuted or single. The fragments are occasionally dis¬
placed in every direction. In transverse fractures, there
is generally no shortening of the limb, but in those
which are oblique, the leg is generally shortened: pa¬
tients have been known to walk many steps without
great inconvenience, after having fractured the tibia
transversely, in consequence of the want of derange¬
ment.
Fractures of the leg are characterized by the gene¬
ral symptoms of fracture. Deformity of the member;
loss of power to move the limb; great pain at the time
of fracture, and on every motion of the part, crepita¬
tion, &c.
The higher up the fracture is situated, in general,
the more favourably does it terminate: very little dan¬
ger of derangement exists when the upper extremity
of the bones are broken, as the bulk of the tibia at
this part, affords large opposing surfaces, which sup¬
port each other, and prevent displacement. Oblique
fractures of both bones of the leg it is sometimes very
difficult to manage; they are attended with great inflam¬
mation from the irritation of the sharp fragments.
The treatment varies according as the fracture is
transverse or oblique. A transverse fracture, is very
20G
ELEMENTS OF SURGER\.
easily reduced and maintained in its proper situation.
One assistant grasps the knee, and another the foot,
extension and counter-extension being made, the sur¬
geon replaces the fragments, and judges of this by the
deformity ceasing, and by the regularity of the anterior
edge of the tibia, which is so thinly covered as to be
easily felt.
A roller is now to be applied, (or a bandage of
strips,) very neatly from the ankle to the knee: two
pasteboard splints soaked in water, are placed one on
each side of the leg-, they should extend from the knee
to the sole of the foot, in order to confine and prevent
the lateral motions of the foot at the ankle joint. Over
these splints a second roller or bandage of strips is to
be applied; the splints soon become dry and form a
solid case for the limb, which supports sufficiently the
fractured bones. It is necessary to avoid bandaging
too tight, and to loosen the dressings if inflammation
render them so, by augmenting the volume of the limb:
an observation which is applicable to most fractures,
and should never be neglected. The limb is now laid
on a pillow, the patient being placed on a mattress on
his back; two strips of wood as long as the pillow, and
three or four inches wide, may be tied with tapes on
the outside of the pillow, and answer the purpose of a
fracture box; the weight of the foot should be support¬
ed by a bandage passed round the toes, and fastened to
the boards on the outside of the pillow. The weight
of the bed clothes should be sustained by some simple
contrivance, as the segments of two hoops tied toge¬
ther. At the end of six or seven weeks the fracture
generally unites.
When instead of a transverse direction, the fracture
has taken a very oblique one, the mode of treatment is
very different, and permanent extension becomes ne*
1
I'LATE J A
ELEMENTS OF SURGERY,
207
cessary: a very convenient mode of applying this was
contrived by the late Dr. James Hutchinson. Two
splints of wood are made, long enough to extend from
the knee six or eight inches below the sole of the
foot; a mortise hole is cut near the lower end of both
these splints, and the upper extremity of each is per¬
forated with four small holes. A piece of wood fitted
to the mortise holes of the splints, eight inches long, is
to be provided.
In applying this simple apparatus, the patient is to
be laid on his back, and extension and counter-exten¬
sion made as usual; a pillow is placed under the leg
upon which is arranged a bandage of strips; two pieces
of tape are next to be secured by numerous turns of a
roller, on each side of the leg below the knee: these
tapes are to be passed through the four holes in the
upper end of the splint, and tied, a silk handkerchief
is next to be passed round the ankle, crossed on top of
the foot, and tied under the sole. The fracture being
reduced, the bandage of strips is applied neatly to the
leg, and the silk handkerchief next tied over the cross
piece connecting the two splints: by which any neces¬
sary degree of extension may be permanently applied,
The annexed plate represents the apparatus and its
mode of application, very intelligibly. It is particularly
convenient in compound fractures, because the exter¬
nal wound can be dressed daily, without disturbing in the
slightest degree, the fragments of the bone; but it can¬
not be used in fractures near the knee or ankle joints,
because the bands for extension and counter-extension
would irritate the inflamed parts and could not be
borne. Excoriation must be guarded against by ap¬
plying soft compresses wherever the skin is irritated
by the extending forces; it is convenient to interpose a
small compress of folded linen with this view, between
208
ELEMENTS OF SURGERY.
the tapes and skin, or what is equally effectual, to pass
the roller once or twice round the limb before they are
applied.^
In some cases the irritation at the knee is very great,
and the leg swells from the pressure of the circular
bandage below it: when this happens in oblique frac¬
tures of the leg, the long splint of Desault must be sub¬
stituted, and the counter-extension made against the
pelvis. It is to be applied in the same manner as to a
fractured thigh, excepting that the leg must be dressed
with the bandage of strips; the two long splints are all
that will be found necessary.
It is of great consequence in all oblique fractures of
the leg to attend particularly from day to day, to the
form of the limb, and the position of the foot, which
should be supported by a bandage, as before directed,
or by a prop of wood attached to the splints or bedstead.
If the heel sinks too low, so as to cause the lower frag¬
ment to fall downwards, a piece of folded linen or flan¬
nel must be placed under it.
The general treatment of the patient is of great im¬
portance in these cases, and blood-letting is to be per¬
formed as often as the degree of fever and inflammation
may indicate. It is by far the most convenient mode
of depletion, and the most efficacious.
Compound fractures of the leg, are, from the
thin covering of the tibia, and its exposure to accidents,
more frequent than any other compound fracture.
The general directions for their treatment have al¬
ready been detailed. But it may not be improper
to remark in this place, that the permanent extension
kept up, either by Desault's or Hutchinson's splints,
enable the practitioner to dress the fracture, as often
as necessary, without any pain, or inconvenience to the
patient, and without retarding the progress of the cure
ELEMENTS OF SURGERY.
£09
by moving the fragments of bone—circumstances of
great importance at all times, but particularly in warm
weather when the dressings must be very frequently
changed. Should the discharge be very copious from
a compound fracture of the leg, the pillow upon which
it rests should be covered with thin oiled silk, to pre¬
vent its imbibing the offensive matter, and great clean¬
liness should be observed.
Fractures of the tibia alone, sometimes happen:
the fracture is generally transverse and attended With
but little derangement of the fragments. The fibula
being uninjured, prevents the shortening of the limb,
and as no great pain or inconvenience is experienced,
the case is sometimes not discovered until a consider¬
able time has elapsed. A careful examination with the
fingers will in general, from the thinness of the cover¬
ing over the tibia, enable the surgeon to detect an
inequality at the place of fracture. Crepitation may
also, in general, be occasioned, by forcibly pressing the
fragments in opposite directions.
The treatment of the case is extremely simple; rest on
a pillow, is all that is essential, but it is most prudent to
apply the dressings recommended for transverse frac¬
tures of both bones of the leg, and to keep the patient in
bed until the cure is effected, viz. forty or forty-five days.
Fractures op the fibula are less frequent than
those of the tibia, notwithstanding its slender size, owing
in great measure to the circumstance that it is not con^
cerned in supporting the weight of the body.
The chief causes of fractures of the fibula, are a vio¬
lent blow on the outside of the leg, or a forcible ab¬
duction of the foot. There is reason to believe that in
many cases of sprained ankle this fracture exists with¬
out being known. No shortening of the limb take*
vol. i.—p d
210
ELEMENTS OF SURGERY.
place, and the only displacement observed, is the frag¬
ments being pushed inwards towards the tibia.
To ascertain the existence of the accident, the bone
should be pressed inwards, and crepitation will gene¬
rally be perceived, or at least a motion of the bone at
the place of fracture.
The mode of treatment, consists, in an attempt to
force the fragments outward by abduction of the foot,
and by pressure upon the interosseous muscles, after
which two pasteboard splints are to be applied, as in
transverse fractures of both bones of the leg, and the
patient must be kept at rest thirty or forty days. The
splints are chiefly useful by keeping the ankle joint at
rest.
The approximation of the fibula to the tibia, is not
so important as that of the radius and ulna, because no
rotatory motion exists between the bones of the leg.
A slight stiffness of the ankle joint is commonly a con¬
sequence of fractures of the fibula, but it soon subsides
without any remedy but exercise,
i j
ELEMENTS OF SURGERY.
211
CHAPTER XXXIII.
Fractures of the bones of the Foot.
Fractures of the os calcis are very rare, but oc¬
casionally happen. The accident may be detected by
a crack at the moment, attended with severe pain at
the part, and great difficulty in standing upright, a
swelling of the heel and mobility of the fragments at¬
tended with crepitation.
To reduce the fracture, the leg must be flexed upon
the thigh, and the foot extended on the leg; in which
situation the fragments can readily be reduced. Boyer
directs, in order to retain the fragments, the slipper in¬
vented by Petit, for a rupture of the tendo achillis, or if
that cannot be procured, the uniting bandage used for
transverse wounds, modified as follows. The end of a
bandage is placed on the superior surface of the foot,
whence the bandage is reverted on the sole, and the
end is made fast by circular casts around the foot; this
bandage is then drawn along the posterior side of the
leg to the ham, the foot being previously extended, on
which part it is fixed by other circular casts, it is thence
brought downward forcibly, and the application termi¬
nated by rolling along the leg what remains. To this
bandage may be added a long compress, the middle part
of which should be applied above the posterior portion
of the os calcis, and the extremities crossed on the su¬
perior surface of the foot, and turned under the sole;
this compress may be fixed by a bandage rolled on the
foot in the shape of the figure 8. The union of the
fracture is effected in thirty or forty days, at the end of
which time the patient may be allowed to bend his foot
212 ELEMENTS OF SURGERY.
He must, however, for some days, avoid any forced
flexion of the foot, as also any excessive extension by
rising on his toes.
" T le other bones of the tarsus, as the astragalus,
cub' ides, scaphoides, and three ossa cuneiformia, are
susceptible only of comniinutive fracture. The same
may be said of the bones of the metatarsus and pha¬
langes of the toes." The treatment of these fractures
can be very sufficiently understood from what has been
said of fractures of the bones of the hand, to which they
are analogous.
elements of surgery. 213
CHAPTER XXXIV.
Of Wounds of Bones.
In the following observations on the denudation and
wounds of bones, I shall avail myself chiefly of the la¬
bours of Boyer and Hunter.
The bones may be stripped, not only of the integu¬
ments, muscles, &c. by which they are naturally cover¬
ed, but also of the periosteum, which is their intimate
and appropriate covering.
Cutting or contunding instruments may produce this
denudation of the bone, without injuring its substance,
or they may cut or contuse its external fibres. These
two cases must be carefully distinguished, as the con¬
tusion of the bone is attended with consequences much
more serious than those of a simple denudation.
If the bone has been merely stripped of its perios¬
teum and integuments, and those parts are immediately
replaced, so as to exclude the contact of the air and
bandages, the reunion of the periosteum is found to take
place in a very short time. But if the external lamina
of the bone has been contused, or if its surface has
been left a long time exposed to the action of the air,
or to the friction of bandages, exfoliation becomes a
natural consequence. All the external lamina must sepa¬
rate; and before this separation is effected, the cicatri¬
zation of the external wound would be rather injurious.
Should the wound in the integuments be prematurely
closed, purulent matter will continue to form under¬
neath, the contused lamina will exfoliate, an abscess
will point externally and burst spontaneously, and the
matter that escapes from it will contain small splinters
214 • ELEMENTS OF SURGERY.
of bone. Old age is unfavourable to the healing of
wounds and contusion of the bones; because as the cure
can be effected only by means of the vascular texture
of the bone and periosteum, the turgescence and expan¬
sion of this must be slow and difficult in proportion to
the person's age. The treatment adapted to the differ¬
ent cases is as follows.
If the bone be simply laid bare, the integuments, if
not completely separated, should be instantly replaced.
This precept holds good in all cases, whatever may be
the patient's age, if the bone has not been already ex¬
posed to the contact of the air. At the same time it
must be allowed, that it is very difficult to know by
mere inspection, whether the bone be contused or not;
but should that be the case, and even should suppura¬
tion and exfoliation be inevitable, no bad consequences
can result fifom the attempt to produce an immediate
cicatrization; whereas, in the contrary event, the dura¬
tion of the treatment will be much abridged. If it be
possible to unite the wound by the first intention, its
lips are to be kept separate by lint interposed, and the
whole is to be lightly covered. In a short time granu¬
lations appear, and the external lamina of the bone ex¬
foliates. Sometimes, however, and particularly in young
persons, the bone becomes soft and red, and granula¬
tions arise from it, which bleed from the slightest cause.
It has been said that the bone exfoliates insensibly in
this case; but this observation is not found to be true:
the laminae of the bone are not broken down, dissolved,
and carried off by suppuration. The change consists
of a softening of the bone, and conversion of it into a
fleshy substance, which unites with the soft parts.
In this last mentioned case, the cure is much more
prompt than when a real exfoliation takes place. The
process of exfoliation resembles that of the separation
ELEMENTS OF SURGERY. 215
of gangrenous eschars: the mode in which the separa¬
tion is effected, is equally unknown in both cases.* In
exfoliation, it is merely known that the subjacent ves¬
sels grow turgid, expand, and pullulate, and that a line
of separation is observed between the contused laminae
and the sound part of the bone. The former are unde¬
termined, as it were, and their connexion shaken by
the purulent matter formed under them, and at length
are entirely detached, and may be easily removed by
the fingers or a forceps. When the bottom of the
wound is entirely freed, the granulations that arise from
it, unite with the soft parts, and in a short time the
wound is cicatrized.
Various processes have been employed for expedit¬
ing the exfoliation. Thus the ancients covered the
bone with pledgets of lint impregnated with spirits, or
with a tincture of myrrh and aloes; but it is found, that
these applications retard the exfoliation by opposing the
expansion of the vessels; for which reason they have
been laid aside, and oily relaxing applications have been
substituted for them.
It has been proposed to perforate, in different parts,
the laminae which are to exfoliate, on the supposition
that this practice facilitates the growth of the granula¬
tions. The perforations certainly have this effect, but
the granulations by shooting up through them, retain
the laminae rather than aid their exfoliation: each ves¬
sel spreading as it rises, and assuming in some respect
the shape of a broad-headed nail. It will then be more
prudent to limit the treatment to the use of unctuous
or emollient applications. By means of these reme¬
dies, the texture of the part will be sufficiently relaxed,
and the developement of the vessels facilitated. But if
* Mr. Hunter has fully explained this formerly unintelligible process,
See page 217 of the present volume.
216 ELEMENTS OF SURGERY.
the portion of the bone to be exfoliated be very consi-
siderable and deep seated, these applications are nearly
useless, at least their effect must be very trifling; then
we must content ourselves with covering the part with
lint, and trusting to time and nature for effecting the
separation.
Though the exfoliation be complete, as may be known
by the motion of the piece, it may still happen that the
circumference of the detached portion may be encroach¬
ed on by the growth of the soft parts, and thus pre¬
vented from separating. In this case it will be neces¬
sary to disengage it by making an incision in some point
of the circumference of the wound, after which it may
be drawn out by the fingers or a forceps. In general
there is but very little difficulty in removing it.
The action of cutting instruments is not always limit¬
ed to the mere denudation of the bone; they sometimes
completely divide it: this, however, is but a rare occur¬
rence. It sometimes happens that a part of the bone is
cut off, of which there are numerous instances in
wounds of the head, where a part of the parietal bone,
with its pericranium, a portion of the occipito-frontalis
muscle and hairy scalp, have been entirely separated
by a blow of a sword.
When a wound of the soft parts is accompanied by a
similar affection of the subjacent bone, an immediate
reunion of the soft parts must not be attempted. Lint
is to be gently introduced into the fissure, and the wound
healed from the bottom; for a solid cicatrix of the soft
parts cannot be expected until the wound in the bone
is first cicatrized.
If the bone in one of our limbs be cut quite through,
as in the cases mentioned by La Peyronie, Warner, and
others; and if a piece of flesh remain undivided, which
contains the principal vessels of the limb, it will be pru-
'elements of surgery.
217
dent to reunite the parts, and place the limb in the ap¬
paratus used in cases of fracture of the part.
The time necessary for the reunion of the parts in
cases of this nature, is full as long as that in those of
fracture, and the consolidation is effected in the same
manner as in the former case.
In the preceding remarks, Mr. Boyer has not at¬
tempted to explain the manner, in which bone that
has been contused and suffers death, in consequence
of a blow, separates from the living bone with which
it is in contact. I shall therefore state in this place the
opinion on the subject, taught by Mr. Hunter, and now
generally adopted.
Exfoliation is the separation of dead from living
bone, as sloughing is the separation of dead from liv¬
ing flesh, and the process, in both cases, is effected in
the same manner, by the action of the absorbent ves¬
sels. There is nothing like a melting down of the
bone; no solution takes place; the bone separated is
solid and in texture unchanged, and the term exfoliation
was derived from the scales or leaves of bone thus de¬
tached. In bones which are most solid, and have
fewest cells, the separation takes place most rapidly.
I have known a portion of the radius exfoliate in a few
days, and I have known the os calcis, several years in
casting off a portion of dead bone. The entire death
of a portion of bone, is necessary to its exfoliation, and
hence, in some cases, the hot iron may be used with
advantage in expediting the process, by destroying the
life of diseased bone. According to Mr. Hunter, caus¬
tics and hot irons may expedite exfoliation in two
ways, first by killing the bone, and secondly by inflam¬
ing the adjacent bone, and thus increasing its vascula¬
rity and its actions. Dead bone, like all other extraneous
matter, stimulates the adjacent parts, in consequence
vol. i.—e e
218 ELEMENTS OF SURGERY.
of which they become more vascular. The bone is
composed of animal gluten, and earth; the earthy por¬
tion of the living bone, is removed by the action of (he
absorbents; just as in health these vessels perform the
process of interstitial absorption, removing from time
to time the solid parts of the body. The consequence
of this absorption of the earthy particles from the bone,
must necessarily be, that the bone is converted into a
soft matter, which is interposed between the living
solid bone, and the dead solid bone. The soft sub¬
stance thus interposed, is last of all absorbed, and the
dead bone left without any connection with the living.
We are, therefore, to consider the living bone as effect¬
ing the whole business of exfoliation, through the
agency of its absorbing vessels, and these vessels act
on the living matter, and perhaps also, on the dead part
immediately in contact with it.
The process of exfoliation begins at the surface of
the bone, and proceeds irregularly, not progressing
uniformly, in the same direction, or with the same
celerity in every part ; circumstances not easy of ex¬
planation. During the continuance of this absorption
of the bone, granulations of a fungous nature, shoot
out from the surrounding parts, and by pressing on the
loosened bone, push it outwards towards the surface of
the body in the same manner as any other loose extrane¬
ous matter would be cast off, by the ulcerative process.
The edge of dead bone, presents an unequal rag¬
ged surface, " a groove or worm-eaten canal" being in¬
terposed between it and the sound bone.
The highly interesting physiology of the absorbent
vessels, and their agency in this process, have been
most ably developed by the late John Hunter, the first
writer who threw any light on the subject.
ELEMENTS OF SURGERY.
219
CHAPTER XXXV.
\ ' <"• '' * c V1 •
Of Dislocations.
\ , '
v • ' 4 r r • t
A Dislocation or Luxation signifies the escape of
the articulating surface of a bone, from its natural situa¬
tion; as of the head of the thigh bone from the aceta¬
bulum.
A knowledge of anatomy is essential to the compre¬
hension of all surgical cases, but the reduction of dis¬
located bones in some instances occasions great diffi¬
culty, and calls for a complete and accurate knowledge
of the parts concerned in forming the joints, and of the
effects of the muscles acting upon the displaced bone;
a kind of knowledge not to be obtained simply from
osteology or a study of the skeleton, but demanding a
frequent inspection of the fresh joints, covered with car¬
tilage and surrounded with ligaments, &c.
Some bones, in consequence of the structure of their
joints and their exposure to accidental violence, are
very frequently luxated, as the os humeri at the shoul¬
der; others, from opposite circumstances, are very rarely
dislocated, as the vertebras. In general the liability to
luxation is proportionate to the degree of motion which
the joint possesses, and hence the ball and socket joint
allowing motion in all directions, is the seat of disloca¬
tion most frequently. In the joints possessing a hing-
like, or ginglimus motion, the accident is proportionally
rare, in consequence of the greater extent of the op¬
posing surfaces forming the joint, and of the strength
of the ligaments which surround them, added to which,
they are less frequently exposed to force in a direction
proper for separating their articulating extremities.
22U
Luxations are said to be complete, when the bones
of the joint are entirely separated; incomplete, when
some portion of the articulating bones remain in contact.
The only instances of incomplete luxation occur in
the^ articulations by ginglimus; as the knee, elbow, or
foot; and here a complete luxation is very rare, from
circumstances obvious to every one who is conversant
with the structure of these joints.
The longer a bone is suffered to remain in the new
situation into which it has been forced, the more diffi¬
cult will it be found to reduce it to its natural place.
The soft parts having accommodated themselves to the
new position; the muscles being shortened; after a lon¬
ger time, adhesions forming; and lastly, actual concre¬
tion of the dislocated bones in a situation remote from
the joint, or the formation of anew moveable joint;
these are circumstances which increase the difficulty
of replacing the luxated bone, in proportion to the
length of time which has elapsed after the accident.
Luxations, like fractures, have been divided into
simple and compound. The simple being accompa¬
nied with no external wound, the compound having
a wound communicating with the cavity of the joint
formed either by the protusion of the bone through
the integuments, or by the cause of the luxation divid¬
ing them at the time of the accident. Luxations may
be complicated with various other mischief, by the
injury of blood-vessels, nerves, &c.
The immediate causes of the luxation of a bone are
violence applied to the joint, and the action of mucles.
In an enarthrosis joint (ball and socket), if the direction
be-not oblique, it is impossible for the bone to be dis¬
located. Boyer has illustrated this by the example of
the os humeri. If this bone "hang exactly along side
of the body, or perpendicularly with respect to the gle-
- ,
ELEMENTS OF SURGERY.
221
noid cavity of the scapula, no force is capable of luxat¬
ing it. H a person fall on the elbow while the fore
arm is in this position, the head of the humerus will be
forced against the cavity formed to receive it; but if the
arm be removed from the body, the axis of the os
humeri will fall obliquely 011 the surface of the glenoid
cavity, which will favour its passing out of the socket;
and this disposition to luxate, will be increased in pro¬
portion as the angle formed by the axis of the bone with
the surface of the cavity deviates from a right angle.
The action of muscles probably very often assists in
dislocating bones; sometimes no other cause exists. I
have known the patella dislocated laterally, by a lady in
dancing, and in convulsions different bones are occa¬
sionally luxated.
Some joints, we have already noticed, are more liable
to dislocations than others. This predisposition may
depend on great latitude of motion; on the small ex¬
tent of articulating surfaces in contact; the laxity and
small number of the ligaments uniting them; paralysis
of the muscles surrounding a joint; and whatever has a
tendency to weaken the different connections between
the bones.
In some instances the soft parts connecting the bones,
are so relaxed that a very slight force suffices to dislo¬
cate them. I have known a woman whose shoulder
was liable to luxation from exertions of the most trifling
force, and Boyer relates the case of a patient who could
not yawn even moderately without dislocating her jaw.
These luxations are, from the same relaxation which
gives rise to them, very readily reduced, unless this
process be too long delayed.
Boyer declares, that " whatever may be the manner
in which the causes act, luxations are always accompa¬
nied with more or less laceration of the ligaments sur-
222
ELEMENTS OF SURGERY.
rounding the joint; and in the round articulations, as
those of the shoulder and hip, the fibrous capsules are
always torn." He ought to have excepted cases simi¬
lar to those noticed in the last paragraph.
The symptoms which distinguish luxations, are pain
and inability to move the member, a change in the ap¬
pearance of the joint, an elongation or shortening ot
the limb, an impossibility of performing certain motions.
By careful examination the displaced bones may often
be felt in their new situations; producing eminences
where there are naturally depressions, and vice versa;
but a more explicit account of these symptoms will be
delivered when the different luxations are particularly
described.
The treatment of dislocations consists in replac¬
ing the bones, and retaining them in their natural situa¬
tion. The reduction is to be effected as in fractures, by
extension and counter-extension. There is in general
no difficulty in keeping the bones in their natural posi¬
tion when they have once regained it.
The principal obstacle to the replacement of a bone,
recently dislocated, is the action of muscles drawing its
articulating surface into a situation remote from that,
which it ought to occupy. It frequently happens, that
after the head of a bone has been forced out of its na¬
tural place, it passes over certain bony prominences, and
then takes a situation in a depression of bone, from
which it must be forcibly raised before its reduction can
be effected. Instances of these bony resistances to the
reduction are found in luxations of the thigh bone; the
head of the femur passing over the high margin of the
acetabulum lodges in the foramen thyroideum, or on the
dorsum ilii, and before it can be replaced in its natural
socket, it must reascend the prominences over which it
has passed.
ELEMENTS OF SURGERY. 223
For the purpose of applying extension and counter-
exten. 1011 for the reduction of luxated bones, a variety
of machines have been contrived, which it is unneces¬
sary to detail in this place. The only means at present
in use, are the hands of assistants, and compound pul-
lies. Whenever we can avail ourselves of the aid of a
sufficient number of assistants, this mode of applying
force is to be preferred, because its direction and de¬
gree may be altered instantly by a word.
The parts to which force should be applied in reduc¬
ing luxations, can be better explained by describing the
different dislocations, than by any general rules. In
most cases the force should be made to act as directly
as possible upon the affected joint. Boyer and the
generality of French surgeons direct, on the contrary,
that '* the extending force should be applied not on the
luxated bone, but on that with which it is articulated,
and as far as possible from it." A rule which can be
applied with advantage to very few cases.*
The degree of force to be employed can only be esti¬
mated by the difficulty of the reduction, it should, al¬
ways be sufficient to accomplish that end. Although it
is to be constantly recollected, that force alone is never
to be relied on, but skill in the direction of it is ever
to be exerted. A force sufficient to tear off a limb has
been applied without reducing a dislocation. In esti¬
mating the force to be employed, (he obstacles to be
encountered should be carefully kept in view, and when
these are clearly understood, the direction of the extend¬
ing powers and the degree of their violence will be the
more easily judged of. It should in every instance be
gradually applied: Mr. Pott remarks, that " whatever
kind or degree of force may be found necessary for the
" '\
* Mr. Pott advocates the principle I have recommended, and most of the
British surgeons, as usual, oppose the French.
224 ELEMENTS OF SURGERY.
reduction of a luxated joint, that such force be employ¬
ed gradually; that the lesser degree be first tried, and
that it be increased gradatim." This important rule if
carefully observed will prevent all serious mischief from
the use of the force necessary even in the most chronic
luxations.
Napkins and strong bands or girths, fastened upon
the limb by means of cotton rollers, enable the requisite
number of assistants to act at the same time. To pre¬
vent excoriation of the skin where great force is neces¬
sary, Dr Physick has applied a piece of buckskin w ith
advantage, between the cuticle and the extending
bands.
Counter-extention applied to the bone with which
the luxated one was articulated, should always be made
at least equal to the extension. If, for example, three
assistants are employed in extending a luxated arm, a
force equal to three should be employed in fixing the
scapula. Counter-extension may often be made by
securing a band to a staple in a wall, or some secure
position.
In attempting the reduction of difficult luxations the
position of the patient should be changed. After an
erect posture has been tried, a recumbent one should
by substituted; if this fail, the patient may sometimes
with advantage be seated in a chair.
" Great advantage is derived in the reduction of dis¬
locations from attending to the patient's mind; the mus¬
cles opposing the efforts of the surgeon, by acting in
obedience to the will, may have that action suspended
by directing the mind to other muscles. Several years
ago, a surgeon in Blackfriar's Road asked me to see a
patient of his with a dislocated shoulder, which had re¬
sisted the various attempts he had made at reduction.
I found the patient in bed with his right arm dislocated;
ELEMENTS OF SURGERY.
225
I sat down on the bed by his side, placed my heel in
the axilla, and drew his arm at the wrist; the dislocated
/ bone remained unmoved. I said, ' Rise from your bed
sir;' he made an effort to do so, whilst I continued
my extension, and the bone snapped into its socket; for
the same reason, a slight effort, when the muscles are
unprepared, will succeed in reduction of dislocation
after violent measures have failed."* (Astley Cooper.)
In recent luxations it has been already noticed that
the principal difficulty experienced, is in overcoming
the contraction of the muscles. The fatigue of the
muscles occasioned by long continued efforts at reduc¬
tion, often produces a relaxation which permits the bone
to return to its natural place. Dr. Physick many years
ago employed copious blood-letting with this view. He
bled the patient until fainting was produced, and during
his continuance in a state of syncope all muscular ac¬
tion being suspended, the reduction was readily accom¬
plished. In a great number of instances which have
since occurred, the practice has been found completely
successful. There are several writers who recommend
bleeding to diminish the action of the muscles in obsti¬
nate luxations, but none (so far as I know) who pro¬
pose bleeding ad deliquium animi, except Dr. A.
Monro, sen. who suggested in his lectures on surgery
copious blood-letting from one or both arms in an erect
posture, as a probable means of facilitating the reduc¬
tion of dislocations; but Dr. Physick I believe was the
first who had the boldness to carry the practice to the
extent necessary for complete success. The first case
in which it succeeded, was a luxated humerus, which
had baffled every mode of applying force, and a very
* This fact, and the practice deduced from it, have been long since point¬
ed out by Dr. Physick, in his Surgical Lectures, and exemplified at the
Pennsylvania hospital.
VOL. I.—F f
226
ELEMENTS OF SURGERY.
great degree of force had been used. During the fainty
state, the hands of the operator were the only means
employed, and in a single moment, without the slightest
difficulty he replaced the head of the bone in its socket.
In cases where blood-letting to the necessary extent
is inadmissible, other means of suspending the action of
the muscles are to be- used. Perhaps nauseating doses
of emetics, or the tobacco glyster, might be employed
with advantage.* Intoxication has been recommended.
I once saw it succeed completely in a case of dislocated
jaw, which no previous efforts were effectual in reduc¬
ing. It was resorted to by Dr. Physick, on account of
the extreme debility of his patient who was dropsical,
and whom blood-letting would probably have destroyed.
The effects of blood-letting ad deliquium animi in
facilitating the reduction of dislocated bones, has been
very strikingly exemplified in several chronic luxations,
which have occurred in different parts of the United
States. Dr. Physick reduced a luxated humerus which
had been out of place forty-five days^ with very great
facility; and in a case which occurred at Baltimore, the
arm had been dislocated five or six months, and was re¬
placed by Dr. M'Kenzie by the aid of the same
remedy.f ?
* From the surgical essays of Mr. Astley Cooper and Mr. Travers, pub¬
lished in this present year, 1818, it appears that blood-letting, the warm
bath, and nauseating doses of emetics, have been freely employed to di¬
minish muscular action, by various British surgeons, and with great success.
f The following extract of a letter to Dr. Physick, contains the history of
this truly remarkable case, of the success of which I believe no parallel is
to be found in the records of surgery.
" 13. J. a seaman aged about thirty-five years,*«was admitted into the Balti¬
more hospital in the month of September 1805, with a luxation of the os
humeri. The account he gave of his case was, that while on a voyage to
Liverpool, and two weeks after leaving this port, he fell from a considera¬
ble height and dislocated his shoulder, and that an attempt was made by
the captain of the ship to reduce it, but without success; that upon liis
arrival at Liverpool repeated trials were made to effect reduction of the
ELEMENTS OF SURGERY. 221
An erect posture, as being most favourable to the
production of syncope, should be preferred.
It is proper to remark, however, that after a bone
has continued several months dislocated, it forms adhe¬
sions in its new situation; probably the rent in the cap¬
sular ligament contracts, or even heals up. Inflamma¬
tion produces great changes in the structure of the
parts and increases greatly the difficulty of reduction.
Rotating the bone and moving the joint in all possible
directions, are necessary to destroy these adhesions,
and long continued efforts sometimes succeed when
the surgeon had nearly despaired of accomplishing his
object. Perseverance, therefore, is to be strongly re¬
commended in all recent luxations, and even in those
which have existed several months.*
bone, bat to no purpose, and he had now. remained in this situation between
Jive and six months.
" Upon examining the shoulder, I found the head of the humerus under
the pectoral muscles, where it had imbedded itself, and appeared to have
formed considerable connexions with the surrounding parts.
" In this state of things I deferred any attempt to reduce the bone till the
following day, when in consultation with my fpiend Dr. Smyth, it was deter¬
mined at once, to have recourse to bleeding ad deliquium, as the only plan
in our view likely to succeed; and having secured our patient in the usual
manner, a vein was opened, and nearly Jive pounds of blood were drawn be¬
fore fainting could be produced; this, however, was at length completely ef¬
fected, and with (comparatively speaking) very little effort the bone was
reduced.
"It is worthy of remark in this case, that neither swelling nor inflamma¬
tion succeeded the reduction of the bone, and the poor man was dismissed
well in the course of two weeks.
«I am, &c.
" COLIN M'KENZIE."
Desault's most chronic case was of three months duration, and I believe
Dr. M'Kensie has accomplished what no other surgeon of this or former
ages can boast of having performed.
* With the view of cautioning the young surgeon of the danger of carry¬
ing his attempts too far, in order to reduce chronic luxations, we are induc¬
ed to give publicity to the following case, which occurred to Dr. Gibson,
in the month of June of this present year, (1823.) The patient was a male,
of the age of fifty years, who had the misfortune to dislocate his os humeri.
Residing in the country, eight weeks elapsed, previously to his making
22S
ELEMENTS OF SURGERY.
To preserve the bone in its proper place nothing but
rest is necessary. Very little bandaging is required
for this purpose, but it should be remembered that a
joint which has been dislocated has suffered necessarily
a great deal of contusion, and that it will probably in¬
flame very considerably. The usual means of combat¬
ting this inflammation when it occurs, among which
rest is indispensable, are to be employed. It is proper
in most cases, to bathe a joint which has been dislocat¬
ed with a solution of sugar of lead or with some cooling
lotion.
Luxated bones which are not reduced, sometimes re¬
main in the situation into which they had been at first
forced; more commonly, however, they change their
situation, being drawn by the action of muscles further
and further from the cavity of the joint In its new
situation it excites inflammation and a thickening of the
surrounding soft parts; if in contact with bone, this bone
becomes inflamed, and after a time a depression is
formed in it which receives the head of the dislocated
bone, and a kind of imperfect joint is formed; the mus¬
cular flesh and cellular texture are changed into a liga¬
mentous matter which assist in supporting and strength¬
ening the new articulation. In various anatomical
collections are preserved curious specimens of these
newly formed joints, affording wonderful proofs of the
application to the Doctor. Several violent efforts hactbeen made by the
physicians of his neighbourhood, in order to replace the bone in its proper
situation; but these were unavailing.
The Doctor directed the man to repair to the Philadelphia Alms-house;
where, in the presence of the students of the house, he finally succeeded
at half past ten o'clock, in reducing the luxation, by the employment of the
usual means, which occupied about thirty minutes. Towards evening of
the same day the man died. Upon dissection a considerable quantity of
blood was found effused into the axilla, and under the pectoral muscles.
Upon removing the coagula, the axillary artery was found ruptured, owing
to an adhesion which had formed between it and the capsule, thereby ren¬
dering this event inevitable, but impossible to have been foreseen. Eb
ELEMENTS OF SURGERY.
229
resources of the animal oeconomy. The socket of
the joint from which the bone had been displaced,
sometimes fills up with a thickening of the ligaments,
and the usual matter of adhesions, though in other cases
it remains very little changed in structure.
The muscles of a limb permanently dislocated shrink
and lose their strength, and although in some cases a
power of motion is regained after a time, yet it is al¬
ways very limited and imperfect.
Of compound dislocations,, These are among
the most dangerous accidents to which the bones are
liable; all the dangers of wounded joints, and of com¬
pound fractures, are to be dreaded from them. The
question of amputating a limb in which a compound
dislocation has happened, is attended with all the diffi¬
culties, already noticed when speaking of wounded
joints. The various circumstances of the patient in
each particular case must be taken into view, and no
general rules for deciding it, can be laid down.
The principal object in the treatment of compound
dislocations is, after reducing the bone, to procure as
speedily as possible the union of the External wound,
thereby precluding the dangers of an exposed joint.
For this purpose its edges should be brought as nearly
as possible into contact, and retained so by adhesive
plaister, and the joint kept perfectly at rest by band¬
ages, splints, and a proper posture
2 30
elements of surgery.
CHAPTER XXXVII.
Of particular Dislocations.
dislocation of the lower jaw.
This accident happens generally in adultsr and never
in young infants, because in the latter the angle of the
jaw is obtuse, in consequence of which the condyles by
which it is articulated with the temporal bones have
the same direction as the basis of the jaw, and from
this structure the mouth cannot be opened wide enough
in infancy to separate the articulating surfaces.
Sometimes one and sometimes both condyles are
dislocated. The only direction in which the displace¬
ment can happen is forwards. In most cases the ac¬
cident is produced by yawning, or opening the mouth
excessively wide. A woman in scolding her husband,
in a very vociferous tone, found herself unable to close
her mouth, and applied to Dr. Physick who found both
condyles of the lower jaw dislocated. A blow upon
the chin whilst the mouth is opened may also occasion
the same effect.
The symptoms which denote this luxation, are an
inability to close the mouth, which is kept considera¬
bly open; immediately before the ears where the con¬
dyles naturally occasion a fulness, an empty hollow
space is perceived; the coronoid process is felt project¬
ing more anteriorly than natural; the cheeks and tem¬
ples are flattened; the saliva flows from the mouth; the
patient speaks and swallows with great difficulty; the
chin projects forward. When the jaw continues dislo¬
cated several days these symptoms are not so strongly
ELEMENTS OF SURGERY. 23]
marked, but they still exist, to a greater or lesser de¬
gree.
To effect the reduction the patient is to be seated
on a low chair, his head supported against the breast
of an assistant; the surgeon defending his thumbs with
a piece of leather, or linen, places them as far back
upon the molar teeth of the lower jaw as possible, the
fingers are then placed under the chin, and whilst he
presses down the back teeth with his thumbs, he at the
same time elevates the chin; by this manoeuvre he uses
the base of the jaw as a lever of which his thumbs
represent the, fulcrum, and disengages the condyles
from the zygomatic fossas in which they had been
lodged; when the condyles are found moving, the chin
is to be pushed backwards, and the reduction effected.
At this moment it behoves the operator to be careful
in removing his thumbs. from between the teeth, for
the condyles regain their situation very suddenly, and
the jaws are spasmodically closed with great force.
To prevent their being bruised he slips them very
quickly outwards between the cheeks and teeth, where
they are safe.
After the reduction the jaws should be kept at rest
a few days by a bandage passed round the head and
chin, the patient being nourished with spoon victuals.
It has been proposed to reduce this luxation by a
sudden blow on the chin, knocking it upwards and
backwards. This plan has sometimes succeeded, but
it is always attended with great danger of breaking
off the condyles of the jaw.
When only one condyle is dislocated the reduction
is effected in the same manner as when both are dis¬
placed, except that only one hand is necessary.
Le Cat succeeded in reducing an obstinate disloca¬
tion of the jaw by introducing a stick between the
232
ELEMENTS OF SURGERY.
back teeth and using it as a lever continually prizing
the teeth of the upper and lower jaw apart, until the
muscles which were spasmodically contracted, became
fatigued and then the reduction was easily effected.
Dr. Physick was consulted a short time ago by a
young woman who had been salivated for the cure of a
dropsy; the inflammation and swelling of the jaws in
consequence of the use of mercury were very great,
and during the continuance of these symptoms she
dislocated (without knowing how or when) both con¬
dyles of the lower jaw. When the effects of the
mercury had somewhat subsided, she perceived her
inability to close her mouth, and her physician soon
discovered that the jaw was luxated. She came to
Philadelphia, and Dr. Physick attempted its reduction
in the usual manner, but not succeeding, the plan pro¬
posed by Le Cat was tried without effect; her molar
teeth being almost all carious prevented any violent
efforts upon them, with the wooden lever. Her ex¬
treme debility and dropsical habit, precluded blood¬
letting, and I suggested to Dr. Physick the propriety
of trying the nauseating effects of tobacco. She re¬
fused this however, and the Dr. next proposed to give
her as much ardent spirit, as should occasion intoxi¬
cation. She consented and became perfectly inebriat¬
ed, and whilst inebriated was prevailed on to smoke
a segar, great nausea ensued, during which time the
measures which had been before unavailing, very
promptly succeeded in effecting the reduction.
-
ELEMENTS OF SURGERY.
2 33
CHAPTER XXXVIII.
Dislocations of the Vertebrce.
The excellent work of Boyer will furnish the follow¬
ing Chapter.
" The large surfaces by which these bones corre¬
spond, the number and thickness of their ligaments, the
strength of the muscles lying on the column formed by
them, the small motion of which each vertebra is capa¬
ble, and lastly, the vertical direction of their articulating
apophyses, render a luxation of them in the dorsal and
lumbar part of the column, entirely impossible. A
violence, though ever so considerable, cannot displace
them without first fracturing them. The same is not
the case with the cervical vertebrae; the extent of their
articulating surfaces is less, the ligamento-cartilaginous
substance which unites their bodies has more pliability,
the motion of their articulations is greater, and their
articulating surfaces have an oblique direction, which
allows them to have an obscure rotatory motion; conse¬
quently luxations of them are sometimes met with. I
have seen a case in which the neck was luxated by a
violent rotatory motion of the cervical vertebra?, and
the luxation resisted all means that were employed to
reduce it. The cause of impediment was felt towards
the middle of the column formed by the cervical ver¬
tebrae; from which circumstance we may conclude that
the dislocation did not consist of a separation of the
first vertebra from the second, which is admitted to be
possible by all authors, but that it took place lower
down in the cervical part of the column.
It appears from well attested facts, that luxations may
vol. i.—g g
2 34
ELEMENTS OF SURGERY.
take place in the vertebral column; such as those of the
head from the first vertebra, and of the first vertebra
from the second. These, and especially the latter, are
the most frequent; but others, though much rarer and
more difficult, may, however, take place.
The articulation of the occipital bone with the first
vertebra of the neck is strengthened by means of many
ligaments, and admits of only very limited motions. It
is well known, that the motions of inclination of the
head to the right and left, and of flexion and extension,
take place along the whole length of the cervical ver¬
tebrae. We have no instance of luxation of the head
from the first vertebras by an external cause; such a dis¬
location. if possible, would instantly destroy the indi¬
vidual to whom it happened, by the compression and
disorganization of the spinal marrow. But nature,
which cannot bear so sudden a change, is habituated to
it when it takes place gradually and insensibly; and the
spinal marrow, which a sudden though inconsiderable
derangement of the spine would totally disorganize, is
not sensibly injured when it takes place by degrees:
cases of rachitis furnish us many proofs of this. It is
only in this way that we can explain how the individual
from whom the preparation in the Museum of Natural
History was taken, could exist until such very great de¬
formity took place in his spine.
It is principally in the triple articulation of these two
vertebrae, that the motion of rotation of the head to the
right or left takes place; for the union of the first vetebra
to the occipital bone is so close, that the motion of both is
the same. This rotation of the first vertebra on the
second, which the laxity and weakness of the ligaments
that go from one to the other, and the direction of their
articulating apophyses, render easy, would be frequently
carried beyond its natural bounds; and luxation woul<J
ELEMENTS OF SURGERY. 235
take place every time we turn our head with force, if
the motion were not confined by two very thick liga¬
ments, which go from the sides and summit of the tooth¬
like process of the second vertebra to the edges of the
great occipital hole. When this motion is forced beyond
its proper limits, the ligaments are torn, and the lateral
parts of the body of the first vertebra glide along on
the articulating horizontal processes of the second. If
the head is turned from the left to the right, the left side
of the body of the vertebra is carried before jits corre¬
sponding articulating surface, whilst the right side falls
behind its corresponding surface. In this luxation,
sometimes the toothlike process, the ligaments of which
are broken, leaves the ring formed for it by the trans¬
verse ligament and the anterior arch of the first ver¬
tebra, and presses on the spinal marrow, the substance
of which it destroys; at other times it remains on its
ring, but the diameter of the vertebral canal is always
diminished at this place, and the spinal marrow experi¬
ences a compression, and at the same time a contor¬
tion, by which it is lacerated. It is easily conceived
that the patient cannot survive a derangement of this
nature; every lesion of the spinal marrow at this height
is quickly fatal. Louis, in making researches on the
manner of dying of hanged persons, found that those
despatched by the executioner of Lyons, perished by
the luxation of the first vertebra from the second; whilst
those hanged at Paris were suffocated by strangulation.
He discovered the cause of this difference in a rotatory
motion given to the body of the culprit by the execu¬
tioner of Lyons, at the moment that the ladder was
taken from under his feet. We ought to attend to this
observation, when we examine in a judicial capacity
the body of a person found hanged. We should care¬
fully examine the second vertebra, and see if it be lux-
236
ELEMENTS OF SURGERV.
ated. If so the individual has not been guilty ol sui¬
cide, for the luxation must have resulted from a violent
motion communicated to the body by the assassin.
The following case by J. L. Petit, furnishes an in¬
stance of luxation produced by the person himself; the
circumstances of it are so extraordinary, that we shall
relate them at full length.
" The only son of a tradesman, aged between six
and seven years, went into a neighbouring shop, the
proprietor of which was a friend of his father's. This
person playing with the child, put one hand under his
chin and the other on the back of his head, and then
raised him up in the air, telling him he was going to
shew him his grandfather, a common expression among
the vulgar. Scarcely was the child raised from the
ground, when he began to struggle, and by his efforts
dislocated his neck, and died on the spot. The father,
on hearing of the death of his child, ran in a fit of pas¬
sion alter his neighbour, who fled before him, but not
being able to catch him, he threw at him a saddler's
hammer which he had in his hand, and buried the cut¬
ting part of it in the depression of his neck. The
weapon cut all the muscles, penetrated into the space
between the first and second cervical vertebra, divided
the spinal marrow and occasioned almost instantaneous
death. Thus both perished nearly in a similar manner."
J. L Petit, who quotes no authority to support this
fact, avails himself of the opportunity of censuring this
dangerous kind of play, and observes with justice, that
the motion which the child gave himself was the cause
of his death.
The relaxation of the ligaments of the toothlike pro¬
cess may favour this luxation. Such probably was the
case of a young man, who found a difficulty to bring
his head back to its natural posture, each time that he
ELEMENTS OF SURGERY.
237
turned it to the right or left. There are many cases
of luxation of the neck, in which death does not suc¬
ceed the accident; but in these the luxation takes place
in the third, fourth, fifth, or sixth vertebras, and only
one articulating process is luxated: in these cases, the
diameter of the vertebral canal is not so much dimi¬
nished as to compress the spinal marrow, and destroy
life; but a wry-neck remains, which becomes incurable,
unless the real cause be found out.
A child, playing on his mother's bed, suddenly felt
pain in his neck, accompanied with a distortion which
he could not remove. Desault, to whom the child was
brought, discovered a luxation of the vertebrae of the
neck; but before trying to reduce it, he informed the
mother that the child might die in the attempt. This
information terrified the mother so much, that she took
the child away without having any thing done to re¬
lieve it.
A lawyer writing at his desk, heard the door behind
him open; he quickly turned round his head to see who
was coming in, but could not bring it back again to
its natural direction. Many surgeons of Paris have
seen this patient: his head was turned to the right, and
slightly inclined to the shoulder of the same side. This
inclination was much less than it would have been in
a spasmodic contraction of the sterno-cleido-mastoide-
us muscle.
Thus when in consequence of a sudden and violent
effort, the head is found turned to one side, either right
or left, with inability to bring it back, the ear a little in¬
clined to one side, and the sterno-cleido-mastoideus in
a state of relaxation, there can be no doubt but that a
luxation of one of the cervical vertebrse, has taken place.
If the luxation produce no symptom which indicates
a compression of the spinal marrow, it is prudent to ab-
I
238 ELEMENTS OF SURGERY.
stain from all attempts to reduce it However, if the
patient absolutely insist on our interfering, we are to
proceed in this way: we begin by inclining the head to
the side towards which it is directed, in order to disen¬
gage the articulating process of the upper vertebrae:
this part of the operation is extremely dangerous, as it
may kill the patient by causing a compression of the
spinal marrow. When the process is disengaged, the
head and neck are brought to their right direction, by
making them perform a rotatory motion the contrary of
that which had taken place in the luxation. A relapse
is prevented by keeping the head free from motion.
This is done by means of bandages which are attach¬
ed to the head and shoulders." (Boyer—Vol. 2.)
rk ■»
ELEMENTS OF SURGERY.
239
CHAPTER XXXIX.
.Dislocations of the Bones of the Pelvis and Thorax.
The nature of the articulation connecting the sa¬
crum and ossa innominata, and their great strength at
the places of their juncture, prevent them from disloca¬
tion except by great violence applied immediately at
the spot where the synchondrosis exists. The acci¬
dent in one instance occurred by a heavy body falling
on the back of a labourer, who died twenty days after,
and upon dissection a luxation of the sacrum was dis¬
covered. The right os ilium passed nearly three inches
behind the sacrum and the luxated bones moved freely
on each other. Great inflammation existed in the parts
contained in the pelvis, and pus was found in the abdo¬
men. This case being very analogous in its symptoms
and effects to a fracture of the ossa innominata, calls
for the same treatment; rest and the antiphlogistic mea¬
sures, to guard against inflammation. Boyer who re¬
lates this case, states further, that in pregnant women
the symphysis pubis becomes in some cases so much re¬
laxed that the ossa innominata may be separated, and
supposes that something similar may take place to a
smaller extent at the sacro-iliac symphysis. These
cases call for no surgical treatment.
Dislocations of the os coccygis, may be occasioned
in early life by the same accidents which, at a more ad¬
vanced age, would occasion a fracture. The circum¬
stances of the cases being similar, no difference of treat¬
ment is required. It is evident that luxations of the
bones forming the pelvis have nothing in common with
other dislocations; they are in fact fractures of the car-
240 ELEMENTS OF SURGERY.
tilage connecting these bones; are produced by the same
causes, and are to be treated by the same remedies as
fractures of the bones. They are extremely rare, as
the bones generally yield and are broken by a force ca¬
pable of producing the dislocation.
The ribs, likewise, are not capable of dislocation,
because no force can be applied to their articulation
with the vertebrae which will not occasion a fracture.
The starting of the cartilages of the ribs in front is
an accident which is not unfrequent; it occurs in cer¬
tain motions of the arm. Mr. Charles Bell observes,
"a young man playing the dumb bells and throwing
his arms behind him, feels something give way on the
chest; and one of the cartilages of the ribs has started
and stands prominent. To reduce it, we make the pa-
l tient draw a Mil inspiration and with the fingers knead
the projecting cartilage into its place. We apply a
compress and bandage, but the luxation is with diffi¬
culty retained."
ELEMENTS OF SURGERY.
241
CHAPTER XL.
Dislocation of the Clavicle.
This is a rare accident compared with the fracture
of the bone. It occurs at the sternal and also at the
humeral extremity.
At the sternal extremity the sternum and the
cartilage of the first rib prevent the dislocation down¬
wards, but. in every other direction it is occasionally
dislocated, viz. forwards, backwards, and upwards.
In general, the displacement is forwards. It is effect¬
ed by violent motions of the clavicle backwards. In
consequence of this motion the sternal extremity is
carried forwards, the ligaments are broken, and the
end of the bone is found before the upper end of the
sternum, forming a hard projecting tumour, which
moves whenever the arm and shoulder are moved.
The treatment of all dislocations of the sternal ex¬
tremity, consists in the same dressings as those used
for fractured clavicle; they reduce the luxation and
maintain the proper situation of the bone. The dress¬
ings should be continued a greater length of time than
in a case of fracture; and in general, some deformity
exists, the clavicle being more salient than natural at
the place of dislocation.
The humeral extremity of the clavicle is not so
often dislocated as the sternal. It is generally dislocat¬
ed upward, but it may take place downward, being
lodged under the acromion. The dislocation up¬
wards is the only one demanding attention, because
the only one in which any difficulty is experienced in
maintaining the reduction.
vol. i.—h h
242 ELEMENTS OF SURGERY.
I
The accident is generally occasioned by falling on
the shoulder, and is ascertained by examination with
the fingers; the extremity of the clavicle being found
under the skin covering the acromion, causing a con¬
siderable projection there. The patient inclines his
head to the affected side, and moves as little as possi¬
ble the arm and shoulder, because he cannot move
these parts without calling into action the deltoid or
some other muscle, which Would consequently extend
the mo on to the diseased pari, and cause pain.
The treatment of the accident is to be the same as
that recommended for fractures of the clavicle, viz.
the apparatus of Desault, which effects and maintains,
better than any other, the reduction. That part of the*
bandage which ascends from the elbow to the shoulder
should i the present case be made as tight as can be
borne, in order to press down the clavicle, and keep it
in its proper place.
The inconveniences resulting from this accident
when improperly treated are very considerable; the
motions of the arm being for a long time greatly im¬
peded; they are, however, after a lapse of years gra¬
dually recovered.
ELEMENTS OF SURGERY, 243
CHAPTER XLI
Dislocations of the Os Humeri.
These are by far the most common dislocations, and
have been supposed to equal in frequency, all others
which occur.* The structure of the shoulder joint, in
which a spherical surface is articulated with a ver) su¬
perficial cavity, and in contact with it in a very few
points, together with the weakness of the ligaments of
the joint, and its exposure to violence in performing a
great variety of motions, are circumstances which suf¬
ficiently explain the frequency of the accident: and it
would be still more frequent, were it not for the admi¬
rable provision by which the scapula moves with it. thus
preventing in a variety of instances the force of per¬
cussion from acting solely on the os humeri. Were the
scapula fixed as is the pelvis, almost every violent mo¬
tion of the arm would be attended with dislocation.
The head of the os humeri may escape from the gle¬
noid cavity of the scapula in any direction except up*
wards where the acromion and coracoid processes and
the ligament connecting them together, prevent its as¬
cent. Mr. Boyer observes, that there is " one species
of luxation of the humerus of which though it has been
described, and the possibility made evident, we are not
acquainted with a single instance, it is the luxation out¬
wards or backwards." Such a case occurred to Dr.
Physick in December, 1811, and I have seen a luxation
directly forwards, the head of the bone being lodged
* At the Hotel Dieu, of the total number of luxatiofis, admitted during a
long period of time, a majority were luxations of the os humeri. (Bichat.)
2U ELEMENTS OF SURGERY.
before the coracoid-process, both of which will be no¬
ticed hereafter.
The situation of the bone after it has been dislocated
is often changed very considerably by the action of mus¬
cles.
The dislocation downwards into the axilla, is by far
the most frequent; the anatomical structure of the joint
has furnished the French surgeons with some ingenious
reasons for this, but they are of no importance in"a
practical point of view. It is probable that in every
case where the head of the bone is found in the axilla,
a considerable laceration of the capsular ligament must
have taken place.
The symptoms of a dislocation of the os humeri
downwards, are very easily distinguished. The prin¬
cipal difference observed between the luxated and sound
shoulder, are the natural rotundity of the latter, and in
the injured one a very remarkable "depression under the
acromion, which of course appears very prominent; this
symptom which was noticed by Hippocrates is never
absent. The arm is longer than the sound one. Its
direction is changed, and instead of hanging parallel to
the side, it stands off at an acute angle from the body,
and no effort of the patient can draw the elbow close
to the side. Great pain is perceived in attempting to
move the arm in any direction, but the motion out¬
wards is less painful than any other. The head of the
os humeri is felt in the axilla, forming a hard round
tumour.
To reduce the bone, a vast variety of means have
been employed; the ambe of Hippocrates is perhaps
the oldest apparatus upon record: to recount the differ¬
ent inventions which have been contrived since his
time would be a very useless and fatiguing task. I shall
therefore very briefly describe the method which I be-
ELEMENTS OF SURGERY, 245
lieve best adapted to the case. It consists in making
counter-extension against the acromion process of the
scapula, and extension by the arm above the elbow,
the fore-arm being flexed.
If the surgeon is called soon after the accident has
happened, he is to press firmly with one hand against
the acromion, and with his other grasping the arm
above the elbow, forcibly to extend it, the patient being
seated. In a great number of instances I have known
this simple manoeuvre to succeed instantly in reducing
the bone, the strength of an individual being sufficient
for the purpose.
If a greater length of time have elapsed, the exten¬
sion and counter-extension are to be made in the same
manner, but with additional power. Several assistants
being employed, to make counter-extension against the
acromion, by placing one hand over another, and an
equal number to make extension.
When the force required is greater than can be thus
applied, a girth or strong band covered with soft buck¬
skin may be passed over the shoulder for counter-ex¬
tension, and this can be held by assistants, or secured
to a staple fastened in a wall; in order to prevent it
from slipping, I have made use of two strips of muslin,
one on each side of the shoulder, which are passed
round the band, and held down by an assistant. To
make extension, a piece of soft buckskin is applied
round the arm above the elbow, and a strong towel is
fastened upon this by very numerous turns of a muslin
roller passed round and round the arm; to this towel,
cords or bands may be attached, and any number of
assistants can act upon them, or if pullies be neces¬
sary these can be affixed. *
The advantage derived from the mode of applying
force which has just been recommended is, that it acts
ELEMENTS OF SURGERY.
almost exclusively upon the shoulder joint. When the
patient is secured by straps, bandages, or jacket* about
the thorax, the scapula moves with the humerus when
this is pulled, and it would probably be possible to drag
off the scapula and clavicle together with the arm, with¬
out reducing the luxation. The mode of treating the
accident, by placing the heel in the axilla, and pulling
at the arm, is a better plan, for in this case some of the
counter-extension is borne by the scapula, and this has
often been successful, but among the numerous methods
which ingenuity has devised to aid in the reduction of
a luxated humerus, I know of none which so completely
and exclusively operates upon the affected part, and
none which can succeed more happily than that which
I have described.*
In general, the extension has not been long continued
in this manner before the head of the bone in the axilla
is found to move, and very often without any other ef¬
fort, slips into its socket; if this, however, should not
be the case, the surgeon is to take the fore-arm bent
to a right angle with the arm, and with some force, ro¬
tate it repeatedly inward and outward. If the luxation
be not reduced thus, pressure against the head of the
bone, is to be made, directing it towards the glenoid
cavity; if it can not now be pushed into its situation,
the extensions may be suddenly suspended, and the
surgeon having his left hand under the arm near the
axilla, as suddenly depresses the patient's elbow towards
his side and thus uses the os humeri as a lever and
brings out the head of the bone to a level with the gle¬
noid cavity, which it consequently enters. By these
means aided, if necessary, by copious blood-letting, the
luxation has in every case I have yet seen been reduced.
• Mr. Freke, Benjamin Bell, Charles Bell, and other writers, recoir-
mend securing the scapuia, but not in the manner here directed.
ELEMENTS OF SURGERY.
247
Amomr the causes impeding the reduction of this
luxation, Desault mentions* ' a narrowness in the open¬
ing of the capsular ligament," to enlarge which, he ad¬
vises moving the arm very freely and forcibly in every
direction. The same measure is useful also by tearing
asunder any adhesions which+:may have formed in the
new situation of the bone.
In all these efforts perseverance is an important rule
If the first attempts fail, they should be repeated, and
varied again and again, and according to Desault, even
when success is not completely obtained, something
will be gained if the head of the bone be brought nearer
to the glenoid cavity, for " the motions of the bone will
be the freer in proportion to its proximity to the natu¬
ral situation."
At what period after its luxation should we consider
it impracticable to reduce a dislocated bone? Did we
believe B. Bell and other writers of the last century, a
week or a fortnight having elapsed, all efforts should be
considered as hopeless. Desault succeeded after three
months. In a variety of instances Dr. Physick has suc¬
ceeded after two and three months, and Dr. M'Kenzie
of Baltimore, has replaced a dislocated os humeri nearly
six months after its luxation. Before answering the
question, therefore, it may be well to consider another
which I shall state in the language of Dr. Physick,
quoted from his lecture on this subject. " If force ap¬
plied can remove a bone from its natural to an unna¬
tural situation, why may not force be so directed as to
remove it from this new, to its former position?" If the
time could be ascertained at which the socket is cer¬
tainly filled up, and its texture completely altered, that
would be the time to give over all attempts at reduction.
The plan we have recommended is proper in most
<eases of dislocated os humeri. In the dislocation back-
248 ELEMENTS OF SURGERY.
ward, fa very rare accident, which neither Desault nor
Boyer ever saw,) in addition to the extensions and coun¬
ter-extensions, some pressure should be made upon the
head of the bone, and an attempt to push it towards its
socket whilst the extension is made. Dr. Physick in
this manner succeeded in reducing a case of the kind,
without difficulty. It was distinguished by a great de¬
pression under the acromion, as in all other disloca¬
tions; by a hard tumour on the dorsum of the scapula
which was evidently formed by the head of the bone;
by an inability to move the arm, in any direction; and
by an absence of the head of the bone from the axilla.
No doubt could exist as to the nature of the accident,
and no difficulty was experienced in its reduction.
It is astonishing that Mr. Charles Bell should deny
positively the possibility of this accident. " No force
can be applied in a direction to dislocate the humerus
and push its head behind the scapula, for this very evi¬
dent reason, that the chest prevents the necessary posi¬
tion of the humerus/'* Mr. Bell's accurate anatomi¬
cal knowledge should have taught him that the chest is
no defence to the shoulder, and that a blow on the
shoulder can luxate the humerus, as readily as a twist
of the arm. In the case recited, the patient fell through
a hatchway and struck the fore part of the shoulder
which was thus pushed directly backwards.
A case of dislocation inwards and forwards occurred
to Dr. Physick in 1812; there is no reason for believ¬
ing this to have been consecutive, for the head of the
bone continued unmoved after the accident, and assum¬
ed the situation in which he found it, immediately after
escaping from the glenoid cavity. As the head of the
bone, in this case, was fixed between the glenoid cavity
and the coracoid process, extension was made by draw-
• Operative Surgery, Vol. II.
ELEMENTS OF SURGERY.
249
ing the elbow backwards arid downwards, and counter-
extension, by pressing the acromion scapulae forwards
and inwards towards the head of the bone, at the same
time a band was passed under the arm by which the
upper end of the os humeri was dragged outwards so
as to unhitch it from the coracoid process. By these
means, after in vain trying extension in the usual way,
the reduction was effected.
In another instance of luxation forwards and in¬
wards, the head of the bone passed completely over the
coracoid process, and was situated directly under the
clavicle. Jn this case by bleeding ad deliquium, and
extending the arm at a right angle from the body, the
reduction was easily effected.*
After the reduction of a dislocated os humeri the arm
should be kept at rest, and if inflammatory symptoms
occur, they are to be treated by the usual remedies.
Many of the preceding remarks are taken from Dr*
Physick's MS. lectures. I am well aware that the idea
of making some counter-extension against the acromion
is to be found in several writers. Mr. Charles Bell and
Boyer, appear to come nearer the plan above proposed
than any others, but their methods are different in many
particulars: Mr. Hey in his practical observations has
* The most singular case of dislocation of the os humeri which we have
ever heard of, is related by Baron Larrey^ who saw the preparation of it
in the cabinet of the University of Vienna. In this instance the head of
the os humeri, owing to a violent fall on the elbow, was displaced from its
proper situation, forced into the hollow of the axilla, under the pectoral
muscles, and passed into the cavity of the chest between the second and
third true ribs, pushing before it the pleura costalis. This patient lived
fifteen years after the occurrence of the accident, and then died of a dis¬
ease entirely unconnected with the luxation. Upon dissection after death,
the head of the bone was found situated as we have described it, surround"
ed by the pleura, and its neck firmly embraced by the two ribs. Its carti¬
lage and osseous texture had entirely disappeared, and it was converted
into a soft membranous ball which could be readily compressed by the
fingers.—Ed.
See Larrey's M^moirea de Chirurgie Militstire, Tom. 2. p, 405—407,
VOL, I,—I 3
250
ELEMENTS OF SURGERY.
some excellent remarks on this luxation, but they an
detailed with less than his usual perspicacity. The
great object to be kept in view, is to act as effectually
as possible on the shoulder joint, and this can best be
done by making the counter-extension as nearly as pos¬
sible to the glenoid cavity, and this can certainly be
accomplished by making counter-extension exclusively
upon the acromion process.
An accidental circumstance which occasioned some
alarm to Desault in attempting a difficult reduction, it
may not be improper to notice in this place, the sudden
formation of a very considerable tumour at the upper
part of the arm, occasioned probably by the rupture of
a vein, as it subsided in a fortnight, leaving a large
ecchymosis: no particular injury resulted from it,
though at first it was mistaken by some, for an effusion
of air from the thorax, and by others for a rupture of
an artery.
The stiffness of a joint which follows a luxation of
the os humeri is generally of short continuance, and its
motions are soon perfectly restored. The arm should
be gently moved after a few days have elapsed, and
these motions are to be gradually increased.
ELEMENTS OF SURGERY. 251
CHAPTER XLIf
Dislocations of the Fore-arm.
The radius and ulna may be dislocated from the hu¬
merus; or secondly, The superior extremity of the ra¬
dius may be separated from the ulna; or thirdly, The
ulna may be luxated at its inferior extremity from the
radius.
1. The articulating surfaces which form the elbow
joint are very extensive, and the joint consequently
possesses considerable strength, which is augmented by
the muscles passing over it and connected with the
bones in its vicinity. The elbow joint possesses the
true hinge-like motion, and is a pure specimen of the
articulation denominated ginglimus. From these cir¬
cumstances it is not frequently dislocated. The luxa¬
tion may take place, however, backwards, and laterally.
The luxation backwards is most frequent. A complete
dislocation laterally cannot take place, from the great
extent of the articulating surfaces in this direction, and
the strength of the muscles and ligaments around the
joint. v
" In the luxation backwards the radius and ulna may
ascend more or less behind the humerus, but the coro-
noid process of the ulna is always carried above the ar¬
ticular pulley, and is found lodged in the cavity destin¬
ed to receive the olecranon. The head of the radius
is placed behind and above the external condyle of the
humerus. The annular ligament which confines the
superior extremity of the radius to the ulna may be
lacerated, in which case even when the bones are re-
252
ELEMENTS OF SURGERY.
duced, it is difficult to keep them in their proper places,
as the radius tends constantly to separate from the ulna.
" This luxation always takes place from a fall on the
hand; for when we are falling we are led by involun¬
tary instinct to bring our hands fowards to protect the
body. If in this case the superior extremity, instead of
resting vertically on the ground, be placed obliquely,
with the hand nearly in a state of supination, the repul¬
sion which it receives from the ground will cause the
two bones of the fore-arm to ascend behind the hume¬
rus, whilst the weight of the body pressing the hume¬
rus obliquely downwards forces its extremity to pass
down before the coronoid process of the ulna.
Ci The fore-arm in this luxation is in a state of demi-
flexion, and every attempt to extend it, occasions smart
pain. The situation of the olecranon with respect to
the condyles of the humerus is changed. The ole¬
cranon which in the natural state is placed on a level
with the external condyle, which is itself situated lower
than the internal, is higher than it.
" This luxation may be mistaken for a fracture of
the olecranon, of the head of the radius, or even of the
lower end of the humerus; such a mistake is attended
with very bad consequences ;for if the reduction be not
effected before the end of fifteen or twenty days, it is im*
possible to accomplish it afterwards* The swelling
more or less considerable which supervenes in twenty-
four hours after fhe accident, renders a diagnosis diffi¬
cult; the bony prominences are so covered by it, that it
is impossible to examine their respective situations.
Besides, the rubbing of the -/coronoid process and ole¬
cranon against the humerus^ (buses a grating noise simi¬
lar to that in fracture. From'these circumstances it must
* This is a great mistake of Mr. Boyer. I have seen a case of this luxa¬
tion which had continued longer than a month, very promptly reduced.
ELEMENTS OF SURGERY. 253
appear, that much attention is requisite to establish a
diagnosis between the fracture of the head of the radius
and a dislocation of the fore-arm backwards." (Boyer.)
The reduction is effected by seating the patient in a
chair, and making extension and counter-extension by
two assistants, one of whom grasps the wrist and the
other the arm near the shoulder. The surgeon now
interlocks his fingers in front of the arm and just above
the elbow and draws it backwards. If greater force be
necessary it is to be applied in the same directions.
Boyer recommends that the olecranon be pressed for¬
wards and the humerus pulled backwards by the sur¬
geon, who is to place the four fingers of each hand on
the fore part of the humerus, and his thumbs on the
olecranon. The only objection to the plan is, that the
surgeon unless a Hercules, could not in this way act
with sufficient power, and if the humerus be forcibly
drawn backwards, there will be no necessity for push¬
ing the olecranon forwards. When the reduction is
effected, the form and motions of the elbow will be re¬
stored and a very evident noise will be heard at the
moment when it takes place. Rest and a low diet
should be observed for a few days after the accident,
the fore-arm being preserved in a state between flex
ion and extension by a roller and compresses or splints.
A week after the accident the arm should be gently
and repeatedly moved to prevent anchylosis; these mo¬
tions are to be daily increased, until they are perform¬
ed perfectly and without pain.
" In a luxation of the fore-arm backwards the annu-
lar ligament which coftfines the head of the radius to
the extremity of the ulna, is sometimes torn, and the
radius passes before the ulna. In such cases, the mo¬
tions of pronation and supination, are difficult and pain¬
ful, though the principal luxation has been reduced,'*
25i ELEMENTS OF SURGERY.
• t s
The head of the radius may be easily replaced by press¬
ing it from before backwards, and it is kept in its place
by compresses bound on the superior and external part
of the fore-arm by a roller passed round the elbow in
form of the figure 8.
When the luxation has not been reduced, the supe¬
rior extremities of the bones, grow to the posterior part
of the os humeri, and flexion and extension are thus
precluded. In young subjects a slight degree of mo¬
tion is sometimes regained.
The lateral luxation, either inwards or outwards, is
easily detected and easily reduced, the reduction is ef¬
fected by moderate extension, and whilst this is made,
by pressing laterally the projecting parts ot the hume¬
rus and fore-arm. If no great degree of contusion ex¬
ists the arm requires no dressing, but to be supported
in a sling.
Besides these dislocations the fore-arm may be luxat¬
ed forwards, but in that case, the olecranon process
must be fractured, and the case, therefore, is to be
treated as a fracture of the olecranon. The reduction
is readily effected.
In all these accidents to the elbow, inflammation su¬
pervenes, and must be remedied by bleeding and a low
diet. N
2. The head of the radius is in some cases dislo¬
cated from its articulation with the ulna. In general
the luxation takes place backwards. The hand is found
in a state of pronation, and cannot be moved out of it
without great pain. The head of the radius is found
projecting at the external side of the olecranon. There
is a considerable depression felt at the part where the
head of the bone is naturally situated.
To replace the luxated bone, the head of the radius
is to be pushed from behind forwards, and the hand of
ELEMENTS OF SURGERY.
25b
the patient is at the same time to be brought to a state
of supination. The reduction is thus effected, and an
audible noise is produced by the re-entrance of the
head of the radius into the sigmoid cavity of the ulna,
The hand regains the power of rotation; the ligament
in this instance being ruptured, it will be some time be¬
fore the joint recovers its motions perfectly, and gen¬
tle motion is to be frequently made, after the lapse of a
few days from the accident. The limb may be sur¬
rounded at the joint by a few turns of a roller, and this
may be wet with a saturnine lotion.
3. The inferior extremity of the ulna is occasionally
dislocated from its connection with the radius. It may
be pushed either forwards or backwards, most com¬
monly backwards. This dislocation is easily distin¬
guished. The hand is kept continually in a state of
pronation, and this position cannot be changed; a tu¬
mour is felt behind the lower extremity of the radius;
the hand is turned a little inwards, and there is an evi¬
dent depression where the lower end of the ulna ought
to be situated. The reduction is easily effected, by
pulling the arm and turning it a little inwards, whilst
the lower end of the ulna is pushed backwards, and
that of the radius forwards, the hand being at the
same time placed in a state of supination. A roller
wet with a solution of sugar of lead is to be applied
after the reduction, and the hand supported at rest in a
sling.
The dislocation anteriorly is more rare. It is known
by the hand being in a continued state of supination
and it cannot be placed in a state of pronation: a tu¬
mour is felt before the radius, and there is an empty
space where the lower end of the ulna should be. The
ulna crosses the radius obliquely instead of being paral¬
lel with it. The reduction is effected as the preceding
25 6
ELEMENTS OE SURGERY.
luxation, except that the hand must be moved in a con¬
trary direction.
If the parts be much swollen before the surgeon is
called, in this as in all similar cases, he should wait un¬
til the inflammation is somewhat abated before making
any attempt to reduce the bone.
elements of surgery.
CHAPTER XLII1
Dislocatons of the Hand.
" four kinds of luxations may take place in the ar¬
ticulations of the bones of the carpus with the inferior
extremities of those of the fore-arm, viz. luxation for¬
wards, backwards, inwards, and outwards. But the two
first, especially that backwards, are the most frequent,
because the motions of flexion and extension are much
more extensive than those of adduction and abduction,
and because the extent of the articulating surfaces is
greater from within to the outside, than from before
backwards; besides, the styloid apophyses of the radius
and ulna, strengthen the external and internal sides of
the articulation, and render dislocation in the transverse
direction still more difficult.
" The articulation of the hand with the fore-arm is
remarkable in this, that it admits of flexion and exten¬
sion nearly to the same extent; whilst these two mo¬
tions, in all the other articulations, have rarely the
same latitude, that of flexion being always the most
considerable.
" Luxation backwards is facilitated by the direction
of the convex articulating surfaces of the scaphoides,
lunare, and cuneiforme, which, inclined more back¬
wards than anteriorly, must be more disposed to slide
in this direction than in any other. It is caused by a
fall on the back of the hand while much bent; in which
case the first range of bones of the wrist slides back¬
wards into the oblong cavity of the two bones of the
fore-arm, extends and lacerates the posterior ligament,
and forms an eminence behind the ends of the radius
vol. i.—k k
258
ELEMENTS OF SURGERY.
and ulna. This tumour, the depression at the anterior
part of wrist, and the extraordinary'flexion ot the hand
which cannot be extended, are the distinguishing marks
of this luxation. It is reduced by fixing the fore-arm,
and drawing the hand, whilst pressure is made on the
eminence formed by the displaced carpus to force it
back into its cavity. An assistant fixes the arm, and
the gurgeon makes extension and adjusts the bones.
Luxation forwards is occasioned by a fall on the
palm of the hands, the lingers being extended and more
force being applied to the inferior part of the palm than
to the superior, it is rarely complete; the hand re¬
mains painfully extended, and cannot be restored to its
natural direction without some difficulty. The numerous
tendons which pass before the wrist, and the annular
ligament which confines them, being pushed forwards,
render it so difficult to discover the eminence formed
by the bones of the wrist before the ends of those of the
fore-arm, that this affection may be easily mistaken
for a sprain. Consequently, in all doubtful cases, we
should proceed as if the luxation had really taken place,
and bring the hand into its proper direction.
" Luxations backwards, but especially those for¬
wards, are always accompanied with a more or less con¬
siderable laceration of the ligaments, and followed by •
an inflammatory swelling difficult to subdue; hence, the
full use of the wrist is not recovered for a considerable
time. When the bones are reduced, the remainder of the
treatment is the same as in cases of sprain: refrigerants
and repellents are to be first used, and then emollients
and resolvents. The patient must not fatigue the hand
much, even for some time after complete recovery, lest
he excite inflammation, and lay the foundation of a
white swelling.
(l Luxations inwards, and those outwards, are never
259
complete. The laceration of the ligaments, a tumour
at the internal or external side of the joint and distor¬
tion of the hand, are the concomitant symptoms of these
luxations, and mark them out sufficiently. The) are
reduced by making gentle extension, and causing the
two surfaces of the joint to slide on one another in a
direction contrary to what they took in luxating, and
by bringing the hand into its natural situation. The
danger of these luxations depends less on the dislocation
than on the straining or laceration of the sott parts,
which are always followed by more or less tumefaction,
a symptom difficult to subdue, and often the cause of
anchylosis or even of caries/'
LUXATIONS OF THE BONES OF THE CARPUS AND METACARPUS.
• v "
" The motions of the bones of the carpus and their
articulations with one another are so limited, and the
connection is so strong, that a dislocation of them ap¬
pears entirely impossible. However, the head of the os
magnum, which is received in a deep cavity formed for
it by the scaphoides and lunarenaris, may escape from
this cavity, be luxated backwards by too great a flexion
of the bones of the first range on those of the second,
and form a tumour on the superior part of the back of
the hand. Boyer and Desault have both seen cases of
this accident.
" As to the bones of the metacarpus, they are con¬
nected so closel) and strongly, and support one another
so firmly in efforts made against the palm of the hand,
that they are never luxated. The ligaments of their
articulations may. however, be overstretched and torn,
and a painful diastasis produced, which will require the
use of emollients and resolvents, with immobility of the
hand as long as the affection continues.
260 ELEMENTS OF SURGERY.
"Notwithstanding the mobility of the articulation ot
the trapezium with the first bone of the metacarpus, the
latter is luxated but very rarely. Efforts made in the
thumb, which is supported by this bone, would produce
rather a luxation of the first phalanx, than that of the
metacarpal bone. The second and third bones are so
firmly articulated with one another, and with the bones
of the second row of the carpus, that they are not sus¬
ceptible of any luxation whatever. As to the fourth
and fifth, a little more moveable, and supported by the
os unciforme, their articulations are more susceptible
of sprains than true luxations/'
LUXATIONS OF THE FINGERS.
" The first phalanges may be luxated backwards at
their articulations with the bones of the metacarpus. A
luxation of them forwards would be very difficult, if
not altogether impossible, on account of the disposition
of the articulating surfaces of the metacarpal bones,
which are much elongated forwards, and allow a great
extent of motion to the phalanges in this direction, with¬
out losing contact with them; and on account of the
resistance made by the palm of the hand, which would
restrain the flexion carried beyond what the inclination
of the articulating surfaces would admit of. Luxations
inwards can take place only in the first phalanges of
the thumb and little finger: as to that outwards, the
first phalanx of the thumb alone is susceptible of it.
This phalanx is also the most exposed to luxations
backwards. When a violent effort is made on the thumb
from before backwards, its first phalanx slips behind
the head of the first metacarpal bone, and remains ex¬
tended, while the second is bent, its flexor-muscle be¬
ing thrown into action by the irritation. The distor¬
tion of the thumb, the impossibility of bending the first
ELEMENTS OF SURGERY.
phalanx, and the pain, render this luxation sufficiently
evident.
" The more violent the effort necessary to produce
these luxations, the more grievous are their conse¬
quences. In some persons in whom the ligaments are
excessively relaxed, they produce no inconvenience. In
such, the first phalanx of the thumb may be luxated at
will; but then it is as easily reduced as displaced.
" These luxations should be quickly reduced, for, at
the end of eight or ten days, they are irreducible. De-
sault in a case of this kind, proposed making an inci¬
sion behind the superior extremity of the phalanx, and
by means of it to introduce £ spatula, in order to push
the phalanx into its place; but the patient, frightened
at the operation, would not submit to it. Citizen Boyer
has also observed in a hair-dresser, a luxation back¬
wards irreducible from having continued too long.
" The reduction is not as easy as one might imagine.
The number and force of the muscles which are in¬
serted into the first phalaiix of the thumb, and the lit¬
tle hold we can take of this part in order to make ex¬
tension, render the reduction difficult. Luxations of
the first phalanges of the thumb and little finger in¬
wards, that of the thumb outwards, and luxations of the
first phalanges of the other finger backwards, are all
reduced by making extension on the inferior extremity
of the affected finger, round which a fillet is to be pass¬
ed if there be occasion for much force. The wrist is
fixed by an assistant, who makes counter-extension, and
the surgeon replaces the bone. The first and second
phalanges are also susceptible of luxation backwards,
which only differs from the former by being more easily-
reduced. After the reduction is accomplished, a roller
is put round the finger to prevent a return of the luxa¬
tion/' (Boyer.)
262 ELEMENTS OF SURGERY.
To the preceding remarks from Boyer I shall add
a very few respecting the dislocation of the thumb.
Mr. Hey observes, that "a peculiar difficulty attends
the reduction, when the head of the metacarpal bone
which is joined to the first phalanx of the thumb, is
luxated completely and depressed towards the palm of
the hand. A dislocation in the opposite direction, is
easily reduced/' Mr. Hey attempts an explanation of
the difficulty, from the manner in which the lateral li¬
gaments are connected with the extremities of the bones
concerned in this luxation; these ligaments are con¬
nected with the two tubercles, which are situated on
each side of the anterior extremity of the metacarpal
bone; upon measuring the distance of these tubercles
from each other, Mr. Hey found "those two, which
are nearest the palm of the hand, to be three-eighths
of an inch from each other, while those on the poste¬
rior part aie distant five-eighths: supposing, therefore,
the head of the metacarpal bone to be pressed forcibly
between the lateral ligaments towards the palm of the
hand, the extremity of the metacarpal bone passes like
a wedge between the lateral ligaments, and having pass¬
ed through them, it cannot return, as the posterior
broad part of the bone presents itself to the more con¬
tracted aperture between the ligaments. From an ana¬
tomical consideration of this joint, it seems impossible
that the metacarpal bone should pass in this direction
to a complete dislocation without tearing off some part
of the lateral ligaments; yet so much of the ligaments
remains as to prevent the return of the bone to its na¬
tural situation."
Mr. Hey himself, experienced great difficulty, and
was foiled in an attempt to reduce this dislocation. He
witnessed also the want of success in other celebrated
surgeons, and states on the authority of Broomfield that
ELEMENTS OF SURGERY,
263
the thumb was actually torn off at the second joint
without effecting the reduction. Under these circum¬
stances, the plan suggested by Desault of cutting open
the joint, would surely be warrantable, since we know
that incised wounds of these joints when properly treat¬
ed seldom occasion any ill consequences. Mr. Charles
Bell has, however, proposed a plan to which I conceive
there can be no valid objection in these obstinate cases;
the introduction of a couching needle obliquely under
the skin, so as to cut one of the lateral ligaments, this
would in all probability very quickly liberate the con¬
fined bone and permit its easy reduction.
The first case of this accident I ever saw, although
attended with great difficulty, was eventually reduced
by Dr Physick. I have, since the publication of the
first edition of this work, met with two other instances.
The first I reduced with great difficulty, the second (in
a child) very readily.
264
ELEMENTS OF SURGERY.
CHAPTER XLIV.
Dislocations of the Thigh.
From a consideration of the structure of the hip-
joint, in a skeleton, it would appear extremely difficult
to effect a dislocation of the os femoris, and this diffi¬
culty is greatly augmented by the cartilages and liga¬
ments connected with the articulation; notwithstand¬
ing, however, these powerful obstacles, the accident not
unfrequently happens. Mr. Boyer is of opinion, that
it is more rare than has been supposed, and believes
that authors have frequently mistaken fractures of the
neck of the os femoris for dislocations. The expe¬
rience of many practitioners is, however, opposed to
the opinion of Boyer, concerning the comparative fre¬
quency of the two accidents. So far as my own limit¬
ed observation has extended, I have witnessed about
three luxations at the hip, for one fracture of the neck
of the os femoris.* Mr. Hey says he has seen but six
cases in a practice of forty-three ;ears, during thirty-
four of which he attended a large infirmary; this, how¬
ever, is what few surgeons of equal experience can de¬
clare.
The dislocation may take place, upwards and back¬
wards (or upwards and outwards) on the dorsum ilii;
secondly, upwards and forwards on the os pubis; thirdly,
downwards and inwards into the foramen thjroideum;
fourthly, downwards and backwards on the os ischium.
* I have had now (1818,) occasion to see this proportion altered, but still
have witnessed many more luxations than fractures. Mr. Astley Cooper states
the proportion of fractures of the neck of the thigh bone which he has seen
to be at least four, to one of dislocation.
ELEMENTS OF SURGERY.
265
Some variety exists in the situations of the bone in
these four kinds of luxation generally described; I have
seen a luxation directly forwards, differing somewhat
from the second species, but yet not in any very im¬
portant respect. I have also seen a luxation directly
backwards.
The most frequent of these accidents are the first
and third, and of these it is not easy to ascertain the
most common. The luxation outwards and upwards I
have met with much more frequently than any other,
though I have seen all except the fourth species which
is extremely uncommon, and perhaps never occurs di¬
rectly, but is owing to a subsequent change in the po¬
sition of the head of the bone from the action of mus¬
cles drawing it downwards.
A LUXATION UPWARDS AND BACKWARDS is described
very accurately by Boyer.
" When by a fall from a place more or less elevated,
on the soles of the feet, or on the knees, the thigh is
pushed forwards and inwards, the head of the femur,
forced towards the superior and external part of the
acetabulum, breaks the internal and orbicular liga¬
ments, escapes through the laceration in the latter, and
ascends on the external face of the os ilium; but as the
part of the os ilium immediately above and at the ex¬
ternal side of the cavity, is very convex, the head of the
femur soon abandons its first position, and slides back¬
wards and upwards into the external fossa of the os
ilium, following the inclination of the plane towards
this fossa, and obeying the action of the glutaei muscles
which draws it in this direction. The head of the fe¬
mur, in ascending thus on the external face of the os
ilium, pushes upwards the glutseus minimus, which
forms a sort of cap for it; and the glutasus maximus
and medius are relaxed by the approximation of the
vol. i.—L 1
266
ELEMENTS OF SURGERY.
points into which they are inserted. The pyriformis is
nearly in its natural state, the gemini, obturatores, and
quadratus femoris, are a little elongated. The psoas
magnus and iliacus internus are relaxed, as are also the
other muscles inserted into the trochanter minor. If
to this description it be added, that the orbicular liga¬
ment, torn at its superior part, is stretched over the
acetabulum and covers it, an exact idea may be formed
of the change occasioned in the surrounding parts by
this luxation of the femur. The affected thigh is shorter
than the sound one: it is a little bent, and carried in¬
wards. The knee inclines more forwards and inwards
than the opposite one; the leg and thigh are turned in¬
wards, and the foot points in this direction. The tro¬
chanter major is brought nearer the anterior and supe¬
rior spinous process of the os ilium, and is at the same
time elevated and carried a little forwards; the latter
circumstance may be considered as the necessary con¬
sequence of the rotation inwards of the thigh. The
natural length of the limb cannot be restored without
reducing the luxation; the foot cannot be turned out¬
wards, and any attempt to do so causes pain; but the
inclination of the foot inwards may be increased. If
the patient endeavours to walk, he extends the foot to
put the top of it on the ground; and though he is
raised, he is still lame; for the diseased limb remains
always shorter than the other, and the pain occasioned
by the attempt to walk renders progression still more
difficult.
" Luxation of the femur upwards and outwards h^s
nothing in common with the fracture of the neck of
this bone but the shortness of the limb. The easy ro¬
tation of the member outwards and inwards, &c. &c.
preclude all possibility of confounding them, unless the
surgeon be remarkably inattentive.
f
ELEMENTS OF SURGERY. 267
" It is difficult to assign the cause of the foot and re¬
mainder of the limb being turned inwards in this luxa¬
tion. It may be established as a general rule, that lux¬
ated members always take a direction determined by
the elongation of the muscles of the side opposite that
to which the luxated bone is carried: thus in luxation
of the arm downwards and inwards, the deltoides and
infraspinatus muscles, lengthened by the separation of
their points of insertion, move the elbow out from the
body, and give the arm an oblique direction. In this
case, the obturatores, gemini, and quadratus femoris,
being elongated, the point of the foot ought Co be turn¬
ed outwards. This phenomenon depends perhaps on
the external portion of the orbicular ligament wtiich
comes from the anterior and inferior spine of the os
ilium-, this portion, which is very thick, being elongated
in the luxation outwards, draws the great trochanter for¬
wards, and consequently turns inwards the entire limb/'
Luxations of the thigh bone are generally extremely
difficult of reduction, from the powerful action of the
muscles surrounding the joint, and from the peculiar
construction of the articulation itself. To effect the
reduction of the first species of dislocation (upwards
and backwards) the patient is to be placed on his back
upon a table covered with a mattress, or with folded
blankets. A strong band is to be passed between the
pudendum and the luxated thigh in such a manner as
to press upon the ischium, and this band is to be secur¬
ed firmly to a post or staple, or it may be held by a suf¬
ficient number of assistants; in this manner counter-ex¬
tension is made by fixing the pelvis. The extending
force is to be made by securing a folded sheet or strong
band above the knee by means of a roller passed tight
round the limb at this place; this band is to be deliver¬
ed to a sufficient number of strong assistants. The
PS • . /
26& ELEMENTS OF SURGERY,
surgeon directs the extension to be made, and with hijf
hands presses upon the trochanter and endeavours to
direct the head of the bone towards the acetabulum.
In recent cases this simple plan is often completely suc¬
cessful. The head slips into its cavity with a very au¬
dible noise, and the symptoms of dislocation imme¬
diately cease.
If this measure, however, should fail, as it sometimes
does, the head of the bone must be pulled outwards9
(that is, more remote from the centre of the body.)
The object of this motion outwards is to raise the head
of the bone to a level with the high margin of the aceta¬
bulum, over which it must pass in order to regain its na-
, tursiT situation. The means of effecting it are to place
the patient upon his side, and to pass a band under the
thigh; an assistant places his knee upon the crista of
the os ilium and thus prevents the pelvis from moving
in a lateral direction; the band may be tied over his
shoulder by which he will be enabled very conveniently
to draw the thigh outwards; or he may place one foot
(without a shoe) upon the pelvis, and draw with his
hands the lateral band; the extension and counter-ex¬
tension, as previously directed, are to be continued,
and the surgeon is to bend the leg to a right angle with
the thigh, and rotate the limb backwards and forwards,
This plan is generally successful. A variety of mea¬
sures have been devised by which extension in the di¬
rections just described may be made, pullies may be
substituted for assistants; bed-posts may be used for
counter-extension, &c. Numerous plans suggested by
the circumstances of each particular patient have been
found successful.
A low diet should be enjoined for several days after
the reduction of the bone, and the patient should re¬
main at rest for a considerable time. The round liga-
ELEMENTS OF SURGERY. 269
ment probably never completely unites after this acci¬
dent, and consequently the joint remains always weak,,
The luxation downwards and inwards into the
foramen thyroideum, is the next in point of frequency.
I shall quote the description of this accident from Boy-
er. " It is favoured by the great extent of the motion
of abduction of the thigh; by the notch at the inferior
and internal part of the acetabulum; by the weakness
of the orbicular ligament at this side; and lastly, by
the situation of the round ligament, the rupture of
which is not a necessary consequence of it. It is oc¬
casioned by a fall on the feet or knees considerably
separated from each other. The head of the femur
slides from without inwards on the bottom of the aceta¬
bulum, and comes against the inferior and internal por¬
tion of the orbicular ligament, which it lacerates and
passes on to the foramen ovale between the ligament
and the obturator externus.
" In this species of luxation of the femur, the state
of the soft parts surrounding the articulation is as fol¬
lows: the glutsei, gemini, obturatores, quadratus femo-
ris, psoas magnus, and iliacus internus, are elongated
by the separation of their points of insertion. The ro¬
tation of the limb outwards is produced by the elonga¬
tion of these muscles. The adductors, elongated, form
at the interior part of the thigh a tense cord, which is
felt from the pubis to below the middle of the thigh.
"The affected thigh is longer than the sound one;
the head of the femur being placed lower than the ace¬
tabulum, the great trochanter is removed to a greater
distance from the anterior and superior spinous process
of the os ilium, and the thigh is flattened in consequence
of the elongation of the muscles. The adductors, ex¬
tended obliquely from the pubis to the femur, form a
Cord which elevates the skin of the internal part of the
270
ELEMENTS OF SURGERY.
thigh. A hard round tumour is felt at the inner and
superior part of the thigh, formed by the head of the
femur, which elevates the soft parts situated before the
foramen ovale. The leg is slightly bent; the knee and
foot turned outwards cannot be brought back to their
proper direction. If the patient attempts to walk a few
steps, he makes a semicircular motion with the foot, and
places at once the entire sole on the ground; and though
he keep the knee bent, still the limb is too long, and oc¬
casions lameness. The mode of progression of persons
whose thigh is luxated in this direction may be com¬
pared to that of a mower:—the elongated extremity,
like the leg which the mower keeps forwards, describes
a semicircular motion outwards.
" All these symptoms taken together form a combi¬
nation too striking to admit of error in our diagnosis,
or to allow us to confound this luxation with any other,
or even with fracture of the neck of the femur.
" The prognosis is somewhat less favourable in this
than in luxation upwards and outwards. The"muscles,
which might oppose the reduction, being all elongated
by the very circumstance of luxation itself, renders the
reduction easier; besides, the contusion of the soft parts
is less considerable, and the round ligament is stretch¬
ed, but not broken."
The reduction is to be effected in the same manner
as that of the luxation last described.
The luxation upwards and forwards is very
rare; Desault describes a case of it, and I had myself
an opportunity of seeing a case which Dr. Physick has
published. In the latter the luxation was not precisely
similar to Desault's, the head of the bone being not at
all higher than the acetabulum. I shall relate this case
as illustrative of the nature and treatment ef the acci¬
dent.
ELEMENTS OF SURGERY.
271
" In February 1805> a man was brought to the Penn¬
sylvania Hospital, in consequence of a dislocation of
the thigh bone at the hip-joint, which had taken place
the day before in the following manner. As he was
riding on a sled, which was drawn rapidly along, with
his legs extended over its side, the foot of his left leg
became entangled in the gears of a team of horses
standing in the road. A great abduction of the leg and
thigh was thus suddenly made, by which the head of
the bone was forced out of its socket, and lodged on
the os pubis, directly before the acetabulum. In this
'situation it formed a tumour, plainly to be seen and felt
in the groin, under Poupart's ligament. The foot and
knee were turned outward, the thigh was extended
with the leg bent backward. By a very particular ex¬
amination it appeared that the dislocated limb was a
little longer than the other, though the difference in
length was very inconsiderable.
" After an unsuccessful attempt, which it is unneces¬
sary to describe, the head of the bone was replaced by
the following means.
" The patient being laid on his back on a table cover¬
ed with a mattress, a firm strap was placed behind his
thighs, and the ends of it being carried upwards, before
and behind his body, were fastened to a staple opposite
his left shoulder, for the purpose of fixing the pelvis,
and making the counter-extension. This strap was ap¬
plied in such a manner as to act as much as possible
against the injured side of the pelvis, and was carried,
therefore, between the dislocated thigh and scrotum,
and then over the tuberosity of the ischium of the same
side, A strong towel was then fastened with a roller
upon the leg just below the knee, and the leg was bent
to a right angle with the thigh. The ends of this towel
Were tied together, and a pulley was hooked to it for
the purpose of making the extension.
212
ELEMENTS OF SURGERY.
" In order to draw the head of the bone directly out¬
wards, a firm strap was passed over the pelvis below the
crista of the ilium of the injured side, and the ends of
it fastened to a staple opposite the sound side of the
patient's body. Another strap was applied over the
upper part of the dislocated thigh, the ends of which
were fastened to a pulley opposite the injured side of
the patient.
68 After the application of this apparatus, before com¬
mencing the extensions, the man was copiously bled,
with the intention of causing him to faint, an effect,
however, which was not fully produced, though he lost'
a considerable quantity of blood, by which he was
much weakened. In this state of debility the exten¬
sions were repeated, and at the same time the leg be¬
ing bent, was moved inwards and outwards, so as to
rotate the thigh bone as much as possible and thereby
to assist in dislodging its head. To prevent the abduc¬
tion of the thigh by the strap over its upper part, the
knee was pressed inwards by the hand of an assistant
applied on its outside.
" In this manner several attempts were unsuccess¬
fully made, but, added to the bleeding, they exhausted
the patient's strength so much, that his body became
covered with a cold sweat. In this state of weakness
the extensions were directed to be again repeated with
greater force than had been before employed, and by
these the head of the bone was suddenly reduced to its
natural situation. The patient in a few minutes re¬
covered sufficiently to move his thigh in every direc¬
tion, suffered very little pain afterwards, and was dis¬
charged from the hospital, cured, in three weeks."*
In Desault's case the following were the symptoms:
44 the limb was nearly an inch shorter than natural.
* Medical Museum—vol. 1.
ELEMENTS OF SURGERY. %%%
The point of the foot was turned outwards, the thigh
being in a state of painful extension could not be flexed
on the body; adduction and abduction were alike pain
ful; the great trochanter being more approximated than
usual to the anterior superior spinous process of the
ilium, was also too far forwards; finally, the projecting
head of the bone could be felt in the groin." The
mode of reduction which succeeded differed but little
from that employed by Dr. Physick; the chief circum¬
stances in which the plan of Desault differs from that
which we would recommend, are, that Desault applied
extension at the ankle, and counter-extension on the
sound side of the pelvis, and not on the side where the
dislocation existed. Dr. Physick's plan appears calcu¬
lated to act more directly and powerfully on the luxat¬
ed joint If the one, however, should fail, the other
ought unquestionably to be tried.
The luxation downwards and backwards I have
never seen, and shall quote Boyer's history of it.*
" Luxation of the femur, downwards and backwards,
may be either primary or secondary. It is primary,
when in consequence of some effort, the head of the
femur is forced from the acetabulum at its inferior and
posterior part, and is placed at the junction of the os
ilium and ischium; it is secondary, when it succeeds to
the luxation upwards and outwards, the head of the
femur, which was placed at first in the external iliac
fossa, sliding downwards and backwards, its passage in
this direction being favoured by the binding of the
thigh on the pelvis.
"In these two cases, the head of the femur rests
upon that part of the ossa innominata, where the os ilium
* Mr. Astley Cooper states, that he has never seen it, and supposes mis¬
takes to have arisen on the subject, though he does not positively deny it?
possibility. Surgical Assays, 1818,
vol. i. m m
274
ELEMENTS OF SURGERY.
and ischium join. The muscles which cover the pos¬
terior part of the articulation, such as the piriformis,
gemini, obturatores, and quadratus femoris, are raised
up and stretched; the psoas magnus and iliacus inter¬
ims are in a great state of tension, and this explains
the turning of the limb outwards. When this luxation
is primary, the extremity is lengthened; a hard tumour
is felt at the posterior and inferior part of the thigh,
the great trochanter, by descending, is removed further
from the spine of the os ilium, and the knee and sole
of the foot are turned outwards; but if it be secondary,
the thigh is much bent against the pelvis; the knee and
sole of the foot are turned inwards, because the pri¬
mary luxation has' been upwards and outwards. Se¬
condary luxation in this direction is much more fre¬
quent than the primary: in reducing it, the same rules
are to be observed as in other species of luxations."
A primary luxation directly backwards was brought
into the Pennsylvania hospital last winter, and after
various attempts to reduce it by powerful extension, in
the different directions before described, Dr. Physick
though it probable that the head of the bone had slipped
through a slit or longitudinal rent in the capsular liga¬
ment, and that this rent embraced it at the neck, as a
button hole does a button; under this impression, after
the extensions had ceased, he made an abduction of
the thigh, bent to a right angle with the body, pushiug
at the same time the head of the bone forwards to¬
wards the acetabulum; this manoeuvre in a moment
succeeded without any more force than the Dr. was
himself able to exert—a strong confirmation of his
opinion respecting the nature of the obstacle previously
existing. In all difficult cases it will be proper to try
every possible motion ol the limb, before abandoning
the case as hopeless; very often after great force has
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ELEMENTS OF SURGERY.
215
failed, a gentle effort in some new direction is found
successful.
When a luxated thigh bone remains long unreduced
a new joint is formed in the situation where the head
of the bone is lodged, and a considerable degree of mo¬
tion is regained. The acetabulum lessens in size and
is eventually obliterated. When the luxation is up¬
wards and backwards an imperfect joint forms on the
dorsum ilii, and of course the limb is considerably
shortened and the patient is very lame, walking prin¬
cipally on the toes and anterior part of the foot, some¬
times he avails himself of a high heeled shoe. If the
luxation be forward and downward the foramen thy-
roideum forms part of the new articulating cavity and
the limb is rather longer, the patient walks much bet¬
ter than in the preceding case. Dr. Wistar has pre¬
served in his collection very interesting specimens of
new joints formed in consequence of unreduced luxa¬
tions of the os femoris.
Spontaneous dislocations of the os femoris are those
in which the head of the bone has* been protruded by
pus, granulations, or tumefaction, in the acetabulum.
It can occur only in cases of extensive disease of the
hip-joint, and is of little moment compared with the
disease of which it is a symptom—this we shall* de¬
scribe more particularly hereafter
216
ELEMENTS OF SURGERY.
CHAPTER XLV.
Dislocations of the Patella.
The patella is occasionally forced over one of the con¬
dyles of the os femoris, and is thus luxated laterally.
A dislocation upwards or downwards cannot take place
without a rupture of the extensor tendon of the leg,
which reduces the accident more nearly to the nature
of a fractured than of a dislocated patella, and is to be
treated like the former case.
The lateral dislocation is most frequent outwards.
The patella is found to have deserted the anterior part
of the knee, and a depression is felt at the place where
it is usually situated. The internal edge of the patella
presents anteriorly, the external posteriorly; the ante¬
rior flat surface faces outwards, the posterior smooth
articulating surface inwards, being thinly covered; all
these symptoms are very obvious. I have known this
accident occur in dancing: a young lady in attempting
some difficult step suddenly felt a great pain in her
knee, and was unable to move it. Dr. Physick was
sent for,' and discovered a luxation of the patella cha¬
racterized by the preceding symptoms; it was reduced
in a moment by extending the leg, flexing the thigh on
the pelvis, and pushing the luxated bone back to its
natural situation—a plan which generally succeeds
very speedily in effecting a reduction of a dislocated
patella.
In some instances much trouble is experienced in ef¬
fecting the reduction: Sabatier was foiled in attempt¬
ing it, and Boyer who was called in, found great diffi¬
culty, though he eventually succeeded. I have myself
ELEMENTS OF SURGERY.
277
experienced much difficulty in such a case. A young
lady in stepping into bed dislocated the patella late¬
rally, and although I saw her within five minutes after
the occurrence of the accident, it occasioned me no
small embarrassment. After many fruitless efforts I
at length succeeded, but not by any particular exertion
of force or skill, and I cannot describe the motion
which effected it.
Sometimes after the reduction, the bone is not ea¬
sily kept in its situation: in all such cases rest should
be enjoined, and a bandage, or laced knee cap, should
be applied, with a compress on the outside of the knee
to prevent the escape of the bone from its central situa¬
tion.
When the luxation is inwards the symptoms differ
only in the situation of the bone. The reduction is ef¬
fected in a similar manner: a blow on the outside of
the knee generally occasions the accident
278 ELEMENTS OF SURGERY.
CHAPTER XLVI.
" Of internal derangement of the Knee Joint.''
Mr. Hey is the author of some interesting observa¬
tions on an accident which may not improperly be con¬
sidered a species of dislocation. I shall, therefore,
quote them in this place.
" The knee joint is so firmly supported on all sides
by tendinous and ligamentous substances, that the bones
of the thigh and leg are very rarely separated from each
other, so as to form a dislocation, in the common sense
of the term. Great violence must take place and a con¬
siderable laceration must happen, before the tibia can
be completely separated from the os femoris. Yet this
joint is not unfrequently affected with an internal de¬
rangement of its component parts; and that sometimes
in consequence of trifling accidents. The disease is,
indeed, now and then removed as suddenly as it is pro¬
duced, by the natural motions of the joint, without sur¬
gical assistance: but it may remain for weeks or months,
and will then become a serious misfortune, as it causes
a considerable degree of lameness. I am not acquaint¬
ed with any author who has described the disease or
the remedy;* I shall therefore give such a description
as my experience has furnished me with, and such as
will suffice to distinguish a complaint, which, when re¬
cent, admits of an easy method of cure.
" This disorder may happen with or without contu¬
sion. In the latter case it is readily distinguished. In
the former, the symptoms are equivocal, till the effects
* i shall presently show that Bromfield was not ignorant of the case.
ELEMENTS OF SURGERY.
279
of the contusion are removed. When no contusion has
happened, or the effects of it are removed, the joint,
with respect to its. shape, appears to be uninjured. If
there is any difference from its usual appearance, it is,
that the ligament of the patella appears rather more
relaxed than in the sound limb. The leg is readily
bent or extended by the hands, of the surgeon, and with¬
out pain to the patient: at most the degree of uneasi¬
ness caused by this flexion and extension is trifling.
But the patient himself cannot freely bend nor perfectly
extend the limb in walking; but is compelled to walk
with an invariable and small degree of flexion. Though
(he patient is obliged to keep the leg thus stiff in walk¬
ing; yet, in setting down, the affected joint will move
like the other. .
"The complaint which I have described may be
brought on, 1 apprehend, by any such alteration in the
state of the joint, as will prevent the condyles of the os
femoris from moving truly in the hollow formed by the
semilunar cartilages and articular depressions of the ti¬
bia. An unequal tension of the lateral or cross liga¬
ments of the joint, or some slight derangement of the
semilunar cartilages, may probably be sufficient to bring
on the complaint. When* the disorder is the effect of
contusion, it is most likely that the lateral ligament on
one side of the joint may be rendered somewhat more
rigid than usual, and hereby prevent that equable mo¬
tion of the condyles of the os femoris, which is neces¬
sary for walking with firmness."
The mode of cure proposed by Mr. Hey, and which
he found successful in a variety of cases, consisted in
placing his patient upon an elevated seat having nothing
underneath it which could prevent the leg from being
pushed backwards towards the posterior part of the
thigh, and then extending the joint by the assistance of
28U ELEMENTS OF SURGERY.
one hand placed just above the knee while with the
other hand he grasped the leg. During the continu¬
ance of the extension he suddenly moved the leg back¬
wards that it might make as acute an angle with the
thigh as possible. Immediately after this simple ope ¬
ration his patients were in general able to walk without
much inconvenience, and the joint soon regained its na¬
tural condition. If one trial should fail, a repetition of
Mr. Hey's method should be made. I have seen seve¬
ral cases of this accident in which Mr. Hey's plan has
been immediately successful; a dancing master among
others, was twice affected with this singular and sud¬
den lameness, dnd was very promptly cured by a few
extensions and flexions of his limb; he began capering
immediately after as if nothing had happened.
Mr. Bromfield appears to have been acquainted with
the accident. " I have, seen (he remarks,) a temporary
lameness happen from one of the semilunar cartilages
within the joint of the knee, having slipped out of its
situation; the knee immediately became swelled, and
very painful. This case I first discovered by accident;
for the assistant having hold of the leg, and sometimes
lightly extending, at other times gently bending it, while
I was examining the joint bf the knee the cartilage
slipped into its place, and the patient soon became easy.
" I dare say many surgeons have seen a lameness in
the shoulder from almost a similar cause, that is, the
tendon of the biceps muscle, which runs in the exca¬
vated groove at the head of the os brachii, having, by
some turn of the limb, slipped out of the sulcus, and
resting on one of the little exuberances of the upper
part of the channel, till it returned, has occasioned not
only an immobility of the joint, but, most violent pain:
when the case is known, the reduction is very easy;
for, the cubit being bent, the muscle is relaxed, and
ELEMENTS OF SURGERY. 281
while an assistant holding the lower extremity of the os
brachii, moves the head thereof, sometimes inward,
sometimes outward in the acetabulum scapula, the ope¬
rator with his fingers will easily replace it, and the pa¬
tient presently becomes perfectly easy."*
* Chirurgical Observations and Cases.—Vol, 2.
282
ELEMENTS OF SURGERY.
CHAPTER XLVII.
Dislocations of the bones of the Leg.
" The tibia, at its articulation with the condyles ot
the femur, may be luxated in four different directions,
viz. anteriorly, posteriorly, and laterally to either side
of the knee. The luxation backwards is always in¬
complete; it could not be otherwise without a great la¬
ceration of the soft parts. It is as often secondary as
primary, and in such cases it is a concomitant of white
swelling, a disease much more grievous than the dislo¬
cation, and almost always requiring amputation.
u Luxation forwards is still more rare than that back¬
wards; the ligaments of the knee and the greater part
of the tendons surrounding it. being placed nearer its
posterior than anterior part, prevent the too great ex¬
tension of the leg. Luxations inwards and outwards
are the most frequent. They are always incomplete,
on account of the extent of the articulating surfaces,
and the strength of the parts surrounding the articula¬
tion. They take place from the femur being drawn
either inwards or outwards, while the leg is fixed.
u The luxation backwards is distinguished by attend¬
ing to the following circumstances: it is impossible to
extend the leg; the patella, closely applied to the pul¬
ley of the femur, forms an eminence, under which there
is an empty space, and the inferior ligament is extend¬
ed obliquely downwards and backwards;, and a projec¬
tion formed by the extremity of the tibia, is felt in the
ham, &c. Sic.
"Symptoms of an opposite kind accompany the lux¬
ation forwards. Those inwards and outwards are easih
ELEMENTS OF SURGERY.
283
known from the deformity of the joint. In the first,
the external condyle of the femur is lodged in the in¬
ternal cavity of the tibia, and the internal condyle pro¬
jects and forms a tumour at the internal side of the
knee; the contrary takes place in the second. When
they are complete, which is extremely rare, the tibia is
carried entirely to the internal or external side of the
femur. In every case of luxation the laceration of the
ligamentous parts is so great, that the ends of the tibia
and femur may be easily placed in their natural situa¬
tions; there is scarcely occasion for even gentle exten¬
sion and counter-extension. It happens sometimes,
notwithstanding the extent of the articulating surfaces,
that a return of the luxation takes place from the great
laceration of the parts which should confine the bones.
To prevent this, an apparatus similar to that used in
fractures of the thigh, is to be applied. Disagreeable
symptoms, occasioned by the laceration of the soft parts,
are always to be expected; our attention should be par¬
ticularly directed to moderate and subdue them. The
antiphlogistic regimen must be strictly observed, and
the other means of preventing and subduing inflamma¬
tion had recourse to. If the inflammation terminates
in suppuration, the abscesses are to be opened by mak¬
ing a large incision. In general, large openings are to
be made in abscesses seated in the neighbourhood of
joints to allow a free evacuation of the pus, which by
stagnating might become acrid, and attack the carti¬
lages of the joint; but if the abscesses be formed in con¬
sequence of a caries of the ends of the bones, a very
small opening is to be made, in order to prevent as
much as possible the inflammation of the joint. II the
inflammation terminates in gangrene, we must wait un¬
til nature has arrested the progress of the mortification,
and then amputate. The separation of the living from
284 ELEMENTS OF SURGERY.
the dead part, is marked by an inflamed circle. The
progress of the mortification is very often so rapid that
it is impossible to save the patient; and perhaps a com¬
plete luxation of the tibia from the femur may be con¬
sidered as a case requiring immediate amputation.
However, before a general precept of this kind can be
established, it must be founded on observations well
made and judiciously compared.
" The fibula is difficultly displaced from the tibia,
with which it forms two articulations; nevertheless we
may conceive, that in a violent and sudden turn out¬
wards of the foot, if its ligaments are naturally relaxed,
it may slide from below upwards, so as to touch the
external condyle of the femur. Citizen Boyer has seen
a luxation of this kind in consequence of a dislocation
of the foot outwards. By putting the foot in its natural
direction, the fibula descended into its proper place.
Compresses soaked in resolvent liquids were placed
over the part, and a roller was passed round the foot and
leg, to prevent a return of the luxations. The patient
had a tardy recovery, and some stiffness of the foot
remained, though the precaution of moving it when the
state of the parts would admit it, was not neglected."
It
A * .
ELEMENTS OF SURGERY.
285
CHAPTER XLVIIf.
Of Dislocations of the foot.
" These luxations are but seldom met with; the
great violence necessary to produce them and the diffi¬
culty of effecting them, account for their unfrequency
Before they can take place, the astragalus must be
partially or totally forced from the quadrangular cavity
formed for it by the two bones of the leg, and in which
it is received like a mortise. The sides of the articula¬
tion are strengthened by very strong ligaments, which
go from the tibia and fibula to the os calcis and astra¬
galus and by the two malleoli. An external violence,
it is true, may distend or even break these ligaments;
but its force being almost entirely spent in producing
this effect, will not be sufficient to force the astragalus
from the cavity in which it is enclosed.
" The foot may be luxated inwards or outwards,
forwards or backwards, and the luxation in any of
these directions may be complete or incomplete. Luxa¬
tions inwards and outwards are the most frequent; the
former, however, occurs more frequently than the
latter: the internal malleolus not descending so low as
the external, the astragalus has a less space to describe
from without inwards, than in the contrary direction.
It is occasioned by a violent abduction of the foot, and
is easily known from the derangement of this part, the
sole of which is turned outwards, and the back inwards;
from the pain, and inability of moving the foot; and
lastly, by the eminence formed below the internal mal¬
leolus by the astragalus.
" In the luxation outwards, it is equally impossible to
286
ELEMENTS OF SURGERY.
move the foot; the sole is turned inwards and the back
outwards, and the astragalus forms an eminence below
the external malleolus.
" Luxations of the foot are always dangerous; their
consequences may be so dreadful as to occasion death,
and in very many cases they render amputation neces¬
sary. However the prognosis is not always so un¬
favourable, for it is clearly proved, that many patients
have recovered without any thing extraordinary having
occurred during their treatment. This invalidates the
general rule laid down by J. L. Petit to amputate be¬
fore twenty-four hours after the luxation. It is also
now well ascertained that dislocations likely to produce
the most mischievous consequences, have had a happy
termination, and that this was the case, though the soft
parts have been very much injured, the ligaments
nearly quite ruptured, and the astragalus completely
removed from the foot.
" The reduction should be accomplished as soon as
possible in every luxation of the foot; if deferred the
inflammatory symptoms and swelling which supervene,
will render it difficult and painful. To effect this, one
assistant makes counter-extension by fixing the leg,
and another draws the foot, whilst the surgeon pushes
the latter part in a direction contrary to that in which
it was luxated. If the luxation be inwards, the external
edge of the foot must be depressed by elevating the in¬
ternal, when it is found that the ligaments yield to the
extension: the contrary is done in luxations outwards.
The articulation is covered with compresses moistened
with resolvent liquids; and splints which reach below
the sole of the foot, are applied on the inside and out¬
side of the leg.
" Consequences more or less disagreeable are always
to be expected, which may be moderated or even pre-
ELEMENTS OF SURGERY. 287
vented by copious and repeated bleedings. Sometimes,
notwithstanding the enormous derangement and lacera¬
tion of the soft parts, no bad symptom succeeds, and
the patient recovers with an unexpected rapidity; but
in very many cases, violent inflammation supervenes
and quickly terminates in gangrene. In other cases the
inflammation terminates in suppuration, abscesses form
and heal up, and the patient recovers. Sometimes, how¬
ever, there is a caries of the ends of the bones conjoin¬
ed with them.
" The experienced practitioner is to judge, from the
nature and violence of the symptoms, when immediate
amputation is necessary. A great number of observa¬
tions posterior to those of J. L. Petit, prove that, by fol¬
lowing his instructions, we should often amputate a
limb which might be preserved. It is also ascertained
by experience that the astragalus may be extirpated
with advantage, when the laceration is such, that it is
only attached by a few shreds of ligament. The tibia,
in consequence of this extirpation, descends, and rests
upon the superior face of the os calcis, to which it
grows, and the patient recovers its use, with an anchy-
losed joint; but such a termination is preferable to
losing the foot by amputation, or running the risk of
the dangerous symptoms arising from preserving the
astragalus. Ferrand performed this operation on an
invalid soldier, who was in the habit of carrying the
bone in his pocket. Desault performed it three limes
with success. One of his three patients (a female)
died three months after the operation; but she evidently
fell a victim to an hospital fever; which was by no
means connected with the complaint for which she was
admitted into the hospital. On dissecting the foot, the
extremity of the tibia was found already partially attach¬
ed to the os calcis. There is no doubt but that the
288
ELEMENTS OF SURGERY.
operation would have been crowned with complete suc¬
cess, had the person survived the other disease.
" Fracture of the fibula near its inferior extremity,
is a frequent complication of luxation of the foot in¬
wards. This bone is to be carefully examined in all
such cases, and the foot is to be supported, whether
the fibula be fractured or not, by means of the ordi¬
nary apparatus for fractures of the leg.
" Luxations forwards and backwards, less frequent
than those described, are, however, sometimes met
with. The first is occasioned by a fall backwards,
while the foot is fixed to the ground; the second by a
fall on the feet, with the body inclined forwards, and
the leg much bent. The luxation forwards is more
difficultly produced than thai backwards, on account
of the articular pulley of the astragalus which inclines
forwards the posterior side, being permitted to slide
much on the tibia, without abandoning it in the exten¬
sion of the foot. When the extension is carried too
far, luxation forwards is produced." (Boyer.)
I have known this accident occasioned in the fol¬
lowing manner: a lady who wore high heeled shoes,
was descending rapidly a flight of stairs, the heel of one
of her shoes hooked itself upon a step, and her whole
weight was consequently impelled against the anterior
part of the ankle joint, the foot beirrg fixed by the shoe
to the step, the tibia was forced forwards, ruptured the
capsular ligament and was luxated anteriorly.
" In the luxation backwards, the external and poste¬
rior ligaments, and the posterior part of the capsule, are
torn; in that forward, the anterior and external liga¬
ments, the anterior fibres of the internal lateral liga¬
ment, and the anterior part of the capsule are torn.
The symptoms of the first species are, a diminution in
length in that part of the foot between the lower part
ELEMENTS OF SURGERY.
289
of the leg and the anterior extremity of the toes, elon¬
gation of the heel, tension of the tendo achiliis, and re¬
laxation of the extensors of the toes. It is impossi¬
ble either to bend or extend the foot: this symptom
distinguishes luxation from sprain, in which the foot
may be moved, though not without pain, however high
the inflammation may be.
" Contrary symptoms accompany the luxation for¬
wards: the foot is lengthened, the heel is shortened, and
the foot, much extended, cannot be bent, &c.
" The reduction of both is easily effected; after which
it will be necessary to use effectual means to prevent a
relapse. The mode of treatment, to be afterwards ob¬
served, for subduing the unfavourable symptoms that
supervene, is the same as that pointed out for luxations
inwards and outwards. When gangrene takes place
in any luxation of the foot, we must defer amputation
until its ravages are arrested. In cases where the in¬
flammation is moderate, and the destruction of the soft
parts not considerable, the articulation may be preserv¬
ed; and to prevent stiffness of the joint, the foot is to be
moved as soon as circumstances will admit of it.
"The very thick and short ligamentous substance
which unites the astragalus to the os oalcis, binds them
so strongly together, that they follow one another in
their motions, and form as it were but one bone. Hence
they are never completely separated, even in the most
desperate cases of the luxation of the foot; but one or
both of them may be luxated from the scaphoides and
cuboides. The transverse direction of the articulation
formed by these four bones, suggested to Chopart the
ingenious idea of amputating only part of the foot. But
these luxations, less dangerous than the others, can be
occasioned only by a violent effort, in which the ante¬
rior part of the foot is fixed, as happened in the two
vol. i.—-o o
290 ELEMENTS OF SURGERY.
cases related by J. L. Petit: the foot was fastened in
an iron grate, whilst the body was drawn backwards.
The astragalus and os calcis may, under these cir¬
cumstances, be luxated, but particularly the former, the
head of which slides from below upwards, in the ca¬
vity of the posterior face of the scaphoides, and forms
a tumour on the back of the foot. The inflammatory
swelling renders it often difficult to ascertain this luxa¬
tion. It is not easily reduced, even shortly after it has
taken place. Citizen Boyer failed in a case of this
kind, in which the head of the astragalus was luxated
upwards and inwards, by a fall from a horse; but after
some time the person felt no inconvenience from the
affection, he could walk without pain or lameness, and
nothing remained but the deformity occasioned by the
tumour. .
" The other bones of the tarsus and metatarsus are
too strongly tied together to admit of luxation. The
phalanges of the toes cannot be luxated by external
violence, on account of their shortness. However, the
possibility of luxation of the first phalanx of the great
toe from the first bone of the metatarsus may be easily
conceived. It is not necessary to give here the rules
to be followed in such a case. They consist in reduc¬
ing the luxation, and amputating the great toe, when
the state of the soft parts renders it impossible to pre¬
serve it." (Boyer.)
. >
ELEMENTS OF SURGERY.
CHAPTER XLIX.
)■ A ,
Injuries of the Head.
Among the various accidents which call for the sur¬
geon's aid, none are more important than those to
which the head is liable; they, in many cases, prove
very speedily fatal, and always require the greatest at¬
tention.
The scalp is liable to wounds and contusions;—
wounds of the scalp have been already noticed, but it
may be useful to mention on the present occasion, that
in addition to the usual effects of blows in which the
scalp is chiefly concerned, a severe pain sometimes re¬
mains for a great length of time after the accident.
Dr. Physick describes in his lectures, several cases
of this singular affection, in which a great variety of
means were employed without any evident advantage,
and in which, after a lapse of time, the pain subsided.
In some cases, an incision through the scalp at the in¬
jured part proved immediately successful; in others, it
was found entirely inefficient. I know of no remedy
for this terrible complaint, which happily is of rare oc¬
currence, but which, in severity and obstinacy, is sur¬
passed by no local pain. Cold-bathing, sea-bathing,
mercury, copious bleeding, blisters, issues, purging,
emetics, all the narcotics, and numerous other reme¬
dies have been used in some instances without any
effect. The incision down to the bone should be tried
as it has in some cases produced immediate relief.*
* I am very happy too add to this edition, that emetics have been tried
by Dr. Physick in several cases of this singular malady, with complete suc¬
cess, and in two instances I also have found them successful. a dose of
ipecacuanha, or tartar emetic is to be given every day, till three doses are
292
ELEMENTS OF SURGERY.
A blow on the scalp sometimes occasions an ecchy-
mosis, in which the blood forming the tumour remains
fluid, and the surrounding scalp feels unusually hard
and elevated, and conveys to the fingers a sensation re¬
sembling that of depressed bone. Mr. Pott has de¬
scribed this accident particularly, with a view to cau¬
tion young practitioners against opening the tumour
under an expectation of finding depressed bone. The
proper treatment consists in promoting the absorption
of the extravasated blood by cold applications, and if
these are unsuccessful a small puncture may be made
with a sharp lancet, and the fluid pressed out. If sup¬
puration take place, the abscess must be treated in the
usual manner. It is prudent in all injuries of the scalp
to enjoin a low diet and prescribe a purge.
The effects of a blow on the head, owe their chief
importance to the affections of the brain which result.
In describing these, we shall first notice those cases in
which the brain is injured by concussion or contusion;
afterwards, those cases in which it is compressed by ex¬
travasated blood or a fragment of bone; and thirdly,
proceed to describe the effects of inflammation.
taken, afterwards, once in two or three days, according- to the urgency of
th ecast. This practice has also effected the cure of several obstinate
cases of an analogous disease, the tic doloureux.
ELEMENTS OF SURGERY.
293
CHAPTER L.
Of Concussion of the Brain.
A patient who receives a violent blow on the head
is immediately deprived of sense and voluntary motion
—in popular language he is stunned. Respiration is
performed slowly, and the pulsations of the heart and
arteries are diminished in frequency. In a lesser de¬
gree the symptoms are stupidity, drowsiness, imperfect
articulation in speech, diminution in the vigour of all
the animal functions, nausea, and vertigo. The pupil
of the eye is generally dilated, at other tim^s contract¬
ed, and often not at all changed. These effects result
from blows on the head which occasioned fractures ot
the skull; from those in which an extravasation of blood
takes place within the cranium,—and also from blows
which produce no fracture and no considerable extra¬
vasation. It is the latter case which is denominated
concussion, but whethel* the symptoms enumerated do
ever result from accidents which occasion no extrava¬
sation, no rupture of a blood-vessel, no organic lesion
in the contents of the cranium, I very much doubt.
Dr. Physick many years ago dissected the brain of a
person who died on the fifth day after a concussion; it
was found to have suffered a contusion; numerous ex¬
travasations of small quantities of blood, were observ ed
throughout the surface of the cortical substance of the
brain in the vicinity of the part stricken, and it resem¬
bled a bruise, in every respect. Probably the state of
the brain after a concussion is always that of a contu¬
sion,—numerous blood-vessels of a small size are nip-
294 ELEMENTS OF SURGERY.
tured, and pour out small quantities of blood in various
places.
That we ought to consider concussion as a lesser de¬
gree of compression from extra vasated blood, in every
instance, I am not prepared to assert; but that in all
cases of violent concussion this bruised state or ecchy-
mosis of the brain does exist, 1 have no doubt. The
doctrine is by no means novel—Le Dran appears to
have entertained it to a certain degree, and John Bell
also advocates it.
When the brain has suffered concussion merely, the
symptoms which have been mentioned gradually sub¬
side, the pulse rises to its natural state, the drowsiness
wears off, sensation is restored, and the functions of
the body are performed as usual.
The immediate effects of concussion being over, the
only ill effects to be dreaded are those which arise from
inflammation of the brain, and its consequences; and to
guard against these is all that is necessary in the treat¬
ment of the case. Cloths wet with cold water should
be applied to the injured part, and the patient should
be kept at rest with his head somewhat elevated, dur¬
ing the continuance of the stupor; after this has gone
off, bleeding, purging, and a low diet are to be directed,
and should inflammation supervene, these remedies are
to be vigorously employed according to the exigency
of the case. Nothing I conceive can be more impro¬
per than the use of ardent spirits, volatile alkali, and
other stimuli which have been recommended in cases
of concussion of the brain. The final cause of the lan¬
guid circulation which succeeds a blow on the head, is
probably the prevention of extravasation, and yet the
officious surgeon attempts to interrupt it by stimuli,
and thus urges on the action of vessels, wounded and
bruised by the previous injury which consequently pour
ELEMENTS OF SURGERY. 295
out an increased quantity of blood and produce all the
ill effects of compression of the brain.
Mr. Abernethy has described with so much accuracy
the effects of concussion of the brain, that I shall tran¬
scribe his remarks in this place. "The whole train of
symptoms following a concussion of the brain, may, I
think, be properly divided into three stages. The first
is that state of insensibility and derangement of the bo¬
dily powers, which immediately succeeds the accident.
While it lasts the patient scarcely feels any injury that
may be inflicted on him. His breathing is difficult, but
in general, without stertor; his pulse intermitting, and
his extremities cold. But such a state cannot last long;
it goes off gradually, and is succeeded by another, which
I consider as the second stage of concussion. In this
the pulse and respiration become better, and though not
regularly performed, are sufficient to maintain life, and
to diffuse warmth over the extreme parts of the body.
The feeling of the patient is now so far restored, that
he is sensible of his skin being pinched; but he lies
stupid and inattentive to slight external impressions.
As the effects of concussion diminish, he becomes ca¬
pable of replying to questions put to him in a loud tone
of voice, especially when they refer to his chief suffer¬
ing at the time, as pain in the head, &c. otherwise, he
answers incoherently, and as if his attention could not
be excited, or was occupied by something else; he is,
in short, like a man in a heavy sleep. The concussion
of the brain, lastly, produces a state of inflammation of
the organ, and this constitutes the third stage, which is
the most important of the series of effects proceeding
from this cause.
" These several stages vary considerably in their de¬
gree and duration; but more or less of each will be
found to take place in every instance where the brain
296
ELEMENTS OF SURGEKY.
has been violently shaken. Whether they bear any
certain proportion to each other or not, I do not know.
Indeed this will depend upon such a variety, of cir¬
cumstances in the constitution, injury, and after treat¬
ment, that it must be difficult to determine.
" With regard to the treatment of concussion, it
would appear, that in the first stage very little can be
done. From a loose, and, I think, a fallacious analogy
between the insensibility in fainting, and that which
occurs in concussion, the more powerful stimulants,
such as wine, brandy, and volatile alkali, are commonly
had recourse to, as soon as the patient can be made to
swallow. The same reasoning which led to the em¬
ployment of these remedies in the first stage, in order
to recall sensibility, has given a kind of sanction to their
repetition in the second, with a view to continue and
increase it.
" But here the practice becomes more evidently per¬
nicious. The circumstance of the brain having so far
recovered its powers, as to carry on the animal func¬
tions in a degree sufficient to maintain life, is surely a
strong argument that it will continue to do so, without
the aid of such means; which tend to exhaust parts al¬
ready weakened by the violent action they induce.
" It seems probable that these stimulating liquors will
aggravate that inflammation which must ensue sooner or
later. The access of it in the cases which I have related,
is sufficiently evident ; and its cure is to be effected by
the common methods. The great benefit of evacuations
was, in those cases, very evident. Indeed, it appears
to me, that there is no complaint which requires such
means to be more rigorously prosecuted, than an in¬
flammation of the brain or its membranes.
" In addition to the reasoning which I have offered
here, I would observe, that the surgical books abound
ELEMENTS OF SURGERY.
297
with cases in which suitable evacuations have been free¬
ly employed in concussions, with the best effects; while
the advocates for a contrary practice, have rested their
arguments upon vague theory, and communicate no
particulars of their success." For the cases referred
to in the preceding quotation the reader is referred to
Mr. Abernethy's book.
IS
V . - •'$>•
VOL. I.—P p
w
298
ELEMENTS OF SURGERY.
CHAPTER LI.
# ^ -
Of Compression of the Brain.
Compression of the brain may be produced by blood
extravasated within the cranium, or by a portion of the-
skull being beat in below its natural level.
OF COMPRESSION FROM EFFUSED BLOOD.
t
Blood may be extravasated between the skull and
dura mater;—immediately beneath the dura mater;—
beneath the pia mater;—into the ventricles;—or into the
substance of the brain. The symptoms in all these
cases are similar. It has always been an object of in¬
terest among surgeons to designate the symptoms which
attend compression of the brain, and to discriminate
them from those arising from concussion, and although
no subject has been more carefully investigated than
this, yet amidst the multiplicity of observations which
are to be found in surgical writings, no accurately
distinctive symptoms have ever been pointed out, and
this furnishes an argument in favour of the opinion that
in concussion there is extravasation.* The loss of
sense, speech, and voluntary motion, which attends se¬
vere concussion, is alike common after extravasations
of blood, and depression of the skull. Mr. Abernethy
observes on this subject, that " If we judge of the symp¬
toms of compression from what occurs in cases of apo¬
plexy, or from cases of the rupture of the middle artery
of the dura mater, we must be of opinion that pressure
f
* Le Dran long ago observed, that " in concussion small vessels may be
ruptured and thereby occasion extravasations in several places." Gata
ker's Translation—P. 377.
ELEMENTS OF SURGERY.
299
on the brain occasions insensibility partially, or gene¬
rally, and in a degree proportionate to its quantity/'
This remark of Mr. Abernethy's is generally, but
not universally correct, for as Pott observes, ■' sometimes
a very small quantity of extravasated blood w ill produce
the most alarming and most pressing symptoms, and at
other times a large quantity will occasion none at all/'
. " In extreme cases the insensibility is manifested by
every circumstance. The pupil of the eye is dilated and
cannot be made to contract, even by a strong light.
The respiration is slow and stertorous, and the pulse
proportionably slow and labouring. There is no vomit¬
ing which would indicate sensibility of stomach. The
limbs are relaxed as in a person just dead. No strug¬
gles take place, nor signs oj sensation appear during
the operation, but on the pressure being removed sen¬
sation and intelligence are immediately restored. In
concussion the insensible state is of short duration, and
during its continuance the body is generally cold, and
the pulse feeble and intermitting. Afterwards the skin
is hotter than usual; the pulse and respiration more
frequent, the former often intermits, and the latter has
not the stertor of apoplexy, (but the absence of stertor
must not be relied on as a proof that there is no com¬
pression, for Morgagni relates dissections of apoplectic
persons where the effusion was considerable, yet no ster¬
tor had occurred, and I have seen cases where it took
place only in a very slight degree.) The pupil of the
eye is not dilated, but rather contracted. The coun¬
tenance expresses pain and uneasiness, and vomiting
occasionally takes place. The state of the patient is
like that of a heavy and uncomfortable sleep; yet being
roused, signs even of intelligence appear." These re¬
marks of Mr. Abernethy contain the best contrast of
the symptoms resulting from concussion and compres-
300 t ELEMENTS OF SURGERY.
sion which are to be found, but in some cases they are
insufficient to afford an accurate diagnosis.
In many instances, however, the symptoms indicating
extravasation are very clearly marked; of a great num¬
ber of cases which I have met with in "books and in
practice, I shall relate the prominent circumstances of
one, to illustrate this observation.
case.
On the tenth of May 1811, Michael Schoch. aged
about forty years, in ascending the first step of a stair¬
case fell backwards on the floor; he arose, rubbed his
head, and did not suppose himself much hurt. About
twenty minutes after the accident, he felt sick at the
stomach and vomited. In half an hour he became
drowsy and stupid, his stupor gradually increased, and
when I saw him, which was several hours after the ac¬
cident, he was perfectly senseless and could not be
roused. His breathing was stertorous, his pulse about
forty, and communicated to the fingers the same sensa¬
tion, as that of a patient in apoplexy.
Upon shaving the head, not the slightest vestige of
injury could be observed. From these circumstances
it was very obvious that a blood-vessel was ruptured
within the cranium. His brother said that he had point¬
ed to the left side of his head above the ear, after his
fall; and with no other direction than this, as to the part
injured, I resolved to perforate the parietal bone, and
accordingly cut through the scalp and applied the tre¬
phine: immediately on removing the bone a large
quantity of blood escaped at the opening, and upon
passing my finger under the cranium, I was literally
unable to feel the dura mater; clots of blood appeared
to occupy the place of the whole left hemisphere of the
ELEMENTS OF SURGERY.
301
forain, the quantity of blood extravasated was very great;
far exceeding any thing I had conceived possible.
Copius extravasations always happen when one of
the principal vessels of the dura mater is ruptured, but
when this membrane is merely separated from the skull
by the accident, and the only vessels divided are those
which connect the bone and membrane, then the quan¬
tity effused is comparatively small, supposing the middle
artery of the dura mater to be opened in the present in¬
stance.
I determined to make another perforation with the
trephine, and then trust the case to copious bleeding
and purges. I accordingly enlarged the incision of the
scalp, and now discovered a small fissure an inch long
in the parietal bone, (which probably was in itself of
no importance,) without any depression; the greater
part of this crack was included in the second portion of
bone which I removed. In a few hours the stupor sub¬
sided and the pulse rose. The patient was copiously
and repeatedly bled, and for three weaks nourished
exclusively by toast and water; the blood for the first
week came away in large quantities through the open¬
ings in the skull, and af terwards blood and matter came
out together. This patient soon recovered, and has
remained perfectly well for two years, except that he
is afflicted with a periodical head-ach with which for
many years he has been troubled, and which has recur¬
red since the accident. His right side was slightly para¬
lytic for a day or two after the operation, but 110 per¬
manent affection of that nature remained. Mr. Hill re¬
lates a case very similar to this, and Mr. Latta also
records one not unlike it.
In the preceding case, as in many other instances of
extravasation, the patient remained well for a consider¬
able space of time; this was owing to the gradual ac-
302
cumulation of the blood which did not immediately col¬
lect in sufficient quantity to occasion stupor. Patients
often walk to a considerable distance before any symp¬
toms of compression appear. In every case, therefore,
when after the blow, the patient remains a considera¬
ble time free from stupor, we may conclude without
much risk of mistake that extravasation has happened,
or if the patient be stunned by the blow and recover
from this first effect of the violence, and regain his
senses, and after this interval of sense, relapse into a
stupid comatose state: we have also great reason to
apprehend extravasation.
It has already been observed that the situation of
the effused blood varies. In general, however, indeed
in a very large majority of instances, the extravasated
blood is found between the dura mater and the skull,
owing to the intimate connection by means of vessels
between this membrane and the bone. In every case,
therefore, where there is good reason to believe that
extravasated blood exists under the skull, it is the duty
of the surgeon to remove a portion of the bone in order
to allow its escape.
In endeavouring to ascertain the part of the head
where this extravasation will probably be found, all the
circumstances of the accident are to be carefully con¬
sidered. The head being shaved, a bruise or wound may
generally be discovered at the injured part, and if so,
the crown of the trephine should be applied at that part.
If, however, (as sometimes happens) no part of the
head appears to have suffered more than another and
the witnesses of the accident can give no account of
the spot which received the blow, still should the symp¬
toms continue to indicate the operation, it ought to be
performed, and the part where extravasations most
generally happen, should be selected; perforations may
303
in such cases with great propriety be made in the
course of the middle artery of the dura mater, and if the
extravasation be not found here the operation should
be repeated on the opposite side of the head, over the
same vessel. If paralysis of one side of the body exist,
it affords a presumption that the opposite side of the
head has suffered. ♦
In attempting to ascertain the place of extravasation,
Mr. Abernethy recommends to scrape the bone where
the mischief is suspected, if it bleed, there will be no
reason to expect an effusion under it, if no blood es¬
cape from the bone when scraped, it is an evidence of
extravasation underneath. This truly ingenious idea
was suggested to Mr. Abernethy, in reflecting on the
vascular connection subsisting between the dura mater
and skull; a great part of the blood of the skull is de¬
rived from the dura mater, and if the connection be
destroyed, there is a deficiency in the quantity of blood
which the bone receives. Mr. Abernethy has in two
instances, by attending to this rule, ascertained the ex¬
tent to which the dura mater and skull were separated
by extravasation*
On removing a portion of bone the blood if fluid im¬
mediately escapes; in most instances, however, a con¬
siderable portion of it will be found coagulated. The
dura mater being separated from the cranium to an ex¬
tent proportioned to the quantity effused, the coagula
if it can readily be done should be removed, but care
should be taken not to injure the dura mater by intro¬
ducing any instruments for the purpose, it is safer to
trust to the action of the brain, which will effectually
* I have myself been less fortunate, and Dr. Parrish has recently put the
matter fairly to the test in a case of very copious extravasation. In this in¬
stance the parietal bone was detached from all its membranous connex¬
ions to a considerable distance, and yet bled freely when scraped.
304
ELEMENTS OF SURGERY
expel these coagula. In cases where the quantity of
blood found uuder the cranium is very great, two per¬
forations may be made, or perhaps cases may occur
where a greater number will be necessary, but from
what I have seen of such cases, and from similar ones
contained in the memoirs of the French academy, [ am
disposed to believe that an extensive removal of bone
in cases of extravasation is improper, the brain does
not immediately react, and the patient expires in some
instances before the operation is concluded. The case
I have detailed in the present chapter, is a convincing
proof of the power of the brain to evacuate the clotted
blood even when it exists in the largest quantities.
In some instances when a portion of the bone is re¬
moved by the trephine, the dura mater is protruded up
into the orifice forming an elevated tumour evidently
containing blood; in these cases it has been recom¬
mended to puncture the membrane and evacuate the
fluid. Of the propriety of this practice I have great
doubts. Dr. Physick has witnessed the operation in
several cases, all of which terminated fatally, and Mr.
Abernethy states that in those cases which he has seen
" where blood was extravasated between the dura
and pia mater and a division of the former membrane
was made for its discharge, in some instances the se¬
rous part only could be evacuated; for the coagulum
was spread over the hemisphere of the brain, and had
descended as low as possible towards its inferior part;
in others, though a portion of the effused blood was
discharged in a fluid or grumous state, a considerable
quantity which was coagulated remained behind, so that
very little relief was obtained by the operation. It
seems then, that extravasation between the dura ma¬
ter and the cranium is almost the only case of extrava-
ELEMENTS OF SURGERY. 3Q5
aation which admits of being remedied by the use of
the trephine."
Cases have occurred, and some such are recorded,
where punctures through the dura mater have been
made for the evacuation of blood, and a favourable
termination has resulted; these cases are, however, ex-
f ^ # )
tremely rare, and a fatal event in most instances re¬
sults. The recoveries which happen after wounds of
the dura-mater, are by no means analogous; because,
in these the membrane is not detached from its usual
connections, and is uninjured except at the wounded
part; whereas in cases where it is punctured for the
purpose of evacuating either extravasated blood or pus,
it is separated from every attachment to the skull and
pia mater to a very considerable extent; under such
circumstances it generally sloughs, and when this hap¬
pens, the brain beneath inflames and suppurates, and
death is the consequence. I believe the best general
practice in cases of extravasation beneath the dura ma¬
ter, whether immediately under it, or in the ventricles,
or in the substance of the brain, will be to bleed copi¬
ously and as often as the patient's strength can permit.
To administer purges daily, to prohibit all nourishment
except bread and water, and to apply blisters over the
head.
Under this mode of treatment, I have witnessed re¬
coveries where there was every reason to believe that
considerable efFusions of blood existed under the dura
mater, and I have never seen success attend any other
method, though I have full confidence in the testimony
of others who have been more fortunate. Mr. Aberne-
thy, for instance, relates a case in which one of his
pupils evacuated five ounces of blood through a punc¬
ture in the dura mater and cured the patient.—Here
the case was recent, the blood was still flowing from
vol. i.—q q
306
ELEMENTS OF SURGERY.
the wounded vessel, and all the circumstances ol the
case were as favourable as possible, and under such cir¬
cumstances the operation may be, and ought to be per¬
formed: that is to say, thp dura mater should be punc¬
tured whenever fluid, frtisfi blood, pushes it out, so as to
form a tumour in the aperture made by the trephine, pro¬
vided the symptoms are also indicative of pressure on the
brain to a great degree.
OF COMPRESSION OF THE BRAIN FROM DEPRESSED BONE.
Fractures of the skull, as they are produced in a va¬
riety of ways, must differ very materially in their na¬
ture and extent. The numerous divisions of the an¬
cients, founded upon these circumstances are, however,
of little importance. The chief differences now regard¬
ed, are the degree of pressure and irritation produced
upon the brain and its membranes.
Fissures or cracks in the skull unattended by a de¬
pression of one of the fragments are not dangerous, and
very readily heal without unpleasant symptoms; but
pressure from a piece of bone beat down upon the brain
must occasion all the symptoms which are produced by
pressure from an .effused fluid: accordingly we find that
patients thus circumstanced are generally affected with
the same apoplectic symptoms,—a complete or partial
loss of sense, speech, and voluntary motion—stertorous
breathing, followed by vomiting, vertigo, hemorrhage
from the ears, nose, mouth, &c. Now these symptoms
often occur without a fractured skull, as has already
been remarked, ahd on the other hand, many cases of
fractured skull, even where the bone is considerably
depressed, are unaccompanied by them. I once saw
a woman who bid been assaulted by a lunatic, and
struck forcibly with an iron bar: I found her skull frac¬
tured near the junction of the parietal bones, a depres-
ELEMENTS OF SURGERY. 307
sion existed which in one part was full half an inch
below the natural level, and yet none of the usual symp¬
toms of compressed brain occurred, and the fracture
healed up without any dressings except a superficial
pledget. Similar cases are recorded.*
Fractures of the skull, although they occasionally pro¬
duce no unpleasant symptoms, are, notwithstanding,
accompanied with many dangers. In addition to the
evils to be dreaded from pressure upon the brain, the
irritation occasioned by the mechanical action of the
sharp and irregular edges of the bone upon the dura
mater and brain is to be feared. The constant pulsa¬
tion of the vessels of the brain, which produces motion
under the fracture, augment considerably the irritation
in consequence of which the dura mater sometimes ul¬
cerates.
In many cases of fracture of the skull the dura ma¬
ter is pierced and the brain wounded, by the body which
caused the accident^ or by a fragment of the bone be¬
ing forced through these parts, in some instances
portions of the substance of the brain escape through
the fracture at the time of the accident. In sabre
* We lately witnessed £ very singular instance of a depression in the
right parietal bone, unaccompanied with any symptoms whatever denoting
derangement of the functions of the brain. The patient was a female of
low standing, who had been engaged a few nights previously in a drunken
broil, which eventuated in a brick bat being thrown at her head, one corner
of which taking effect produced the injury we have above stated. The
fractured portion was plainly felt to be depressed considerably beyond its
whole thickness, without occasioning either stupor, or paralysis, or at all
affecting her recollection.
This woman was carried to the Philadelphia Alms-house, and there came
under the care of Dr. Horner, attending surgeon of the house, by whose
judicious treatment she soon entirely recovered, without any means being
made use of to elevate the depressed piece. From all the evidence we
have been able to collect on the treatment of these accidents, we believe
Mr. Pott was mistaken in supposing, that all depressed fractures of the skull
necessarily required the application of the trephine,—En.
308 ELEMENTS OF SURGERY.
wounds, slices of brain, together with considerable por¬
tions of skull, are sometimes removed.
To ascertain the existence of a fracture of the skull,
the bone must be laid bare and examined. In general
the part which received the blow is fractured, but some¬
times the skull suffers in a remote situation, in conse¬
quence of what the French surgeons have called a
contrecoup: very good proof exists that fractures have
been thus occasioned by counter-strokes, on the oppo¬
site side of the skull. If a wound of the teguments
accompanies the accident, the fracture is often obvious
on the first examination. If the wound be too small
to afford a view of the skull, or if only a contusion
exist, it is easy with a scalpel to cut down to the bone
and expose it sufficiently. This, however, should
never be done unless symptoms of compressed brain
exist, because the exposure converts the injury to a
compound fracture, and greater inflammation is there¬
fore to be expected, from which possibly the dura ma¬
ter and brain may suffer.
Respecting the treatment of fractured skull, a variety
of opinions exist among surgeons. The practice I
would recommend I shall briefly state. In every in¬
stance where symptoms of compression exist, whether
these arise from fracture or from extravasated fluids, a
perforation ought to be made through the skull by
means of a trephine, at the spot where such pressure
is reasonably judged to exist. The immediate effects
of concussion of the brain, generally subside in a few
hours, and as these may be supposed to exist in all
cases of injured brain, it will (except in particular in¬
stances presently to be noticed) be proper to defer the
operation, until such effects shall have subsided. If
then it be found after waiting twelve hours,* that evi-
* Tbis is a very general direction, and of course many exceptions will be
ELEMENTS OF SURGERY.
309
dent symptoms of compression exist without abatement,
the operation should be no longer delayed, but the
fracture sought for, and if depressed bone be found it
should be elevated, and all loose fragments removed.
If a crack or fissure only be found, still the symptoms
existing, a perforation should be made to discharge the
blood which is probably effused under it.
The particular cases in which the operation should
be promptly performed, are those in which the extent
of injury leaves no doubt as to the existence of frac¬
ture with depression, and where there can be no proba¬
ble expectation that the symptoms will subside when
the immediate effects of concussion are over. A man
is thrown from his horse head foremost upon a stump
or on a stone, and the surgeon on his arrival finds an
extensive fracture, with depression, and all the symp¬
toms of compressed brain—in such a case it is right to
perform the operation immediately.
Should depressed bone be removed, or the opera¬
tion of trephining ever be performed to prevent the ill
consequences of inflammation of the brain? Mr. Pott
under particular circumstances, recommended the prac¬
tice,—Mr. Abernethy however opposes it, and Mr. John
Bell, Desault, and many modern surgeons, deny that it
is ever proper, and assert that the trephine is only to be
applied with a view of relieving present symptoms. I
have never seen reason to differ from this opinion, and
though cases may be imagined where the trephine
would certainly prevent fatal consequences, yet in prac¬
tice, such certainty is seldom evident., It would be im¬
proper in a compendious work like the present to enter
into any discussion on this question: I shall therefore
made to it, as the effects of concussion subside in some cases much sooner
than in others,—whenever a doubt exists postponement is the preferable
plan. Mr. Abernethy and Mr. John Be'll, both sanction this practice.
310
ELEMENTS OF SURGERY.
conclude this part of the subject by recommending to
postpone the operation of trephining in all cases where
doubt exists as to its propriety, because in many cases
it will be found, that when inflammation moderates, the
symptoms of compression will be diminished by the di¬
minution of fulness in the vessels, and if the operation
be indicated afterwards it can still be performed, and
perhaps with as good a prospect of success.
OF INFLAMMATION OF THE BRAIN AND ITS MEMBRANES
FROM EXTERNAL VIOLENCE.
Mr. Abernethy very judiciously remarks, that "in
the generality of cases of injury done to the head, the
symptoms of concussion, compression, and inflamma¬
tion, are so combined as to appear inexplicable. It is
only by an attention to those rare cases, in which the
symptoms of each appear distinctly, that we are likely
to increase our knowledge of their specific effects.''
Inflammation of the brain and its membranes is a con¬
sequence of different species of violence to which it
is subject, and therefore, its symptoms will be more or
less blended with those resulting directly from the ac¬
cident, as stiipor, &c. In describing the inflammatory
symptoms which occur, I shall principally avail myself
of the descriptions given by Mr. Pott and Mr. Aber¬
nethy. The INFLAMMATION OF THE DURA MATER is Well
described by the first of these writers.
" If there be neither fissure nor fracture of the skull,
nor extravasation, nor commotion underneath it, and
the scalp be neither considerably bruised, nor wounded,
the mischief is seldom discovered or attended to for
some few days. The first attack is generally pain in
the part which received the blow. This pain, though
beginning in that point, is soon extended all over the
ELEMENTS OF SURGERY.
311
head, and is attended with a langour, or dejection ofx
strength and spirits, which are soon followed by a
naosea and inclination to vomit, a vertigo, or giddiness,
a quick and hard pulse, and an incapacity of sleeping,
at least quietly. A day or two after this attack, if no
means preventative of inflammation are used, the part
stricken generally swells, and becomes puffy and tender,
but not painful; neither does the tumour rise to any
considerable height, or spread to any great extent: if
this humid part of the scalp be now divided, the peri¬
cranium will be found of a darkish hue, and either
quite detached, or very easily separable from the skull,
between which and it, will be found a small quantity of
a dark-coloured ichor.
" If the disorder has made such progress, that the
pericranium is quite separated and detached from the
skull, the latter will even now be found to be somewhat
altered in colour from a sound healthy bone. Of this
alteration it is not easy to convey an idea by words, but
it is a very visible one, and what some very able writers
have noticed.
" From this time the symptoms generally advance
more hastily and more apparently; the fever increases,
the skin becomes hotter, the pulse quicker and harder,
the sleep more disturbed, the anxiety and restlessness
more fatiguing, and to these are generally added irregu¬
lar rigors, which are not followed by any critical sweat,
and which instead of relieving the patient, add consider¬
ably to his suffering. If the scalp has not been divided
or removed, until the symptoms are thus far advanced,
the alteration of the colour of the bone will be found to
be more remarkable: it will be found to be whiter and
more dry than a healthy one, or, as Fallopius has very
justly observed, it will be found to be more like a dead
bone: the sanies or fluid, between it and the pericra
.312
ELEMENTS OF SURGERY.
ilium, will also, in this state, be found to be more iu
quantity, and the said membrane will have a more livid
diseased aspect.
" In this state of matters, if the dura mater be denud¬
ed, it will be found to be detached from the inside of
the cranium, to have lost its bright silver hue, and to be,
as it were, smeared over with a kind of mucus, or with
matter, but not with blood. Every hour after this pe¬
riod, all the symptoms are exasperated and advance
with hasty strides: the head-ache and thirst become in¬
tense, the strength decreases, the sighs are more fre¬
quent, and at last convulsive motions, attended in some
with delirium, in others with paralysis or comatose stu¬
pidity, finish the tragedy.
" If the scalp has not been divided or removed till
this point of time, and it he done now, a very offensive
discoloured kind of fluid, will be found lying on the
bare cranium, whose appearance will be still more un¬
like to the healthy natural one; if the bone be now per¬
forated, matter will be found between it and the dura
mater, generally in considerable quantity, but different
in different cases and circumstances. Sometimes it
will be in great abundance, and diffused over a very
large part of the membrane; and sometimes the quan¬
tity will be less, and consequently the space which it
occupies smaller. Sometimes it lies only on the exte¬
rior surface of the dura mater; and sometimes it is be¬
tween it and the pia mater, or also even on the surface
of the brain or within the substance of it.
" The primary and original cause of all this, is the
stroke upon the skull; by this the vessels which should
carry on the circulation between the scalp, pericranium,
skull, and meninges, are injured, and no means being
used to prevent the impending mischief, or such as have
been made use of, proving ineffectual, the necessary and
ELEMENTS OF SURGERY. 313
mutual communication between all these parts ceases,
the pericranium is detached from the skull, by means
of a sanies discharged from the ruptured vessels, the
bone being deprived of its due nourishment and circu¬
lation, loses its healthy appearance, the dura mater (its
attaching vessels being destroyed or rendered unfit for
their office) separates from the inside of the cranium,
inflames and suppurates.
" Whoever will attend to the appearances, which the
parts concerned make in every stage of the disease, to
the nature of the symptoms, the time of their access,
their progress, and most frequent event, will find them
all easily and fairly deducible from the one cause, which
has just been assigned, viz, the contusion. As the in¬
flammation and separation of the dura mater, is not an
immediate consequence of the violence, so neither are
the symptoms immediate, seldom until some days have
passed; the fever at first is slight, but increases gradu¬
ally; as the membrane becomes more and more diseas¬
ed, all the febrile symptoms are heightened; the forma¬
tion of matter occasions rigors, frequent and irregular,
until such a quantity is collected, as brings on delirium,
spasm, and death.
" Hitherto ! have considered this disease, as unac¬
companied by any other, not even by any external mark
of injury, except perhaps a trifling bruise on the scalp;
let us now suppose the scalp to be wounded at the time
of the accident, by whatever gave the contusion; or let
us suppose, that the immediate symptoms having been
alarming, a part of the scalp had been removed, in or¬
der to examine the skull; in short, let the injury be
considered as joined with a wounded scalp.
" In this case, the wound will for some little time
have the same appearance, as a mere simple wound of
this part unattended with other mischief, would have;
vol, i.—jt T
314
ELEMENTS OF SURGERY.
it will, like that, at first discharge a thin sanies or gleet,
and then begin to suppurate; it will digest, begin to in-
carn, and look perfectly well; but, after a few days, all
these favourable appearances will vanish; the sore will
lose its florid complexion, and granulated surface; will
become pale, glassy, and flabby; instead of good matter,
it will discharge only a thin discoloured sanies; the lint
with which it is dressed instead of coming off easily (as
in a kindly suppurating sore) will stick to all parts of
it; and the pericranium, instead of adhering firmly to
the bone, will separate from it, all round, to some dis¬
tance from the edges.
" The first appearance of alteration in the wound im¬
mediately succeeds the febrile attack, and as the febrile
symptoms increase, the sore becomes worse and worse,
that is, degenerates more and more from a healthy,
kindly aspect.
" Through the whole time, from the first attack of
the fever, to the last and fatal period, an attentive ob¬
server will remark the gradual alteration of the colour
of the bone, if it be bare. At first it will be found to
be whiter, and more dry, than the natural one; and as
the symptoms increase, and either matter is collected,
or the dura mater becomes sloughy, the bone inclines
more and more to a kind of purulent hue, or whitish
yellow; and it may also be worthwhile to remark, that
if the blow was on or very near to a suture, and the
subject young, the said suture will often separate in
such a manner as to let through it a loose, painful, ill-
natured fungus; at which time also it is no uncommon
thing for the patient's head and face to be attacked
with an erysipelas." (Pott.)
The pia mater is often attacked with inflammation
in consequence of blows on the head. The free com¬
munication by vessels between this membrane and the
ELEMENTS OF SURGERY.
315
brain, necessarily occasions an extension of the inflam¬
matory action to the substance of the cerebrum. The
degree of inflammation of the brain varies, in propor¬
tion to the affection of the pia mater. It differs also in
the extent of the inflamed surface, and in the depth to
which it proceeds; these circumstances occasion a dif¬
ference in the degree to which the functions are inter¬
rupted.
Sometimes the inflammation of the brain is attended
with a copious secretion of fluid, and at others a small
quantity only is poured out, of course a difference in
the subsequent symptoms of compression from this
cause will ensue.
Mr. Abernethy remarks, " If the inflammation be vio¬
lent and general, the patient will be irrational and dis¬
turbed, having his mind strongly affected by wrong
ideas and endeavouring to act inconsequence of them.
If the inflammation be moderate and affect the surface
only, he will be irrational, uneasy, restless, and per¬
haps endeavour to get out of bed, but without the vio¬
lence of mania. Should a moderate inflammation be
blended with the effects of concussion, he will have less
appearance of irrationality, will lie pretty quiet, and
inattentive to slight impressions." Some variety will
occur probably in the symptoms in different patients,
" but in all there will be more or less derangement of the
powers both mental and corporeal depending upon the
degree of inflammation, &c. The symptoms which chief¬
ly characterize the complaint, are those of an increase
of sensibility; the pupils of the eyes are contracted; the
patient often withdraws his arm on being touched, and
his pulse and tongue denote general, as well as local
inflammation. It seems of the utmost importance that
those means which in general cure inflammation should
be prosecuted very vigorously at the commencement of
316
ELEMENTS OF SURGERY.
this complaint, since otherwise, although they will
check, they will not overcome it. Large blood-lettings,
brisk purging, and extensive counter-irritation by blis¬
ters, ought to be employed at the very commencement;
for if omitted, the disease will then become established,
and the powers of the body will soon be too much sunk
to admit of the same active treatment at a later period."
Suppuration takes place when the remedies are un¬
successful in arresting the progress of the inflammation,
and when this happens the symptoms of compressed
brain are repeated, and a deep coma comes on.
The pus in this case is very often situated directly
under the skull, but sometimes under the dura mater,
and at other times an abscess is found in the brain. The
trephine can only be used with success when the matter
can be evacuated, but where the symptoms denote that
pus has been actually secreted, a perforation through the
bone at the injured part should be made, and the usual
means for ascertaining this part, are to be employed.
Mr. Abernethy's test of scraping the bone, will proba¬
bly be found useful in this instance, as well as in cases
where the pressure is caused by extravasated blood.
When the perforation has been made, if the pus exist
under the skull it will flow out, if under the dura mater
this membrane should be punctured with a sharp lan¬
cet, though recoveries under such circumstances are not
to be expected.
Although inflammation of the brain generally occurs
within a few days after the accident which causes it.
yet in some cases months elapse before its commence¬
ment. I assisted Dr. Physick to trepan a gentleman,
whose dura mater we found thickened and in a state of
suppuration, one year after the occurrence of the acci¬
dent which occasioned the formation of the abscess.
ELEMENTS OF SURGERY.
317
THE OPERATION OF TREPANNING OR TREPHINING.
The manner of removing portions of the cranium,
when this becomes necessary, is next to be described.
The various obsolete instruments of the ancients, and
many of the useless contrivances of modern surgeons
maj be dispensed with in proceeding to this operation,
for as Mr. Pott remarks, " Reduction of the number of
instruments to be used in an operation, and an extreme
simplicity and plainness in those which may be requir¬
ed, are a part of the merit of modern surgery." The
instruments wanted for removing portions of the skull,
area scalpel (with the steel projecting through the han¬
dle (Fig. 1.), a trephine with a sliding centre pin (Fig.
2 ), a saw (commonly called Hey's saw) (Fig. 3.), an
elevator (Fig. 4.), a quill tooth-pick, needles, and liga¬
tures. The lenticular, the rhaspatory, the brush, and
the other instruments commonly found in the trepan¬
ning cases, are quite useless.
The hair being previously remov »d, an incision is to
be made through the scalp down U the bone, and if a
longitudinal incision should not sufficiently expose the
surface, it may be crossed by another, and extended in
any necessary direction. The removal of a portion of
scalp as practised by the older surgeons and recom¬
mended by Mr. Pott, should never be performed. In
making the incision down to the bone, great caution is
in some cases necessary, to avoid plunging the knife
through the fracture into the brain. After having de¬
nuded the bone of its pericranium, by means of the
end of the knife handle, the centre-pin of the trephine
is to be protruded, and fixed on the part of the skull
which is to be removed. If in a case of fracture, this
centre-pin must always be placed upon a piece of firm
solid bone, not detached from the skull, and as near as
318
ELEMENTS OF SURGERY.
possible to the fracture, and therefore more than half
the bone included by the crown of the instrument will
generally be uninjured bone. The instrument is to be
now freely turned backwards and forwards, by the
surgeon, who presses it firmly against the skull, until
a groove is formed of sufficient depth to allow the re¬
traction of the centre-pin, which must always be care¬
fully withdrawn as soon as this groove is made, to pre¬
vent a wound of the dura mater. The action of the
circular saw is to be continued and the depth of the
groove very frequently examined. The teeth of the
instrument are to be wiped from time to time with a
towel, and when they have penetrated to the diploe, less
resistance is experienced, and now a great degree of
care is necessary on account of the inequalities in the
thickness of the inner table of the skull, in consequence
of which one part may be completely cut through be¬
fore the other is nearly divided. The tooth-pick is the
most convenient probe for ascertaining the depth of the
groove, but when the trephine reaches the tabula vitrea
and has made some little impression upon it, it is safer
to attempt to break out the circular portion of bone by
means of the elevator, than to proceed completely
through it with the saw. If any part of the bone is
entirely divided and the tooth-pick is found to touch
the dura mater, considerable force should be exerted
to separate the section of bone without further sawing,
as the dangers of a wounded dura mater, are very
great; if this, however, be impracticable, the action of
the trephine should be directed against the undivided
portion of bone exclusively until it is thin enough to be
broken off; this can always be done with the common
trephine without resorting to the old instrument with
a file-like circumference.
If any inequalities of bone remain round the edge
ELEMENTS OF SURGERY.
319
the foramen, they may be broken off by the end of
the elevator; the lenticular which has been constructed
for this purpose, is by no means a convenient instru¬
ment.
When one perforation has been made, in general
the depressed bone may be elevated to the proper level,
and any loosened portions may be entirely removed. If
the operation have been performed in order to evacuate
extravasated blood or pus, one opening is generally suf¬
ficient, but if necessary the operation may be repeat¬
ed. The ancient surgeons were in the habit of apply¬
ing the trepan very frequently, and in some cases very
numerous perforations have been made without fatal
consequences. In one instance, we are assured that
twenty-seven perforations were made through the skull
of a nobleman in consequence of a fracture, but no one
can doubt that the removal of portions of the skull is
a very serious evil, and that it should be performed as
rarely as possible.
The introduction of the straight saw into practice
has diminished the frequency of using the trephine, and
although the instrument is to be found in many old
books of surgery, yet until Mr. Hey of Leeds in a pub¬
lication a few years ago, recommended its use in frac¬
tures of the skull, surgeons were ignorant of its great
advantages. A variety of cases occur in which it may
be substituted for the trephine in removing portions of
skull, without the additional loss of bone which the lat¬
ter instrument occasions.
With respect to the parts of the skull where the tre¬
phine may properly be applied, I believe the surgeon
hesitates at none, to which he can get access, provided
the urgency of the symptoms demand the operation.
The sutures offer no barrier and the large blood-vessels
none—indeed the basis of the skull is the only part
ELEMENTS OF SURGERY.
where the operation cannot be performed, and with
safety, by a prudent operator. Should the longitudinal
sinus or the great arteries of the dura mater be open¬
ed either by a fragment of bone, or by the operator,
the bleeding is easily arrested by a dossil of lint. I
have seen a profuse hemorrhagy from a large opening
in the longitudinal sinus occasioned by a fragment of
bone, immediately stopped by appl)ing lint over the
orifice. The middle artery of the dura mater wound¬
ed in the same manner, is as readily secured. Dr. F.
Dorsey of Maryland, once tied up this vessel with a
needle and ligature, and no ill consequences resulted.
In some cases which I have seen this would easily be
effected, because the artery could be separated to some
distance from the dura mater, with which it is not al¬
ways intimately connected. I have seen it projecting a
quarter of an inch from that membrane in an extensive
fracture of the parietal bone, but if the ligature must
pass through the dura mater in order to secure it, the
operation of tying it up ought never to be performed.
If the bleeding from the vessels of the scalp should not
spontaneously cease, the needle and ligature are most
convenient for securing them.
The only dressing in general required after trephin¬
ing, is a light poultice of bread and milk; great care
should be taken to guard against pressure upon the ex¬
posed brain. The remedies proper to prevent and re¬
lieve inflammation are always to be employed with
great activity. In some cases it may be proper after
removing the bone, to place the scalp and dura mater
in contact and to allow them to unite, but in a majority
of cases this cannot be effected, and when it is attempt¬
ed great care should be taken to prevent collections of
blood and serum or pus from being confined under the
scalp, and thus compressing the brain. Where a small
ELEMENTS OF SURGERY. 321
Wound of the dura mater exists, I believe its adhesion
to the scalp at the wound and around it, would greatly
diminish the danger of suppuration in the brain.
hernia cerebri.
When ulceration takes place in the dura mater a tu¬
mour generally rises through it, which has been called
hernia cerebri; this tumour in all the cases I have
seen, consisted evidently of the substance of the brain,
and under the pia mater in several places clots of blood
of a dark colour were observed.
These tumours sometimes acquire a large size, and
if removed, speedily return. Mr. Abernethy has de¬
scribed some cases which have led him to an opinion
that " the disease frequently described by the term
hernia cerebri, consists of a tumour formed by coagu¬
lated blood; for an organized fungus could hardly be
produced in so short a time as that in which these tu¬
mours are usually formed." I have no doubt that the
tumour consists partly of coagulated blood; but chiefly
of the substance of the brain, which is pressed out at
the aperture through the dura mater, in consequence of
an abscess having formed in the brain, or immediately
under the skull, and in consequence of the increased
volume of the brain which is greatly swelled by inflam¬
mation.
Mr. Abernethy is of opinion that extravasated blood
pushes out the brain, and that what would be apoplexy,
if the cranium were entire, becomes fungus cerebri, in
consequence of the deficiency of bone which allows
the brain and coagulated blood to protrude. This no
doubt occasionally happens, but a considerable quantity
of pus was found in two cases which I have dissected,
and the protrusion appeared to be caused by the pres¬
sure of this pus, Mr. Charles Bell supposes that
vol. i.—s s
3 22
elements of surgerv.
though Mr. Abernethy's account be correct, yet two
other kinds of tumour arise from the brain—the one a
fungous excrescence from the dura mater, the other a
proper organized fungus of the brain.
Haw far these opinions are correct, I shall not de¬
cide, but I shall take a greater liberty with his prac¬
tice than with his opinions, and condemn without hesi¬
tation his proposal to cut off the tumour: this I con¬
ceive could not answer any good purpose, and would
probably be productive of very copious hemorrhagy,
which in the exhausted state of the patient might prove
fatal. The best application is a light soft poultice, or a
pledget spread with simple cerate. Should the tumour
however acquire a very great size, portions may be
separated with the knife, as in some of Mr. Hill's cases.
Some rare instances are recorded of recoveries from
this dangerous affection, but in general it terminates
speedily in death.
Since writing the preceding sentences, I have wit¬
nessed in my own practice, the recovery of a patient
in whom hernia cerebri occurred. On the 5th of Au¬
gust, 1814, I trepanned a girl, aged between eight and
nine years, and removed a large portion of the left pa¬
rietal bone. She had sustained an extensive fracture
and depression of the skull, from falling through a
hatchway or trap door in a sugar refinery. She was
relieved by the operation, from stupor, convulsions,
and the usual symptoms of compressed brain, and con¬
tinued till the twelfth day free from all bad symptoms:
at this period a tumour was perceived protruding
through a small ulceration in the dura mater: it gra¬
dually enlarged and pulsated strongly. This tumour was
unattended by any augmentation of fever or stupor, and
slowly increased till the thirty-first day. My next visit
was a few days after this, and during my absence (the
ELEMENTS OF SURGERY.
323
precise time I could not learn) vomiting occurred,
during which a copious flow of blood took place from
some ruptured vessels in the tumour. From this time
I had the pleasure to find the tumour gradually subsid¬
ing; granulations formed, the tumour cicatrized, and
afterwards diminished, till it returned to the original
level of the skull. The patient has remained quite well
for several years, and bone has now formed so as nearly
to supply the deficiency occasioned by the original in¬
jury.
Dr. Physick, in his lectures, suggests the propriety
of puncturing the tumour with a lancet, in order, if an
abscess can be found, to evacuate the pus.
I have endeavoured to avoid confusing the preceding
condensed history of the affections of the brain from
external violence by a detail of opinions, or a quota¬
tion of wonderful cases. I may now, however, not im¬
properly remark, that although the opinions of our pre¬
decessors on the subject, are many of them fanciful
and unimportant, yet their histories of cases merit the
greatest attention. One general principle I would in¬
culcate from them, which is, that injuries of the head
apparently trifling should never be neglected; and on the
other hand, those which appear most dangerous and
alarming should never be despaired of. In proof of
this I could select instances of death from a blow
which scarcely excited attention, and of recovery where
the brain had been shot through by a musket-ball. I
have myself seen several skulls in an European collec¬
tion, in which the bony, cicatrices demonstrate that
large portions of brain and skull had been cut out, and
subsequent cures had been effected.
I shall now proceed to relate a case, which I think
illustrates more of the usual circumstances ol injury cf
the brain than any other I have met with.
324 ELEMENTS OF SURGERY.
case.
P. Welch, aged about twenty-four years, received
at midnight, June fifteenth, a violent blow from a brick¬
bat. He instantly fell, and was conveyed home stun¬
ned and scarcely breathing; a quack in the neighbour¬
hood was sent for, and by the time of his arrival the
symptoms of the first stage of concussion had subsided,
and the patient's breathing was much improved, his
pulse rose, he remained stupid, but moved occasionally,
and when his head was touched appeared to suffer pain
and put up his hands, as patients generally do in the se¬
cond stage of concussion. He remained in this situa¬
tion till the afternoon of the succeeding day, the doctor
having declared that the skull was not fractured and
that he would soon be well. His friends becoming
uneasy at the continuance of the stupor had him bled,
and sent for surgical aid. I made my visit about
twenty hours after the accident, and found him snoring,
but if spoken to in a loud tone of voice, he attempted
to answer, but could not articulate distinctly. His
pulse was full and slow. Over the left ear was a con¬
tusion and a small wound which when touched occa¬
sioned pain, and the patient moved his head and hands
to escape from the examination of it. 1 made an in¬
cision down to the bone and discovered that a portion
of the squamous plate of the temporal bone was frac¬
tured and depressed. During this operation it was
with extreme difficulty that the patient could be kept
in bed; he screamed, and moved about violently. Under
these circumstances I postponed operating, and drew
from the arm eighteen ounces of blood in addition to
several ounces which had flowed from the branches of
the temporal artery.
The next morning, (June seventeenth) no fovourable
ELEMENTS OF SURGERY.
325
change having taken place, but on the contrary the stu¬
por being increased, I proceeded to remove the depress¬
ed bone, to which the trephine was applied twice, and
all the depressed bone as large as a half dollar taken
away, a crack extended forwards toward the parietal
bone the extent of which appeared considerable, but no
cause for tracing it further existed. A little extrava-
sated blood was found under the skull. After the ope¬
ration the pulse rose, and in the evening - xvi of blood
were drawn from his arm, after which he appeared
more sensible.
On the eighteenth, the day after that on which the
operation had been performed, he was evidently better,
was perfectly rational, though still somewhat drowsy,
had no recollection of the accident—was bled gxii in
the morning and §viii in the evening, drank toast and
water.
For several days no particular alteration was observ¬
ed, the wound appeared sloughy, and a portion of the
temporal muscle which had been cut through sloughed
off. He vomited occasionally and was bled pretty regu¬
larly twice a day till the twenty-third. A tumour co¬
vered by the dura mater gradually protruded at the
wound; this membrane was tense and appeared evi¬
dently to contain a fluid. His stupor was increased.
On the twenty-fifth, ten days after the accident, the
nurse informed me he was greatly better and was more
rational. I immediately suspected that the dura mater
had given way and that pus had been evacuated; upon
inspecting the head this was found to be the case—a
large quantity of pus had been discharged during the
preceding night, and a hole was observed in the dura
mater through which it had issued. I anticipated now
the formation of a hernia cerebri, which accordingly
326
ELEMENTS OF SURGERY.
happened: on the twenty-seventh (twelve days alter the
accident) a tumour began to appear protruding through
the aperture in the dura mater which gradually increas¬
ed to the size of a hen's egg, and was evidently covered
in some parts by the pia mater, and in others had rup¬
tured this membrane and appeared to consist of brain
and clotted blood. During the formation of this tu¬
mour, and the discharge of matter which attended it,
the patient regained, the entire use of his mental faculties,
and appeared to his friends to be getting well; I assured
them that these hopes were delusive, and that he would
not survive many days. He complained of hunger, and
his pulse being languid, he was allowed chicken broth,
and a few oysters.
On the first of July he had a violent chill, a slough
came away from the dura mater, and the tumour of
the brain enlarged very considerably;—On the second,
copious hemorrhage from the tumour;—On the third
at midnight eighteen days after the accident he expired,
much blood having been previously discharged from
the tumour.
On dissection, the crack noticed during the operation
was traced, and I found it to extend completely round
the head, having passed through the temporal bone, a
small part of the parietal, and separating the os frontis
into two portions, by a crack situated immediately above
the frontal sinuses parallel to the superciliary ridges.
Where the fungous tumour had existed clots of blood
only were seen, and on removing these a considerable
hole was found in the brain, occasioned by a loss of
its substance, the brain to some distance round this
vacuity was intermixed with coagula, and completely
disorganized, a layer of pus, thick and viscid, interven¬
ed every where between the dura and pia mater, and at
ELEMENTS OF SURGERY.
327
one place under the fissure in the bone, an extravasa¬
tion of one half an ounce of blood was found.
In this case the effects of concussion were very evi¬
dent, afterwards those of compression, then the usual
effects of inflammation (not so distinctly marked as in
some cases, because compression still existed) followed
by suppuration and by hernia cerebri.
In consequence of gun-shot wounds and other con¬
tusions of the skull, exfoliations occasionally happen,
sometimes of one and sometimes of both tables of the
skull. When the external table is killed, and exfolia¬
tion commences, the inner table inflames, and the ac¬
tion of the absorbents as described formerly, removes
the earthy matter of the bone, granulations shoot out
from the inner table and push off the scale of dead
bone, after which, these granulations probably secrete
and deposit osseous matter and are converted into solid
bone. This process goes on more rapidly in young
than in old subjects. In some cases it is performed
very slowly in consequence of the granulations shooting
up into cavities in the dead bone* and thus connected
they prevent' for some time the separation; where the
delay is evidently owing to this cause some force may¬
be used in removing the dead bone. If both tables of
the skull are killed as in cases of gun-shot wounds, the
symptoms generally call for the trephine, but if this be
not applied, the separation of the dead bone is effected
in the usual manner, and granulations arise from the
dura mater and fill up the space. The deficiency of
bone after portions of the skull have been removed, is
supplied by granulations from the surrounding bone
and from the dura mater. The bone forms first in con¬
tact with the remaining solid bone, and a thin plate af¬
terwards extends gradually over the aperture. Previ¬
ously to the formation of this plate of bone, the brain
328 ELEMENTS OF SURGERY.
is defended only by a soft cicatrix of skin under which
it may be observed pulsating. From this exposed state
it is proper,to defend it, especially when large portions
of skull are deficient, by means of firm plates of tin,
silver, or leather, which may be worn under a wig, or
cap, until the bone is replaced.
ELEMENTS OF SURGERY.
329
CHAPTER LII
Diseases of the Eye and its Appendages.
Having treated of the most usual accidental injuries
to which the body is exposed and of the remedies to
be employed, we pass on to describe certain morbid
affections submitted to the care of the surgeon.
The term disease does not convey a precise and ac¬
curate notion of many of these affections; in a quali¬
fied sense, however, it may be retained and cannot
mislead, when the nature of the various cases is un¬
derstood.
Inflammation attacks the eye and its appendages as
well as the other parts of the body; it may be excited
by accidental irritations, or by diseases of the constitu¬
tion. In some cases it makes its approach without any
obvious remote cause.
Inflammation of the eye-lids occasions some pain,
but less than when the eye-ball is affected—the lids
swell in consequence of an effusion of serum into the
cellular texture—the skin becomes red and a burning
sensation is felt. In some instances, this inflammatory
tumefaction of the eye-lid comes on at night, and as
only one eye-lid is generally affected the patient ascribes
it to the bite of an insect; the cause is not always easily
ascertained.
If fever accompany it, as is sometimes the case, the
patient should lose blood from the arm, if not, a brisk
mercurial cathartic and low diet will generally remove
the affection very promptly. A lotion of brandy, or
camphorated spirit is often found useful. Should it
resist these remedies, repeated blood-letting, the ap-
vol. i.—t t
330
ELEMENTS OF SURGERY
plication of a dozen leeches, and the usual antiphlo¬
gistic measures are to be employed.
A discharge of pus from the edges of the eye-lids,
called psorophthalmy, often calls for the aid of the
surgeon. The patient waking in the morning finds his
eye-lids closed by a secretion of pus which has dried
and keeps them in contact. The glands of Meibomius
are generally considered as the seat of this affection.
Dr. Physick has been led to believe from his own obser¬
vations, that the inflammation is seated at the roots of
the eye-lashes. The affection of the head called tinea
capitis is probably of the same nature, ulceration exist¬
ing in both cases at the roots of the hair. One proof
of the correctness of this opinion is, that the hair being
pulled out the inflammation often gets well, and another,
that the tar ointment and spermaceti oil, remedies very
successful in tinea capitis, are advantageous in the
present case.
The edges of the eye-lids are sometimes ulcerated
in this complaint. The most successful application is
the citrin ointment, applied to the part;* a solution of
lunar caustic has also been used with great benefit.
Common mercurial ointment is sometimes successful.
Lamp oil, and tar ointment I have several times used
with advantage. When the inflammation is very great,
leeches should be applied, and purges administered.
A chronic inflammation of the eye-lids called lippi-
tudo sometimes proves extremely obstinate; the pa-
tient's eye appears surrounded with a red circle, and the
lids are agglutinated in the morning. The treatment re¬
commended in the last case is sometimes successful in
this; but in many cases it is extremely obstinate and
requires great attention to diet and regimen. I have
* The citrin ointment should be melted and applied with the end of the
fore-finger, or a small pencil brush, every night on going to bed.—Ed.
ELEMENTS OF SURGERY. 331
known instances where it has lasted through life, and
has appeared in several members of the same family.
The eye-lids are subject to an inflammatory tumour
called hordeolum or stye. It resembles at first a small
pimple situated on the edge of the eye-lid, which aug¬
ments, becomes painful and suppurates. It is in fact a
small boil, or phlegmonous tumour, and in general gets
well without any surgical aid, occasionally an induration
remains after the inflammatory tumour has subsided.
If this become troublesome it may be destroyed by lunar
caustic. ,
The eye-lids are subject to two very opposite affec¬
tions which become sources of great trouble and incon¬
venience, the one an eversion of the lid, called Ectro-
pium, the other an inversion called Entropium, or
Trichiasis.
ectropium.
The eversion of the eye-lid most frequently occurs in
the lower lid, which is turned outwards towards the
cheek and does not come into contact with the eye. In¬
flammation results from the exposure of the eye, and
from the unnatural situation of the puncta lachrymalia,
the tears cannot pass through them and of course over¬
flow the cheeks, and a very unpleasant tumour of a red,
fungous appearance forms in consequence of the dis¬
tention of the vessels of the conjunctiva. The com¬
plaint is occasioned sometimes by the contraction of
granulations in the healing of burns, wounds, or ulcers
on the cheek, but oftener from a relaxation and elon¬
gation of the eye-lid. The only remedy hitherto relied
on, is the removal of the everted lining membrane of
the eye-lid, which becomes indurated and enlarged;
when this is done by a scalpel or scissors, the lid should
be supported in its natural situation by a compress care-
332
ELEMENTS OF SURGERY.
fully applied, and the wound in healing generally con¬
tracts sufficiently to counteract the disease.
A more ingenious operation, however, is described
by Sir William AdamS in a work published in 1812, at
London, for the cure of this affection: it consists in cut¬
ting out a portion of the lower eye-lid resembling the
letter V—the piece thus removed is one-third of an
inch wide at its upper part, the sides of the wound are
approximated by a stitch, and the diseased conjunctiva
cut off—this effects invariably a complete and speedy
cure. > !
ENTROPIUM.
In the entropium or trichiasis, the eye-lid is in¬
verted upon the eye, in consequence of which, the cilia
irritate excessively the surface of the eye, and keep up
a constant and violent inflammation. According to
Scarpa and other write^, two species of this disease
are met with; in one the cilia are turned inwards with¬
out the tarsus having changed its natural position and
direction, in the other thb tarsus is inverted, and conse¬
quently all the eye-lashes are in contact with the globe
of the eye. The second form is most common, and to
this only the term Entropium is properly applied.
The causes of Trichiasis are by no means well un¬
derstood—ulceration and consequent cicatrices are sup¬
posed to have produced it in most cases, but of this
there is no proof. It seldom occurs in the under eye¬
lid.
The consequence of the inversion of the eye-lids is a
constant irritation and inflammation of the eye, from
which the cornea becomes opaque; but the patients
from time to time relieve themselves by pulling out the
cilia, and then the inflammation abates; it is, however,
soon repeated when the eye-lashes begin to grow, and
333
blindness sooner or later results; nor is this a termina¬
tion of the patient's sufferings, for the inflammation
goes on, and the pain continues. A callosity and com¬
plete change in the structure of the eye is the only
event which affords a complete relief to the unhappy
sufferer.
A great variety of means have been proposed and
adopted for the cure of this disease, which it is unne¬
cessary here to detail.
In reflecting on the nature of the complaint, several
years ago, I was induced to think that the eye-lid could
very readily be cut half off, without much inconvenience,
because the orbicularis muscle is capable of contract¬
ing in such a degree as to throw the folds of skin into
numerous wrinkles, thereby demonstrating that much
of it could be removed, and the eye still be closed. A
case of trichiasis came under my care in the Philadel¬
phia alms-house, in July 1810, in which several opera¬
tions had been performed, but without effecting a cure:
about one-third part of the cilia were inverted. In this
case I made an incision through the tarsus, and cut out
completely all that portion of the eye-lid, from which
the cilia proceeded. My patient in a few days was per¬
fectly cured, was extremely pleased with the operation,
and very little disfigured; indeed, compared with her
inflamed eye, her appearance was improved. Encou¬
raged by the success of this case, I have twice since
performed the operation of removing totally the lower
half of the tarsus cartilage, together with the skin co¬
vering it and the inverted cilia; the success has been
complete in both cases—the wound healed up very-
read ily, the inflammation quickly subsided, and the opa¬
city of the cornea was soon removed.
By one of those coincidences which are often occur¬
ring, the late Mr. Saunders, of London, contrived and
334 ELEMENTS OF SURGERY.
performed the same operation, and with equal success
A small volume on the diseases of the eyes, which for
the first time I saw during the present winter, though it
was published in 1811, contains an account of this ope¬
ration. Mr. Saunders remarks, " the certainty of its
relieving the patient, is what I more value than the cre¬
dit, if there be any, of having suggested it;" and in this
sentiment I heartily join him. I shall therefore pro¬
ceed to describe the manner of operating proposed by
Mr. Saunders, and afterwards relate my own method.
Mr. Saunders directs the operation to be performed
as follows: "a piece of thin horn or a plate of silver
having a curvature corresponding with that of the eye¬
lid, is to be introduced, and its concavity turned to¬
wards the globe within the eye-lid which is to be stretch¬
ed upon it. An incision is to be made through the in¬
teguments, and orbicularis palpebrarum, immediately
behind the roots of the cilia to the tarsus, and should
extend from the punctum lachrymale to the external
angle. The exterior surface of the tarsus is then to
be dissected until the orbital margin is exposed, when
the conjunctiva is to be cut through directly by the side
of the tarsus which must now be disengaged at each
extremity; the only caution necessary being to leave
the punctum lachrymale uninjured."
The manner in which I have performed the opera¬
tion is extremely simple. A hook is passed through
the edge of the eye-lid in order to gain a secure hold
of it, and with a pair of sharp scissors the necessary
portion of the eye-lid is removed by two or three cuts.
" Nothing can be more simple than this piece of dis¬
section." A remark applied by Mr. Saunders to his
operation, but which is much more applicable to mine.
The punctum lachrymale must be carefully avoided.
The wound generally heals in a few days; no dress
ELEMENTS OF SURGERY.
335
ings are necessary, but a soft compress may be lightly
bound over the eye. Mr. Saunders says a fungus arose
from the cicatrix in all his cases, which required caustic
or the knife; all the cases I have seen, healed immedi¬
ately without any inconvenience, and the deformity is
not so great as would be imagined.* The appearance
of the eye after the cure, is represented in Fig. 2. of
the Plate next succeediug.f
When the eye-lids are contracted by cicatrices so as
no longer to cover the eye, systematic writers have call¬
ed the affection lagophthalmy, or hare-eye. I have
seen it in consequence of burns, and there is no remedy
but careful dissection of the surrounding parts, by
which the skin may be loosened in sufficient quantity
to defend and cover the eye; after the dissection care
must be taken to prevent, by adhesive plaster or even
a suture if requisite, the subsequent retraction of the
skin.
* The operation is I believe new, though Haller in his Bibliotheca Chi
rurgica states, that Rhazes recommended cutting and burning the eye-lid,
in similar cases; the nature of his operation I cannot ascertain, as the only
copy of Rhazes which I have been able to see, contains nothing on the sub¬
ject. It is a black letter edition, very ancient in barbarous Latin, belonging
to the Loganian library in this city.
f Since my first edition an enlarged experience has convinced me of
the propriety of this operation. ^
336
1 '
CHAPTER LIII.
Of Ophthalmia.
Inflammation of the eye, or in medical language
ophthalmia, is a frequent, and very distressing com¬
plaint. Its symptoms are very well known; they gene¬
rally commence with a severe pain in the eye, redness
of the eye-ball, and a copious secretion of tears—the
patient is unable to bear the light, and keeps his eyes
closed—sometimes a violent burning is perceived in
the eye; head-ache and in general fever attend—the in¬
flammation is either seated in the adnata, or in the globe
of the eye, in which latter case there is less external
evidence of inflammation, but the same general symp¬
toms. In some cases an effusion of blood takes place
into the cellular texture under the adnata, and occa¬
sions a great tumefaction.
Coagulating lymph is sometimes poured out by the
inflamed vessels, and opacity of the cornea is the con¬
sequence. In some cases a pimple or inflamed speck
appears in some part of the adnata, generally in the
vicinity of the cornea. Small red vessels are often
seen ramifying over the cornea.
It is unnecessary to enumerate the various causes of
ophthalmia; they are numerous mechanical and chemi¬
cal irritants, and certain diseases, as small-pox, syphilis,
scrofula, catarrh, &c.
When the disease occurs in the adnata only, the
pain is tolerable, compared with the sufferings of those
patients in whom the internal parts of the eye are af¬
fected with severe inflammation; in these the pain is
ELEMENTS OF SURGERY.
337
excruciating, and if it be not soon relieved, blindness
is generally the result, and death sometimes takes place.
The treatment of ophthalmia, whether confined to
the adnata, or seated more internally, consists in the ac¬
tive employment of the usual remedies for inflamma¬
tion. Of course the remote causes, if they continue
to act, should be removed; all extraneous matters which
may irritate the eye should be wiped off; this may
generally be done by passing a small piece of rag wet
with clean water upon the end of a probe, round the
eye between the eye and lid, or by injecting a stream
of milk and water under the eye-lids by means of a
syringe. In many cases, however, the foreign substance
sticks in the cornea or sclerotica, and cannot be thus
easily removed. It is very common for blacksmiths, in
filing iron, to detach small portions of the metal with
great force, so that when they strike the eye, they pene¬
trate to some depth. In these cases the point of a
lancet, or a cataract knife, must be used to detach the
foreign body.
The remote causes being removed, blood-letting is
to be peformed, as extensively as the nature of the
case may require. After this remedy has been carried
as far as may be necessary, topical bleeding by leeches,
and cupping in the neighbouriug parts is to be next
used. The European surgeons do not employ blood¬
letting so extensively in ophthalmia, as is necessary in
the treatment of the complaint in this country. I have
known, in one case, seventy bleedings required for the
cure of an obstinate acute ophthalmia; the quantity of
blood lost at each operation was generally six or eight
ounces. In the Pennsylvania hospital, 1 have generally
directed the patients afflicted with acute ophthalmia to
be bled every second day, and on the intermediate day
to be purged; to live upon a very abstemious diet, and
VOL. I. U LI
338 ELEMENTS OF SURGERY.
to remain constantly in a dark room. These remedies
are, in almost every recent case, very speedily success¬
ful, and active measures ought surely to be preferred
to tampering with serious diseases.
In some cases, after bleeding, and cupping, and leeches
have been tried, if the inflammation continue, scarifica¬
tions become necessary; the vessels of the adnata may
be conveniently divided by the edge of a sharp scalpel,
or the shoulder of a lancet. A few drops of blood eva¬
cuated in this way, from the inflamed part, will often
prove extremely serviceable.
Purges are to be frequently administered, the saline
cathartics are generally employed, and antimonial pre¬
parations in combination with nitre are also useful.
Blisters to the back of the neck, or behind the ear,
or to the forehead, are in many cases extremely bene¬
ficial; but Dr. Physick has introduced a mode of apply¬
ing blisters, in cases of ophthalmia, which is more
quickly useful than any other; the plaster is to be spread
with the epispastic ointment covered with gauze, and
applied directly over the eye, the lids being closed; in
this manner the whole surface of the upper and lower
eye-lid, and a portion of the cheek, arc blistered, a co¬
pious discharge of serum takes place, and great relief
is in general immediately experienced. I have for
several years availed myself of this practice, and have
been much pleased with its efficacy. I was formerly
in the habit of cutting off the cilia, and applying a strip
of adhesive plaster to prevent the flies from coming in
contact with the eye, but of this, if the blistering plas¬
ter be carefully prepared, there is no risk, and I have
often omitted the precaution; indeed, the copious se¬
cretion of tears would wash out any extraneous matter
which might be insinuated between the eye-lids.
When, notwithstanding a vigorous perseverance in -
ELEMENTS OF SURGERY.
339
the use of the preceding remedies, the inflammation
continues unabated, and great pain is felt in the ball of
the eye, mercury should be administered in such a
manner as to excite a speedy salivation, the ointment
should be rubbed upon the thighs, and calomel admi¬
nistered in doses of two or three grains in the twenty-
four hours.
No collyrium but of the mildest kind should be em¬
ployed during the acute stage of ophthalmia. Milk
and water answers very well. The pith of sassafras,
infused in water, forms a mild mucilage, which in these
cases is.a very pleasant application to the patient; the
youngr twigs of the sassafras split open, afford consider¬
able quantities of pith; a tea spoonful will render eight
ounces of water sufficiently viscid. A soft light poul¬
tice of bread and milk sometimes relieves the pain of
ophthalmia, but in general compresses of soft linen, wet
with cold water or milk and water often changed, give
more ease; the poultice keeps the part too hot, and its
weight is an inconvenience.
After the more active symptoms of inflammation
have abated, the employment of gently irritating or as¬
tringent collyria, becomes useful; the formula I have
found most beneficial is the following:
R. Sacchar: saturn: (Acetatis plumbi) gr. v.
Vitriol: alb: (Sulphatis zinci) gr. iij.
Laud: liquid: 5- ij-
Aq: fluvial* iv.
M. f. collyr.
The addition of 3ij of vinegar sometimes improves
the medicine. Dr. Physick employed tar water several
years ago in a most obstinate case of ophthalmia* which
340
ELEMENTS OF SURGERY.
bad resisted all the usual remedies, it proved completely
and speedily successful.
In the employment of an eye-water, a rag wet with
the fluid should be placed over the eye-lids, and occa¬
sionally they should be opened so as to admit it into
contact with the ball of the eye. The tar water should
in the first instance be diluted, and afterwards applied
of the usual strength. Diluted laudanum, and the vin¬
ous tincture of opium, are in some cases very useful
as collyria. A great variety of collyria have been con¬
trived ; I have already named those which appear to me
most useful.
In general by these measures the inflammation is* re¬
lieved; but it sometimes terminates in suppuration, and
pus is poured out under the cornea, forming the disease
called hypopion. In these cases it is proper to make
a puncture with a cataract knife through the cornea for
the evacuation of the pus; for if this be suffered to re¬
main until ulceration takes place, vision will inevitably
be destroyed. It generally happens, however, that brisk
purging, and a continuance of the antiphlogistic mea¬
sures, produce an absorption of the effused pus, and
render it unnecessary to puncture the cornea.
Confinement to a dark room, and a very abstemious
vegetable diet, should be enjoined during the whole
course of the disease. Setons and issues in chronic
cases are sometimes useful; they may be made on the
back of the neck. When the inflammation abates,
light should gradually be admitted to the eye, and a very
cautious return made to the usual habits of diet and
exercise.*
* The greatest difficulty winch the surgeon experiences m the treatment
of ophthalmia, is to discriminate accurately between the first and second
stages of this affection, or as they have been termed the acute and chronic
states. The active depletory measures which require to be so promptly
applied in the first stage, are decidedly injurious in the second,—it there-
x-
ELEMENTS OF SURGERY.
341
Within a few years much attention has been excited
in England by an epidemic ophthalmia, evidently con¬
tagious, accompanied by a puriform discharge from the
adnata. To this complaint the British surgeons have
affixed the name of Egyptian ophthalmy, from its re¬
semblance to the disease which occurred among the
troops in Egypt, in the year 1801.
This malady commences with a sensation of irrita¬
tion, as if from a mote; the white of the eye becomes
suddenly red, and the lower eye-lid very vascular. In
this stage it readily yields to active antiphlogistic re¬
medies. If these be not employed, the disease advances;
and in the second stage the upper lids inflame, and se¬
crete a 6? scalding fluid," which excoriates the cheeks,
and suppuration soon follows. The remedies for in¬
flammation are still proper, and sometimes successful;
but if they are not, the third stage comes on, the cornea
inflames, becomes opaque, and ulcerates.
Numerous treatises on this subject have appeared in
the medical writings of Great Britain. An excellent
history of it may be seen in Mr. MacGregor's paper,
fore becomes highly important to decide, if possible, when one state has
subsided and the other commenced. Accoi'ding to Beer, a German writer
who has lately written extensively on diseases of the eyes, the accession of
the second stage is marked, " by a sudden increase of redness in the inflam¬
ed texture ; with a brown and afterwards a blue tinge ; actual extravasations
of blood in the chambers of the aqueous humours; ec'chymosis of the con¬
junctiva ; a considerable increase of swelling; decline and irregularity of
the pain ; decrease of the inflammatory heat and throbbing; a sensation of
cold and heaviness in the organ; more or less cedematous swelling of the
surrounding parts ; and a return of the secretions and excretions which dur¬
ing the first stage were completely stopped, but more copiously and of a
different quality from what they were in a state of health."
In this second stage every thing which has a tendency to produce fur¬
ther weakness of the eyes must be avoided. They should be cautiously
exposed to their accustomed stimuli. To this stage also the different stimu¬
lating local applications, such as tar water, vinous infusion of opium, diluted
laudanum, astringent collyria, &c. are applicable.
The constitution is also to be supported by a moderately stimulating
diet.—Ed.
342 ELEMENTS OF SURGERY.
describing the disease as it occurred in the military
asylum at Chelsea, in the 3d vol. Medico-Chirurgical
Transactions. Sir William Adams has been very suc¬
cessful in the treatment of the Egyptian ophthalmia.
His practice has been approved by the most respecta¬
ble surgeons of London, and consists in copious depic¬
tion in the early stage; and in the latter, cutting oil
with a knife the granulations which arise from the ad¬
nata, and irritate the cornea. For a minute account of
this and other diseases of the eye, the reader is refer¬
red to his excellent treatises written in 1812 and 1817.
In cases which I presume to call Egyptian ophthal¬
mia, I have cut olf the granulations of the adnata with
' obvious advantage.
ELEMENTS OF SURGERY.
343
CHAPTER LIV.
Unguis or Pterygium.
Unguis or Pterygium, is an affection of the eye,
not unfrequently met with; it consists in an enlargement
of the vessels of the adnata proceeding from the inner
canthus of the eye, and at length forming a dense opaque
red membrane of a triangular figure pointing and pro¬
gressing towards the cornea, over which at length, it
gradually spreads and of course impedes vision, in pro¬
portion to its extent. In some rare cases it proceeds
from the external canthus of the eye. Scarpa observes
that the unguis in some rare instances proceeds from
other parts of the globe of the eye, but always maintains
a triangular shape,—the apex of which is presented
towards the cornea; occasionally two or three pterygia
form upon the same eye; when these unite upon the
cornea, a complete obstruction to vision takes place.
Scarpa considers the vessels of the eye in chronic
ophthalmia to be in a varicose state, and in the present
case in addition to the varicose state of the vessels which
are extended over a certain part of the cornea, there is
a preternatural thickening of the thin lamina of the con¬
junctiva which covers it, upon which these small vari¬
cose veins are situated.
Hence it seems that the pterygium appears at first,
to be a new membrane formed upon the cornea, while
it is nothing more than the line lamina of the conjunc¬
tiva, forming its natural external covering, which in
consequence of chronic ophthalmia has degenerated
from a transparent into a thick and ppaque tunic inter¬
woven with varicose vessels.
344
elements of surgery.
Scarpa supposes the unguis to be nothing fnore than
an increase of the same affection which forms nebulje,
or spots on the cornea. These nebulae consist of di¬
lated knotty vessels upon the cornea, which ought in
their forming state to be treated by astringent collyria,
and stimulating applications, as the citrin ointment, &c.
in order to prevent their extending over the lucid cor¬
nea and thus impeding vision. A peculiarity of unguis
or pterygium is, that it appears very loosely connected
with the sclerotica; if taken hold of by a hook or for¬
ceps it moves easily, and seems connected only by loose
cellular texture. Scarpa remarks that cancer has
sometimes resulted from this complaint.
The remedy consists in seizing the thickened mem¬
brane with a hook or pair of forceps and dissecting it
carefully off with a pair of curved scissors, (Fig. 3.)
Where it adheres to the cornea the union is more inti¬
mate, and here a sharp knife is the most proper instru¬
ment for the dissection. It is most convenient to com¬
mence the incision near the canthus and proceed
towards the cornea.
Scarpa remarks, that in some cases after the removal
of the pterygium, the cicatrix prevents the freedom of
motion outwards, to avoid which inconvenience in the
treatment of pterygia which have a very extensive base
upon the white of the eye, he has found it convenient
to divide them from the apex, only as far as the cornea
and sclerotica unite, and then to separate them at their
base by a semicircular incision including about a line
in breadth of the substance of the conjunctiva, in a di¬
rection concentric to the margin of the cornea. I3y
operating in this manner, he has found that the after-
treatment is much shorter, than when it is executed af¬
ter the common mathod, that the cicatrix does not form
a ridge or frasnum, and that the conjunctiva being
ELEMENTS OF SURGERY. 345
stretched circularly and equably upon the white of the
eye by the cicatrix, loses that relaxation and varicose
state of its vessels which formed the base of the ptery¬
gium. This nicety, however, is not necessary where
the pterygium is small, and does not extend much upon
the white of the eye.
After the operation no particular dressings are re¬
quisite, a wet compress should be loosely bound upon
the eye, and the patient for a few days confined to a
low diet.
A species of disease very analogous to this is called
Encanthis; it is a tumour of the same texture as the
unguis and formed in the same manner, growing from
the caruncula lachrymalis and semilunar fold of the ad¬
nata. It is to be extirpated by sharp scissors.*
* It sometimes happens, particularly in cases of thin pterygia, that the
disease does not pass beyond the edge of the cornea ; but remains station¬
ary at that part during the lifetime of the patient. When the disease is
observed to assume this stationary character, it may safely be left to itself,
as little or no inconvenience will result from it.—En.
vol. i.—x x
346
ELEMENTS OF SURGERY.
CHAPTER LV.
Opacity of the Cornea and Artificial Pupil
Inflammation of the eye sometimes terminates in
opacity of the cornea. Several distinct appellations
have been given to the various forms of opacity in the
cornea, as nebula, albugo, leucoma. &,c.; for an account
of these I refer to Scarpa.
In some cases the texture of the whole cornea ap¬
pears to be changed, in others opaque spots are visible;
sometimes the opacity depends on increased vascula¬
rity and subsides when the inflammation is over, in
others it remains permanent.
Some practitioners are in the habit of blowing into
the eye powdered sugar, molasses, white vitriol, or
pulverized glass, with a view to grind off this film, as
they call it: the practice is extremely pernicious, and
ought never to be used; the remedies for inflammation
already recited are the only ones in which confidence
should be placed. When a portion of the cornea re¬
mains lucid, an artificial pupil, if necessary, may be
made opposite to this lucid spot in the cornea, and thus
vision will be restored; the operation should not be per¬
formed unless the patient has lost the sight of both eyes.
The same operation may also become necessary, in
cases where the pupil has become obliterated, from an
adhesion of the iris at its margin, in consequence of
inflammation. In both these cases Dr. Physick has
for many years been in the habit of making a section
of the cornea, as for the extraction of cataract, and
afterwards of removing a portion of the iris, by means
of a pair of forceps terminating in narrow extremities
ELEMENTS OF SURGERY.
347
upon one of which is fixed a sharp circular punch
(Fig. 12.); the iris, in cases where the pupil is oblite¬
rated, must be punctured by the point of the knife in
making the section of the cornea, and then the forceps
can readily seize it. A variety of methods have been
contrived for effecting this purpose.
Baron WenzeFs I think is preferable to all before
described. The one I have just noticed is an improve¬
ment of Baron Wenzefs.
Mr. Charles Bell remarks that he had thought it pos=
sible to restore sight by making an artificial pupil, in
cases of opaque cornea; what he considered possible,
I have seen accomplished in a variety of cases. In¬
deed the advantages of the operation would be limited
to a very narrow boundary if it were only adapted
to cases in which the pupil is obliterated, because this
is a very rare case in comparison with opacities of the
cornea.
A portion of iris ought in most instances to be re¬
moved, because a simple puncture or incision through
it is apt to contract, and of course it becomes necessary
to repeat the operation.
Professor Scarpa has lately contrived a mode of
forming artificial pupil which consists, not in making
an aperture through the iris, but in separating the iris
from the ciliary ligament. The patient being seated,
and held as in the operation for cataract, a couching
needle is to be introduced through the sclerotic coat,
about two lines distant from the cornea; the needle
enters on the side next to the external canthus, and
its point is made to advance as far as the upper and
internal part of the margin of the iris, that is, on the
side next the nose. The instrument is then made to
pierce the upper part of the internal margin of the iris
close to tire ciliary ligament, until its point is just
348
ELEMENTS OF SURGERY.
perceptible in the anterior chamber of the aqueous
humour. As soon as the point of the needle can be
seen in the anterior chamber of the aqueous humour,
it should be pressed upon the iris from above down¬
wards, and from the internal towards the external an¬
gle; by this means a separation will be made of the
iris at its margin, from the ciliary ligament, and a black
spot will be observed. The light can in this manner
be transmitted to the retina.
I have mentioned the operation, because sometimes
the only lucid part of the cornea is its margin, and in
such cases, Scarpa's operation would probably answer
extremely well, but under common circumstances Dr.
Physick's is vastly preferable, because the pupil can be
made wherever it is requisite, and with as little pain
and difficulty as possible.*
Mr. Saunders has recommended the use of Bella¬
donna to prevent the obliteration of the pupil, when
the iris is inflamed: it produces a great dilatation of
the pupil. Stramonium has been employed in this
country with the view of dilating the pupil in certain
cases, and would probably be equally effectual in this;
indeed most of the narcotic plants possess the same pro¬
perty.
r • . ; . '
ULCERS OF THE CORNEA.
These sometimes form in consequence of inflam¬
mation, and sometimes an accidental injury ends in
ulceration. The application of lunar caustic is the
proper remedy. It is to be scraped to a point; se¬
cured in a quill, and then applied to the ulcer, and
* It may not be improper in this place to ascribe the invention of the arti¬
ficial pupil to Cheselden, his publication on the subject is contained in the
Phil. Trans, for 1735. His mode of operating has lately been revived and
modified by Sir Wm. Adams. See his works.
ELEMENTS OF SURGERY. 349
suddenly removed; the slough suppurates in a day or
two, and the operation is to be repeated; the pain and
intolerance of light gradually diminish, and the ulcer
generally fills up and cicatrizes. For more minute in¬
formation on ulcers of the cornea, I refer to Ward-
rop's morbid Anatomy of the Human Eye.
i ... j
' *• v
350 ELEMENTS OF SURGERY.
CHAPTER LV1
Fistula Lachrymalin. .
The tears secreted by the lachrymal gland after lu¬
bricating the eye, are taken up by the puncta lachry-
malia, and conveyed to the lachrymal sac, whence they
pass through the ductus ad nasum into the nose. This
ductus ad nasum, however, is liable, like all other ca¬
nals in the body, to stricture. Whenever, in conse¬
quence of a stricture in this duct, the course of the
tears into the nose is interrupted, they accumulate in
the sac which becomes tumid, and upon being pressed
they regurgitate and flow partly over the cheek, and
partly through the nasal duct The tumour is situated
on one side of the root of the nose below the inner
canthus of the eye. The tears are constantly over¬
flowing the eye, because the sac being full the puncta
can receive no more. To the disease in this state the
term fistula is improperly applied. The patient expe¬
riences but little inconvenience from it, except a con¬
stant watery eye; no pain and inflammation exist.
Eventually, however, the stricture becomes complete,
the sac inflames and suppurates, and now a fistulous
sore is formed which discharges tears mixed with mu^
cus and pus. It is generally accompanied with in¬
flammation of the eye, and often with caries of the os
unguis. The puncta, in this stage, are often obstruct¬
ed, and no tears find their way into the sac, but all which
are secreted pass over the eye-lids.
In the first stage of the disease which has been call-
ad epiphora, and by Scarpa the puriform discharge
of the eye-lids, while the lachrymal sac is entire the
ELEMENTS OF SURGERY.
351
only remedy necessary is to inject by means of a fine
syringe, called from its inventor Anel's, a stream of
warm water through the puncta lacrymalia which will
wash away any thickened mucus or similar obstruc¬
tion. The sac should be kept empty by frequent pres¬
sure. Scarpa recommends in addition to this washing
out of the "via lachrymalia" the use of an astringent
ointment, to be applied between the eye-lids and upon
the ball of the eye. He prefers the celebrated oph¬
thalmic ointment of Janin. It is composed of the fol¬
lowing ingredients; hogs-lard half an ounce, prepared
tutty and armenian bole of each two drams, white pre¬
cipitate (calx hydrargyri alba) a dram. Scarpa dilutes
the ointment at its first application by adding hogs-
lard. By the use of these remedies the disease has in
many cases been prevented from ulcerating and has
been completely cured.
Mr. Pott, who condemns the use of Mr. AneFs probes
which were intended to pass through the lachrymal
puncta into the nose, recommends the employment of
the syringe; he found it, however, sometimes unsuccess¬
ful. Mr. Ware's testimony is in favour of the syringe
of Anel; he injects warm water through the lower
punctum and places a finger upon the upper one to
prevent its escape. He repeats the operation four or
five days in succession. If he is unsuccessful in forc¬
ing any of the fluid into the nose, he makes use of topi¬
cal blood-letting, from the angular vein, or by a leech
applied near the lachrymal sac. He also varies the in¬
jection, and tries the effect of a weak vitriolic or ano¬
dyne lotion. Mr. Ware has in some cases passed a
fine gold probe through the punctum, when unable to
force the fluid into the nose, and by gently insinuating
this, he has overcome the obstruction, and immediately
ELEMENTS OF SURGERY.
afterwards the injection has readily found its way through
the ductus ad nasum.
Mr. Ware remarks that " when an epiphora is occa¬
sioned by an acrimonious discharge from the sebaceous
glands on the edges of the eye-lids, it must be evident,
that injections into the sac will be very insufficient to
accomplish a cure, because the sac is not the seat of
the disorder. The remedies that are employed must be
directed, on the contrary, to the ciliary glands them¬
selves, in order to correct the morbid secretion that is
made by them; and for this purpose, I do not know
any application that is so likely to prove effectual as
the unguentum hydrargyri nitrati, of the new London
Dispensatory, which should be used here in the same
manner in which it is applied in common cases of the
psorophthalmy. It will be proper to cleanse the eye-lids
every morning, from the gum that collects on their edges
during the night, with some soft unctuous application;
and I usually advise to apply to them, two or three
times in the course of a day, a lotion composed of three
grains of white vitriol, in two ounces of rose or elder-
flower water." Mr. Ware recommends whenever
collyria are applied, to substitute for linen compresses,
eye-glasses, or to apply the fluid by camel's hair pencils.
In the second stage of the disease, where the fistulous
sore exists, or where the inflamed state of the parts pre¬
cludes the hope of any other termination, a different
mode of treatment becomes requisite.
When the abscess of the sac has actually formed, it
is best to open it with a lancet, because a puncture of
this kind leaves a smaller scar than the sore formed by
the absorbents. A probe should now be passed if pos¬
sible into the ductus ad nasum; if it enter readily a
bougie should be introduced of a conical form, so as to
dilate the canal at the part where the obstruction exists,
ELEMENTS OF SURGERY,
353
and this bougie should be suffered to remain, and a
superficial mild dressing applied to the sore. In some
cases this simple plan succeeds effectually. If, however,
a bougie cannot readily be passed, a silver style or short
probe is to be substituted; the size and form of this in¬
strument is represented in Fig. 17. The circular button
on its extremity may be covered with black sealing wax,
or court plaster; when this instrument is introduced,
the patient must wear it for several months, care being
taken to cleanse it twice or thrice a week, and to inject
whenever it is removed, a stream of tepid water through
the canal. It might be supposed that the tears during
this time would flow entirely over the cheek; but this
is not the case; they pass by the sides of the probe and
moisten the nostril. Very little inconvenience is sus¬
tained by the patient in wearing the style constructed by
Mr. Ware, and it occasions no more deformity than a
small black patch. In six weeks sometimes the obstruc¬
tion will be permanently removed, but as it occasionally
recurs even when the style has been continued a greater
length of time, I have been accustomed to direct its use
for six months. Some of Mr. Ware's patients have
worn it for years, all the tears passing by its side into
the nose. A great advantage is derived by gradually
increasing the thickness of the style. Dr. Physick em¬
ploys three or four in succession, the last being double
the thickness of the first.
Mr. Ware directs, if the disease has not yet occasion¬
ed an aperture in the lachrymal sac, or if this aperture
be not situated in a right line with the longitudinal
direction of the nasal duct, a puncture to be made into
the sac at a small distance from the juncture of the pal-
pebras, and nearly in a line drawn horizontally from
this juncture towards the nose, with a very narrow
spear-pointed lancet. The orifice thus formed soon
vol. i.—y y
354
ELEMENTS OF SURGERY.
becomes fistulous round the style, and no irritation is
experienced in the subsequent introductions of this in¬
strument.
When the ductus ad nasum is completely obliterated,
instead of any attempt to form a new passage in the
old situation, it is the practice to perlorate the os
unguis. Mr. Pott used a trocliar for this purpose, but
an inconvenience occasionally follows the use of the
trochar; the aperture closes up by the fragments of
bone inflaming and reuniting; to obviate this, Mr. Hun¬
ter constructed an instrument like a shoemaker's punch,
by which a circular piece of bone may be cut out com¬
pletely, and then the aperture cannot again be closed.
It is true that a dossil of lint, or a probe of lead, or a
bougie, kept in the passage will prevent its reuniting:
but if Mr. Hunter's plan be adopted there will be no
need of this trouble. Mr. Ware recommends a nail-
headed style to be worn in this case, as well as in those
instances where the natural canal is to be dilated, but
for this practice I think there can be no necessity.
The operation of removing a portion of the os unguis
is very readily performed. The only necessary caution,
says Mr. Pott, " is to apply whatever instrument is used
so that it may pierce through that part of the bone
which lies immediately behind the sacculuslachrymalis,
and not to ptjsh too far up into the nose, for fear of
injuring the os spongiosum behind, while it breaks its
way." Mr. Hunter recommends a piece of thin smooth
horn to be passed up the nostril, to receive the circular
punch, which is to be passed into the lachrymal sac and
forced through the os unguis, till it comes in contact
with the horn. When the perforation is completed, air
passes out of the nose through the wound, and blood will
flow through the wound into the nostril. The external
opening may now be dressed with adhesive plaster and
ELEMENTS OF SURGERY.
3 55
suffered to.heal immediately. If carious bone exist it
will be separated by the absorbents, and should fungus
arise from the wound it is to be destroyed by caustic.
Mr. Ware's plan of introducing the style through the
ductus ad nasum, and of continuing its use for a great
length of time supersedes the use of this latter opera¬
tion in all but a few rare instances in which there is
complete obliteration of the nasal duct. He is entitled
to the greatest credit for his improvements in the treat¬
ment of this disease.
356
ELEMENTS OF SURGERY
CHAPTER LVII.
Of Cataract.
By this term is designated an opacity of the chrystal
line lens or its capsule, or of both. The pupil of the
eye, which is naturally perfectly black, becomes grey 01
white, except in some rare cases where it has a dark
colour; the colour, however, is always distinguishable
from the deep black of the pupil in a sound eye. In
its commencement it occasions a weakness or dimness
of sight, which increases until vision is totally de¬
stroyed. In general, cataract occurs in advanced life,
seldom commencing before the age of forty; in some
cases, however, it begins much sooner, and is in some
instances congenital; in congenital cataract the capsule
(according to Wenzel and Saunders) is generally
opaque and the lens fluid and milky.
The causes of cataract are not very easily ascertain¬
ed. Baron Wenzel found it most frequent among
persons exposed to the light of strong fires, as black¬
smiths, glass-blowers, &c. It now and then happens
from external violence.
The disease generally commences without pain; the
first symptom is commonly an appearance of motes,
specks, cobwebs, or insects floating before the eye; the
patient attempts to remove them, but without effect.
The pupil at this time does not generally evince any
morbid appearance, but as the disease advances, a set¬
tled mist or cloud obscures every object—vision is
greatly impaired, and a turbid whitish appearance of
the pupil begins to be observed. In some cases these
symptoms proceed very slowly, and in others the entire
ELEMENTS OF SURGERY.
357
obfuscation of the lens takes place in a few weeks.
When the disease is fully formed, the patient is gene¬
rally able to discern the situation of a strong light; can
distinguish day from night; or perhaps count the win¬
dows in a room, but is unable to discern most objects,
and in some cases even this faint degree of vision does
not exist.
In the incipient stage of the disease it is proper to
employ certain remedies which are occasionally useful
in preventing its formation. Bleeding, purging, and a
low diet, are to be recommended; mercury has been
supposed useful; setons, issues, and blisters, are also to
be employed. In some cases, more especially where
the disease has resulted from external injuries, these
remedies have been found successful, and the opacity
has been removed by absorption; but in general no
such favourable termination is to be expected; and
Wenzel declares, that " internal remedies, either of the
mercurial or of any other kind, are inadequate to the
cure of this disorder, and equally so whether opacity
be in the chrystalline or in the capsule, whether inci¬
pient or advanced." This is not quite correct ; I have
seen one patient in whom the lens or its capsule was
universally opaque, and the pupil perfectly white; and
this opacity subsided in the course of four or five
months; the chief remedies employed were bleeding,
purges, and mercury; how far they were serviceable,
I am not able to determine, for Pott and Hey both re¬
mark, that cataract from external violence sometimes
subsides spontaneously—the case alluded to was con¬
sequent to a wound of the eye.
Mr. Ware believes in the occasional absorption of
the opaque chrystalline, and recommends to expedite
it, by the application of a drop or two of aether to the
ball of the eye once or twice a day, together with fric-
358 ELEMENTS OF SURGERY.
tion over the eye-lid with a finger smeared with mer¬
curial ointment. Little confidence is to be placed in
such remedies, and it is now very generally conceded that
the only method of restoring sight to persons afflicted
with cataract, is to remove the opaque chrystalline from
the axis of vision; this may be done either by extract¬
ing it, or depressing it to the bottom of the eye. Both
of these operations are performed by surgeons of the
present day, and each has powerful advocates among
the most respectable members of the medical profes¬
sion. Other operations have recently been invented
for the cure of cataract, which shall be described pre¬
sently.
Before comparing the merits of the two operations,
it will be proper to inquire what cases of cataract pro¬
mise to terminate successfully. Scarpa observes, " it
is easy to determine whether an operation can be per¬
formed with a prospect of success or not. A favoura¬
ble issue may be expected whenever the cataract is
simple, or without any other disease of the eye-ball; in
a subject not quite unhealthy or decrepid, and in whom
the opacity of the chrystalline humour has been gra¬
dually formed without having originated from any ex¬
ternal violence, or habitual ophthalmia, especially the
internal; where there has not been frequent pain in
the head, eye-ball, and supercilium; where the pupil,
notwithstanding the cataract, has preserved its free and
quick motion, as well as its circular figure in different
degrees of light; and lastly, where, notwithstanding the
opacity of the chrystalline lens, the patient retains the
power, not only of distinguishing light from darkness,
but also of perceiving vivid colours, and the principal
outlines of bodies which are presented to him, and
where the pupil has that degree of dilatation which it
is usually found to have in a moderate light."
ELEMENTS OF SURGERY. 359
When the pupil does not contract and dilate in va¬
rious degrees of light, there is reason to apprehend
gutta serena (paralysis of the optic nerve and retina) but
in some cases of gutta serena, even in both eyes, this
contractility of the iris exists, and on the other hand,
cases have occurred where no motion could be observ¬
ed in the pupil, in which, nevertheless, the operation of
extraction has proved the retina to possess its power of
vision as usual; the probable cause of the immobility
of the pupil in these cases, is adhesion between the
posterior surface of the iris and the anterior portion of
the capsule of the chrystalline lens. These are to be
considered however very rare exceptions to a general
rule. ' /
In distinguishing gutta serena from cataract, the co¬
lour of the pupil is to be considered; it is black in the
former disease, and turbid and lighter coloured in cata¬
ract; but Wenzel has met with black cataracts, in which
scarcely any change could be detected in the colour of
the pupil.
Both Wenzel and his commentator, Mr. Ware, be¬
lieve it possible to distinguish the blackness of a cata¬
ract from the natural blackness of the pupil. De Haen
and Van Swieten have been mistaken, yet they were
not professing oculists. Mr. Ware decides boldlj^that
" it is a rule as certain as almost any in surgery, that
when an eye in a state of blindness, is accompanied
with a clear black pupil which is incapable of varying
its size according to the degree of light to which the
eye is exposed; this blindness is produced by a defect
of sensibility in the immediate organ of vision, and re-
moveable only by the application of proper stimuli to
rouse it again to its natural action/'
To ascertain with precision the nature and consist¬
ence of a cataract by examination, is perhaps impossi-
360
ELEMENTS OF SURGERY.
ble. Scarpa says, " all that has been hitherto written
and taught upon this subject, has net that degree of
certainty which can serve as a guide in practice, and
the most experienced oculist of the present day is not
able to determine with precision what the nature and
consistence of the cataract is, upon which he proposes
to operate, nor whether the capsule be yet transparent
or not, although the lens be evidently opaque. For it
is an indisputable fact, that the capsule sometimes pre¬
serves its transparency when the lens does not. The
want of accurate notions, however, upon this subject
does not materially influence the success of the opera¬
tion, as the surgeon ought in every case to be prepared
to employ such means as the particular species of cata¬
ract which presents itself to him, may require during
the performance of the operation, whether hard or soft,
accompanied by opacity of the capsule which invests it,
or not. The firm chrystalline cataract undoubtedly
admits of being more easily removed by the needle
from the axis of vision than any other; and does not
rise again to its former place, if the surgeon in remov¬
ing it from the pupil, use the precaution of burying it
in the vitreous humour. The soft, the milky, or the
membranous cataract, however, when met with in the
operation, may be also removed from the pupil, effused
or Ulcerated with the same needle, without the neces¬
sity of introducing any other instrument into the eye."
In the next place it will be proper to compare the
advantages of extraction and depression as remedies
for cataract. Scarpa says truly that " in the warmth
of discussion the advantages of the one, and the disad¬
vantages of the other, have been exaggerated by both
parties/5
The most ancient of these operations is depression
or couching. The extraction was not performed till
ELEMENTS OF SURGERY.
361
near the conclusion of the seventeenth century. Frey-
tagius Lotterius, and Wenzel, are the principal sur¬
geons concerned in contriving and perfecting the ope¬
ration of extraction. The last named oculist had
wonderful success in the latter part of his life, (though
he confesses that he spoiled a " hat full of eyes" be¬
fore he learned how to operate,) and his son who suc¬
ceeded him, was also extremely celebrated. He re¬
marks in his treatise, that " the accidents which are
charged upon the operation of extraction may be re¬
duced to the eight following:—first, the staphyloma;—
secondly, pain;—thirdly, the discharge of the vitreous
humour;—fourthly, the irregularity of the pupil;—
fifthly, the deformity of the cicatrix;—sixthly, the clo¬
sure of the pupil;—seventhly, the secondary cataract;
and eighthly, the section of the iris.
First. With regard to the staphyloma; Wenzel re¬
marks " that the mode in which the cornea is divided
most commonly prevents this accident, by hindering the
iris from coming forwards. But if such an accident
should at any time happen, notwithstanding this care to
prevent it, it may be reduced by merely rubbing the
eye-lids; and it does not occasion those ill effects which
some authors have dreaded.
Secondly. The unavoidable pain that attends the
operation of extraction is to be moderated, as in other
operations, by general remedies. It is, however, not¬
withstanding the assertion of a late author, less severe
than that which is produced by depression.
Much has been said respecting the comparative pain
of the two operations: I do not consider it an object of
great magnitude to decide this contest, because it must
be conceded on all hands that if an important advantage
is to be gained by a temporary addition to the suffer¬
ings of the patient, this slight evil should not enter into
vol, i.—z z
362
competition with a permanent benefit; and it is notori¬
ous to all who are conversant with the subject, that
neither couching nor extraction, are to be considered as
very painful operations. Notwithstanding this, from
what I have seen, and I have seen very numerous cases
where extraction has been performed, and some cases
of couching, I am very decidedly of opinion that couch¬
ing is the more painful operation. One patient in par¬
ticular I recollect who had been couched, and whose
cataract had resumed its situation, when the operation
of extraction was finished (which was performed on
the other eye) exclaimed, " is it possible the operation
is aver? it was not half so severe as the couching." I
have never heard a single patient complain of much
pain during the extraction of a cataract, but have often
heard them express great astonishment at having suffer¬
ed so little.
Thirdly. The escape of the vitreous humour, if the
operation be properly performed, will seldom take
place. In some cases, however, notwithstanding every
caution, portions of this fluid will escape. Wenzel
thinks that although this is a slight evil, yet the clear
perception of objects is sometimes diminished by this
accident; but I have known a very considerable quan¬
tity of vitreous humour lost in several instances, in
which not the slightest inconvenience resulted, but the
cure was perfected as well as in the most successful
cases. This is therefore no objection to the operation
of extraction; first, because the escape of vitreous hu¬
mour can generally be prevented; and secondly, if from
its unusual fluidity, or any other cause, a portion of it
should escape, no harm results from its loss.
Fourthly. An irregularity of the form of the pupil is
an occasional consequence of the extraction of a cata¬
ract,—but I would observe that it is a very rare acci-
ELEMENTS OF SURGERY,
363
dent, and of little moment when it occurs. The shape
of the pupil is of no great consequence, and though F
do not agree with Wenzel that it becomes an advan¬
tage by enlarging the aperture through which the rays
of light are to pass, yet I do maintain that patients see
as well in whom some irregularity of the pupil exists,
as they in whose eyes the pupil is a perfect circle.
Fifthly. The cicatrix of the cornea. " If the inci¬
sion be made with one instrument and one stroke, if it
be near the margin of the sclerotica and large enough
to allow the opaque chrystalline to pass through it with-
out violence; in this case the cicatrix will be scarcely
visible and will not at all obstruct the rays of light in
their passage to the retina." When the incision is made
originally too small and is enlarged by means of scissors,
the cicatrix becomes opaque, but if it be near the scle¬
rotica it does not, even if opaque, interfere with vision.
In general it is impossible to discern a vestige of the
wound made in the cornea.
Sixthly. A total closure of the pupil. This I never
saw, and Wenzel asserts that it is much more frequent
after couching: certainly the iris is often scratched and
injured by the needle used in the latter operation, and
of course is liable to inflammation from which this clo¬
sure generally arises.
Seventhly. A secondary cataract, or opacity of the
capsule of the lens. This happens both after extrac¬
tion and couching, and I know not which it most fre¬
quently succeeds-, Wenzel of course says it is most
common after couching. One thing is certain, that if
the capsule be found opaque it is easily removed at the
same time with the lens; if it become opaque afterwards,
a repetition of the section of the cornea will readily
enable the surgeon to extract it.
Eighthly. A wound of the iris by the edge of the
364 ELEMENTS OF SURGERY.
knife. This accident it is generally in the power oi
the surgeon to prevent. It commonly arises (except in
awkward hands) from an escape of a small portion of
aqueous humour at the puncture made by the knife in
passing through the cornea; whenever the iris is found
floating before the edge of the knife, (as in Fig. 11.) a
gentle friction should be made upon the cornea with
one finger of the hand which is at liberty, and the iris
in this way becomes disengaged from the edge of the
knife. Whether the friction acts by stimulating the
iris to contract, or whether by pressure on the cornea
the iris is stretched at its margin, and thus mechani¬
cally disengaged, is not easily ascertained. Mr. C.
Bell (without much experience in the operation) re¬
commends pressure, and gives what he calls " an intelli¬
gible reason" for it. The fact is that friction succeeds
immediately in reducing the iris to a situation behind
the knife, and how this is effected is of no sort of con¬
sequence.
Mr. Hey, for whose judgment in common with the
medical world, I entertain a very high respect, differs
with Ware and Wenzel, and prefers the operation of
couching to extraction. Scarpa, who has attended with
great diligence to the subject, prefers couching; and to
such authority great deference is unquestionably to be
paid. Each of these gentleman has invented a couch¬
ing needle different from that in common use, and
never perform any other operation than depression.
Scarpa has offered no defence of couching, but
roundly asserts that "observation and experience, the
great teachers in all things, seem to have decided in fa¬
vour of the ancient method of treating the cataract, or
that by depression." Mr. Hey, on the contrary, enters
into a laboured vindication of the operation, against the
attack of Baron Wenzel.
ELEMENTS OF SURGERY. 365
The Baron alleges against couching many evils which
probably in the hands of Scarpa or Hey, never have
occurred, and like most other disputants has urged his
objections in language too strong and general.
The consequences to be dreaded from couching he
states under eight distinct heads■, first, great pain at the
time of the operation and subsequently to it; second,
vomiting from a wound of the ciliary nerves, occasion¬
ing collections of matter; third, pain and suppuration
of the eye from puncturing the retina; fourth, violent
long continued pain in the eye, sometimes during life;
fifth, bleeding into the cavity of the eye occasioning
suppuration; sixth, the impossibility of depressing fluid
or milky cataracts; seventh, the rising again of the lens;*
eighth, wounding the ciliary processes. Enlarging on
these ideas Wenzel very strongly contends in favour of
extraction, and Mr. Hey taking up each of the argu¬
ments very ingeniously endeavours to refute them, and
states that the pain in couching is very trifling;—that
the vomiting seldom occurs, and when it does, is re¬
moved by an opiate;—that suppuration of the eye—
that the long continued pain and bleeding within the
eye, he never has met with in his practice.
The milky cataract Mr. Hey declares " has in some
respects the advantage over a hard one, as the former
is less apt to adhere to the iris, and consequently there
is less risk of deranging the ciliary processes or their
investing membrana nigra, by breaking down a soft
cataract than by removing a hard one." Mr. Hey con¬
fesses, however, that " the softness of the cataract gene¬
rally requires a repetition of the operation but does not
prevent the patient from receiving a cure." The ob¬
jection that the cataract if depressed is liable to rise
again, Mr. Hey admits to be " true, but of little conse-
* The lens has been found undissolved seventeen years after couching,
*
366
ELEMENTS OF SURGERY.
quence. A repetition of the operation is not in this
case always necessary, as the chrystalline will sometimes
spontaneously subside and disappear, and when it does
not, a repetition of the operation has never failed with¬
in the compass of his experience of being attended with
success."
The wound of the ciliary processes, Mr. Hey prevents
by a change in the shape of the needle, which instead of
being spear-pointed should be square.
Mr. Hey further states that the opaque capsule,
though it cannot be depressed, may be so lacerated by
the needle, as soon to be absorbed. Mr. Hey does not
believe with the Baron that a closure of the pupil or an
opacity of the capsule of the lens, are to. be considered
as solid objections against couching.
Mr. Hey, when he quits his defensive attitude, and
attacks the operation of extraction by replying to Baron
Wenzel and Mr. Ware, in their account of its advan¬
tages, appears by no means a powerful opponent. Unit¬
ing with Mr. Hey in the sentiment with which he closes
his chapter upon cataract, I can declare with truth my
wish " that that mode of operating may prevail which
is most beneficial to the afflicted/' I have no hesita¬
tion in deciding from what I have seen and read, and
from having myself performed the operation (though
not frequently) that extraction in a great majority of
cases, ought to be performed in preference to couching,
and I have no doubt that its advocates would be much
more numerous, if the operation were as easily per¬
formed, for the greatest advantage which I conceive
couching to possess is the facility with which it is done;
it is in fact an operation, requiring very little dexterity
or science. I shall describe both operations.
ELEMENTS OF SURGERY.
367
CHAPTER LYI1L
Of Extraction.
It will generally be proper that the patient for a week
before the operation be confined to a low diet—he
should be free from catarrh and other diseases—cough¬
ing, sneezing, or vomiting, would prove extremely per¬
nicious after the operation. The seasons to be prefer¬
red are the spring and fall, when the weather is settled
and mild.
The instruments necessary in the operation of ex¬
traction are a knife for dividing the cornea; the one to
be preferred is the instrument invented by the elder
Wenzel. " It resembles the common lancet employed
in bleeding, except that its blade is a little longer and
not quite so broad. Its edges are strait. The blade
is an inch and a half long and a quarter of an inch
broad, in the widest part of it, which is at the base.
From hence it gradually becomes narrower towards the
point, so that this breadth of a quarter of an inch ex¬
tends only to the space of about one-third of an inch
from the base, and for the space of half an inch from
the point, it is no more than one-eighth of an inch
broad."
One edge is sharp through the whole length of the
blade; at the distance of a quarter of an inch from the
base, this lower edge has a slight projection. The up¬
per edge is divided into three portions for the space of
five-sixths of an inch from the basis; this edge is blunt,
and very little flattened. For the space of half an inch
or rather six lines and a half* further towards the
* A line is the twelfth part of an inch.
368
ELEMENTS OF SURGERY.
point, it is blunt and rounded, although very thin. The
extremity of this edge to the extent of one-eighth of an
inch from the point, is keen like the lower edge, in or¬
der to facilitate the conveyance of the instrument
through the cornea—the handle is octangular. The
knife is represented in Fig, 14.
I have described it particularly, because much of the
success of the operation depends upon the perfection of
the instrument. Mr. Ware uses a knife very little dif¬
ferent from WenzeJL's; it is rather wider near the point,
in order that the edge may quickly get below the infe¬
rior margin of the pupil and thus avoid wounding the
iris.
It has been customary in operating on the eye to
make use of a contrivance called a speculum to keep
the eye motionless; a variety of specula have been con¬
structed, but in the opinion of Baron Wenzel they are
useless. In addition to the knife, a curette, or small
scoop of silver or gold, and a curved needle of steel,
which are generally fixed to one handle (Fig. 15.);—
a small steel hook (Fig. 13.);—and a pair of small for¬
ceps (Fig. 16.), are all the instruments required for the
operation. Instead of the forceps copied from Wenzel,
a more convenient form is that delineated (Fig. 4.), the
extremities are to be flat, and their surfaces of contact
when closed about the fourth of an inch.
OPERATION.
The patient is to be seated in a low chair before a
moderate light which strikes the eye obliquely. Baron
Wenzel directs the operator to proceed in the follow¬
ing manner.
" The sound eye being covered with a compress re¬
tained by a bandage, an assistant, placed behind, must
hold the patient's head, and support it on his breast
ELEMENTS OF SURGERY. 369
With the fore-finger of the hand that is at liberty, he is
then to raise the upper lid of the eye to be operated
upon, and gently to press the tarsus, with the extremity
of the finger, against the upper edge of the orbit. In
order to assist this arrangement, and properly to fix the
upper lid, the Assistant should take care to draw up the
skin over the orbit, and strongly to fold the teguments
that support the eye-brow. By this method, the eye
will be entirely uncovered, an undue pressure upon it
will be avoided, the fingers of the assistant will not in¬
terfere with those of the operator, and the eye-lid will
be so fixed as to be incapable of any motion.
" The operator is to be seated on a chair, a little
higher than that of the patient. The eyes naturally
turning towards the light, he is to place the head cf the
patient obliquely to a window; so that the eye to be
operated upon may be inclined towards the outer angle
of the orbit. This position of the eye will enable the
operator to bring out the knife, on the inner side of the
cornea, opposite to the part where it pierces this tunic,
more exactly than he would otherwise be able to do.
The operator is to rest his right foot on a stool, placed
near the patient, that his knee may be raised high
enough to support the right elbow, and to bring the
hand with which he holds the knife, to a level with the
eye on which he is to operate: (this direction I think
unnecessary if the operator have a steady hand.) He
is then to take the cornea knife in his right hand, if it
be the left eye on which he is to operate, and, vice
versa, in the left hand, if it be the right eye. The knife
is to be held like a pen in writing, and his hand is to
rest steadily on the outer side of the eye, with the little
finger, separated a little from the rest, on the edge of
the orbit. In this position he is to wait, without any
hurry to begin the incision, until the eye which is usu-
vol. i.—3 A
370
ELEMENTS OF StfRGERY.
ally very much agitated by the preparations for the opt
ration, becomes perfectly still. This always take?
place within a few seconds of time; and, therefore, as I
have fully expressed myself on this subject, every in¬
strument invented to fix it is useless.
" When the eye is still and so turned towards the
outer angle of the orbit, that the inner and inferior part
of the cornea, through which the point of the instru¬
ment is to come out, may be distinctly seen, the opera¬
tor is to plunge the knife into the upper,and outer part
of the tunic, a quarter of a line distant from the sclero¬
tica, in such a direction, that it may pass obliquely from
above downwards, parallel to the plane of the iris. At
the same time,, the operator must depress the lower lid
with his fore and middle fingers, which are to be kept
a little distant one from the other, and must take the
greatest care to avoid all pressure on the globe, which
is to be left perfectly free, as the surest way to diminish
its power of moving*
" When the point of the knife has proceeded so far
as to be opposite to the pupil it is to be dipped into this
aperture, by a slight motion of the hand forward, in or¬
der to puncture the capsule of the chrystalline;f and
then by another slight motion, contrary to the former,
it must be withdrawn from the- pupil, and, passing
through the anterior chamber, must be brought out
near the inferior part of the cornea, a little inclined to
the inner angle, and at the same distance from the scle¬
rotica, as when it pierced the cornea above. If the
knife has been well directed, and the fore and middle
fingers of the hand opposite to that which holds the in-
* Mr. Ware very properly condemns this direction, and advises the eye
at this time to be moderately pressed, which certainly serves to fix it, and
prevent its motion.
t Baron Wenzel's practice in this particular, is not to be imitated by an}
but experienced operators.
ELEMENTS OF SURGERY.
371
strum en t, have been properly applied, the section of
the cornea, thus completed, will be found sufficiently
large; its shape will be semi-circular; and it will be
quite near enough to the margin of the sclerotica.'
(Wenzel.)
When the iris is unusually convex, and in making the
section of the cornea, becomes entangled before the
knife, the cornea is to be rubbed downward with the
finger, which disengages it. A fear of wounding the
iris, should never induce the operator, to make the sec¬
tion of the cornea at too great a distance from the
sclerotica, because the section will in that case be too
small to allow the lens to escape.
While the section of the cornea is proceeding, and
when the point of the knife has passed out at the side
opposite to the part at which it entered, the assistant
lets the upper eye-lid drop, and all pressure is immedi¬
ately taken off.
The next part of the operation consists in punctur¬
ing the capsule of the chrystalline lens, for I believe
few surgeons have dexterity and confidence enough to
do it, generally, with the cornea knife. The best mode
of effecting this will be to introduce the needle (Fig.
15.) through the wound in the cornea, into the pupil,
and move it gently, but freely and quickly, in all direc¬
tions; by this manoeuvre the anterior portion of the
capsule will be lacerated, and a gentle degree of pres¬
sure being made upon the eye, the pupil is observed
gradually to enlarge, and one edge of the lens is ob¬
served escaping through it; all pressure is to be imme¬
diately removed, and the opaque chrystalline escapes.
Sometimes it is necessary to assist its escape through
the aperture in the cornea, by the use of the needle, or
scoop, and any portion of opaque glutinous matter
which remains behind is to be carefully removed by
372
ELEMENTS OF SURGERV.
the curette. If the capsule be not opaque, the pupil
will now be observed to have regained its natural black¬
ness, and the patient will discover the surrounding ob¬
jects. In a majority of the cataracts which I have
seen extracted, the centre has been firm and dense,
but portions of the external part have been soft and
glutinous, and have remained after the extraction oi
the central portion. If it be inconvenient to remove
them all, it will be better to wait for their absorption
than to augment, the danger of inflammation by pro¬
tracting the operation too long.
Sometimes the cataract, according to Wenzel, ad¬
heres, and must be separated by the needle from its ad¬
hesions; this is in general readily effected by inserting
the needle in the lens, and moving it gently in differ¬
ent directions.
If the capsule of the lens be found opaque, it may
now be extracted, by means of a pair of sm&ll forceps;
those recommended by Wenzel, (Fig. 16.) are much
too clumsy, they cannot, from their bulk, be readily
opened and shut in the wound of the cornea; it is more
convenient to have forceps resembling those delineated
in Fig. 4.
The anterior portion of the capsule is most frequently
opaque, and sometimes considerably thickened and in¬
durated; when this is the case it comes out at once; if
it be torn, however, the fragments are to be removed,
and during this part of the operation, great care must
be taken to avoid the escape of the vitreous humour;
the eye should not be. kept open long at a time, and the
attempts to extract the portions of opaque capsule,
should be repeated as often as necessary, but not con¬
tinue more than a minute at a time, and the eye in the
intervals should be covered with a small compress of
fine linen wet with clear cold water.
ELEMENTS OF SURGERY. * 375
Dr. Physick.has, in some cases where the capsule
was evidently opaque, extracted it first with the forceps;
when this is done the lens descends below its usual
situation, but its falling to the bottom of the eye " does
not appear to be quite correct;" it was in the cases allud¬
ed to, very easily extracted with a curved needle, or-
small hook, (Fig. 13.); this hook is occasionally useful
in removing portions of the capsule as well as of the
lens, and should always be at hand.
The lens does, however, in a diseased state of the
vitreous humour, descend in some cases to the inferior
part of the eye, and in these cases pressure cannot be
used, and it must be extracted with the hook.
If the capsule, though lucid at the time of the ope¬
ration, should become subsequently opaque, forming
what is called secondary cataract, the section of the
cornea is to be repeated, and the opaque membrane re¬
moved. The subsequent treatment consists in prevent¬
ing inflammation. The patient should lie on his back
for eight or ten days, the room being somewhat dark¬
ened: the eye requires no dressing but a compress loose¬
ly applied: the hands ought in every instance to be se¬
cured to the sides of the bed by means of tapes, in such
a manner as to prevent their reaching so high as the
head; persons waking, are very apt to rub their eyes,
and sight has been destroyed by such accidents, the
caution just given ought never therefore to be neglected:
a low diet, and if necessary from the accession of
fever, bleeding and purging ought to be directed.
For much useful information on the present subject,
the reader is referred to the writings of Mr. Ware^
and Baron Wenzel.
374 ' ELEMENTS OF SURGERY
V'AW.jbe
, : »
» - . * # iip
»\ • » '•'.■■■»» *x •
CHAPTER LIX ,
! * .
• »
. O/V Couching.
It has already been mentioned, that this operation
consists in depressing the opaque chrystalline lens and
removing it from the axis of vision. The couching
needles generally employed are those of Saunders, fig.
5; of Scarpa, fig. 6; and of Hey, fig. 7. No very parti¬
cular description need be given. Scarpa's needle is, in
my opinion, to be preferred; it possesses firmness enough
to enter the eye without danger of its breaking, and has
a point somewhat curved. The curved extremity is
sharp at the edges, and polished and flat upon its con¬
vex dorsum; there is a mark on the side of the handle
which corresponds to the convexity of the point. It
should be made rather shorter than Scarpa directs. I
shall quote the description given by this celebrated ocu¬
list of his operation.
operation.
•. v • •
• v •
"Every thing being arranged for performing the ope¬
ration, the surgeon should place his patient on a low seat
on the side of a window which has a northern aspect,
so that the light coming from it may only fall upon the
eye which is to be operated on laterally. The patient's
other eye being covered, although affected with cata¬
ract, the surgeon ought to place himself directly oppo¬
site the patient, upon a seat of such a height, that when
he is prepared to operate, his month shall be on a level
with the patient's eye. And, in order to give his hand
a greater degree of steadiness in the several motions
ELEMENTS OF SURGERY.
375
which the depressions of the Cataract require, the elbow
corresponding to this hand should be supported upon
the knee of the same side, which for this purpose he
should raise sufficiently by resting his foot upon a stool,
and according to circumstances also, by placing a small
hard pillow upon his knee. An able assistant situated
behind the patient, with one hand fixed upon the chin,
should support the patient's head against his breast,
and with the other placed on the forehead, gently raise
the upper eye-lid by means of Pellier's elevator, care¬
fully observing to gather the eye-lid against the arch of
the orbit, without pressing upon the globe of the eye.
" Supposing then the eye to be operated on is the
left, the surgeon taking the curved needle in his right
hand, as he would a writing pen, with the convexity of
the hook forwards, the point back, and the handle in a
direction parallel to the patient's left temple; should
rest his fingers upon the temple, and boldly perforate
the eye-ball in its external angle, at rather more than a
line from the union of the cornea and sclerotica, a little
below the transverse diameter of the pupil, gradually
moving the extremity of the handle of the needle from
behind forwards from the patient's left temple, and
consequently giving the whole instrument a curved mo¬
tion, until its bent point has entirely penetrated the eye¬
ball; which is effected with the greatest readiness and
ease. The operator should then conduct the convexity
of the needle upon the summit of the opaque chrystal-
line, and by pressing upon it from abov6 downwards,
cause it to descend a little, carefully passing the curv¬
ed point at the same time between the corpus ciliare
and the capsule of the chrystalline lens, until it be visi¬
ble before the pupil, between the anterior convexity
of the capsule of the lens and the iris. Having done
this he should cautiously push the hook with its point
376
ELEMENTS OF SURGERY.
turned backwards towards the internal angle of the eye,
passing it horizontally between the posterior surface of
the iris, and the anterior convexity of the capsule,
until the point of the needle has arrived as near the
margin of the chrystalline and capsule as possible, which
is next the internal angle of the eye, and consequently
beyond the centre of the opaque lens. The opera¬
tor then inclining the handle of the instrument more
towards himself, should press the curved point of it deep¬
ly into the anterior convexity of the capsule, and sub¬
stance of the opaque chrystalline, and by moving it in
the arc of a circle, should lacerate the anterior con¬
vexity of the capsule extensively, remove the cataract
from the axis of vision, and lodge it deeply in the vi¬
treous humour, leaving the pupil perfectly round, black,
and free from every obstacle to the vision. The nee¬
dle being retained in this position for a short time, if
no portion of opaque membrane appear behind the
pupil, which would require the point of the instrument
to be turned towards it, in order to remove such ob¬
stacle, (for with respect to the chrystalline, depressed
in the manner now described, it never rises again) the
surgeon should give the instrument a small degree of
rotatory motion, in order to* disentangle it easily from
the depressed cataract, and should withdraw it from the
eye in a direction opposite to that in which it had been
introduced, that is greatly inclining and turning the
handle towards the" patient's left temple.
" In every species of cataract, with considerable opa¬
city and density of the anterior hemisphere of the cap¬
sule of the chrystalline, the surgeon may very easily
know during the operation, whether the curved point
of the needle, insinuated between the corpus ciliare
and the capsule, is exposed between the pupil and the
anterior hemisphere of that membrane: or, whether
ELEMENTS OF SURGERY. 377
having penetrated into the membranous sac of the
chrystalline, it has only advanced between the anterior
hemisphere of the capsule and the opaque lens. But
when the capsule, notwithstanding the opacity of the
chrystalline lens, preserves in a great measure, or en¬
tirely, its transparency, it is an easy matter for a young
surgeon, not sufficiently conversant with this opera¬
tion, to commit an error, and one of great importance,
that is, to remove the cataract from the axis of vision,
and lodge it in the vitreous humour, leaving the ante¬
rior convexity of the capsule untouched, which after¬
wards gives rise to the secondary membranous cata¬
ract.
"To avoid this serious inconvenience, every operator
should be particularly careful to satisfy himself, before
making any movement with the point of the needle for
depressing the cataract, that the curved extremity of
the instrument is really, and not apparently, situated
beiween the pupil and the anterior portion of the cap¬
sule. of which he will be convinced by the degree of
light which the convexity of the hook presents to him,
and the facility which he finds in pushing it forwards
through the pupil towards the anterior chamber of the
aqueous humour, and in moving it horizontally between
the iris and anterior hemisphere of the capsule. In
the opposite case he may be certain that the curved
point is within the membranous sac of the chrystalline,
by observing that the extremity of the needle is ob¬
scured and covered by a more or less transparent veil;
that he meets with some resistance in pushing it through
the pupil into the anterior chamber of the aqueous hu¬
mour; and that in doing it, this membranous veil which
covers the hook is elevated towards the pupil, and lastly,
that the point of the needle is with difficulty conducted
vol. 1.—3 F
:378
ELEMENTS OF SURGERY.
horizontally between the iris and the cataract, from the
external towards the internal angle of the eye.
C£ The surgeon will remedy this inconvenience, by
giving a slight rotatory motion to the needle, by which
the point being forwards will pass through the anterior
convexity of the capsule opposite the pupil; the point of
the instrument being then turned backwards again,
should be passed horizontally between the iris and the
anterior hemisphere of the capsule towards the internal
angle of the eye, and having reached this part should be
boldly plunged into the capsule, and the substance of
the opaque lens, in order to lacerate the former ex¬
tensively, and to carry the latter deeply into the vitreous
humour out of the axis of vision, and thus complete the
operation.
" When, without observing this precept, the opaque
lens is removed, or, more strictly speaking, enucleated
from its capsule and lodged in the vitreous humour; and
the anterior convexity of this membrane being left en¬
tire, is slightly opaque, the pupil will appear black, and
so free from obstruction to the light as easily to deceive
the young surgeon, and induce him to believe that the
operation has been properly executed. But persons ex¬
perienced in this part of surgery, will instantly perceive
that the pupil, under such circumstances, has not that
just and perfect degree of blackness which it ought to
have, and that this slight dimness is caused by an imper¬
fectly transparent membranous veil, placed between the
pupil and the bottom of the eye, which when suffered
to remain, never fails, in process of time, to give rise
to the secondary membranous cataract. In this case,
the expert operator having depressed the opaque lens,
should immediately turn the curved point of the needle
forward, and pass it through the pupil into the anterior
chamber of the aqueous humour, in order to perforate
ELEMENTS OF SURGERY.
379
this semi-transparent membranous veil with the greatest
certainty; then turning the point of the needle back¬
wards and making it pass as far as possible between the
posterior surface of the iris and this membrane, should
press the point of the instrument into it and lacerate it
from before backwards, making a movement as if he
had to depress the lens again. In doing this he will
have the satisfaction to see the pupil assume the deep
black colour of velvet, and a degree of clearness which
it had not before, although the opaque lens had been
completely removed from the axis of vision.
" Hitherto I have supposed the cataract to be of a
tirm consistence, and to resist the pressure of the needle.
But if the operator should meet with a fluid cataract,
the milky for instance, which is not an unfrequent oc¬
currence, when he has passed the needle between the
corpus ciliare and the capsule, until it appears uncover¬
ed between the pupil and the anterior hemisphere of
the membranous sac of the chrystalline lens, and the
curved point has been cautiously advanced between the
iris and the margin of the capsule, nearest the internal
angle of the eye; at the moment that the point of the
needle is deeply pressed into the capsule and cataract, a
whitish milky fluid will be seen to issue from the cap¬
sule, which extending itself in the form of a cloud or
smoke, will be diffused through both the chambers of
the aqueous humour, and obscure the pupil and the
whole of the eye. The surgeon should not on this ac¬
count lose his confidence, but, guided by his anatomical
knowledge, should make the small hook describe the
arc of a circle from the internal towards the external
angle of the eye, and from before backwards, as if he
were depressing a solid cataract, with a view of lacerat¬
ing as much as possible, the anterior hemisphere of the
capsule, upon which the favourable success of the
380
ELEMENTS OF SURGERY.
operation principally depends, not only in this, but in
every other species of cataract. For as to the effusion
of the milky fluid into the chambers of the aqueous
humour, it disappears spontaneously a few days after
the operation, and permits the pupil and the whole ol
the eye to resume their former natural brightness.
" The method of operating which the surgeon should
employ will be little different from this, if, during its
performance, he should meet with a soft or cheesy
cataract. The anterior convexity of the capsule should
be lacerated as much as possible opposite the pupil, so
that the opening may equal the diameter of the pupil
in its ordinary dilatation. And with respect to the pulpy
substance of the cataract, which, in such cases, remains
behind, partly diffused in the aqueous humour, and
partly swimming beyond the pupil, all that is necessary,
is to divide the most tenacious parts of that substance,
that they may be more easily dissolved in the aqueous
humour, and to push those moleculas of the caseous
substance of the chrystalline, which cannot be suffi¬
ciently divided, through the pupil into the anterior
chamber of the aqueous humour, in order that they may
not be carried opposite the pupil, but being situated at
the bottom of the anterior chamber, may be gradually
dissolved and absorbed without obstructing the sight.
(Scarpa.)
ELEMENTS OF SURGERY.
381
CHAPTER LX.
Of Congenital Cataract.
The late Mr. Saunders of London, instituted an
infirmary for the reception of patients afflicted with
diseases of the eyes—he lived but a few years after its
foundation, long enough, however, to be very useful as
surgeon to the establishment, and a small posthumous
volume, published in 1811, contains a number of highly
interesting remarks on various affections of this impor¬
tant organ. The following observations on congenital
cataract are extracted principally from his writings.
The causes of congenital cataract are unknown: it
appears sometimes in several of the same family. Mr,
Saunders saw sixty cases of the disease between June
1806, and December 1809, so that it is by no means
unfrequent. He relates many cases where several
children of the same parents were born blind.
The opacity is generally seated in the capsule; the
lens being absorbed. Sometimes the lens is opaque,
and solid or fluid as in adults. Mr. Saunders found
that the only treatment necessary, was to perforate the
centre of the capsule, and if a permanent aperture was
made in that membrane, the lens if it existed was sub¬
sequently absorbed.
Children affected with the disease possess various
degrees of vision. Some indistinctly see external ob¬
jects, others can only discern bright colours or vivid
lights. If the privation of vision be nearly complete,
volition for want of an external object to attract these
organs, is not exercised over the muscles belonging to
them, and their actions are not associated, but the eye
382 ELEMENTS OF SURGERY.
rolls here and there with rapidity, and trembles as it
moves.
The excessive mobility of the eye, the unsteadiness of
the little patient, the small field for the operation, and
the flexibility of the opaque capsule, are the difficulties
with which the surgeon has to contend. Mr. Saunders
overcame them by fixing the eye-ball with a speculum,
controlling the patient, dilating the pupil with belladon¬
na, and by using a diminutive needle armed with a cut¬
ting edge from its shoulders to its point, and thin
enough to penetrate with the most perfect facility.
This needle is delineated in Fig. 5.
The extract of belladonna is to be diluted with water
to the consistence of cream and dropped into the eye,
or the extract undiluted may be smeared over the eye¬
lid and brow. In half an hour, or an hour the pupil
is fully dilated, and the application should be then
washed off. The patient is confined in a proper posi¬
tion and in a situation near a window by a sufficient
number of assistants, who take great care to fix the
head motionless, and to secure the limbs from moving.
The operator is seated on a high chair, behind the pa¬
tient, takes the speculum in one hand and the needle
in the other.
Should the capsule contain an opaque lens, the sur¬
geon gently introduces the bow of the speculum under
the upper eye-lid, his assistant at the same time depress¬
ing the lower, and at the moment he is about to pierce
the cornea, he fixes the eye by resting the speculum
with a moderate pressure upon the eye-ball. The po¬
sition of the operator enables him to do this with per¬
fect safety, and by that consent which can only exist
between the hands of the same person, he not only dis¬
continues the pressure, by using the speculum merely
as an elevator of the lid, as 6oon as his purpose is
ELEMENTS OF SURGERY.
383
complished, but he with facility renews or regulates the
pressure at any moment in which it may be required.
He penetrates the cornea as near to its junction with
the sclerotica as it will admit the flat surface of the
needle to pass, in a direction parallel and close to the
iris, without injuring this membrane. When the point
of the needle has arrived at the centre of the dilated
pupil, he does not boldly plunge it through the capsule
into the lens, and perform any depressing motion; it is
a material object with him not to injure the vitreous
humour or its capsule; neither does he lift the capsule
of the lens on the point of the needle, and by forcibly
drawing it forward into the anterior chamber, rend it
through its whole extent. Such an operation would
dislocate the lens, deliver it into the anterior chamber,
or leave it projecting in the pupil, and stretching the
iris; and although its soft texture in the child should
exempt him from any disorganizing inflammation, the
most favourable result will be a permanently dilated
iris, deforming the eye. He proceeds with a gentle la¬
teral motion, working with the point and shoulders of
the needle only on the surface and centre of the cap¬
sule, in a circumference which does not exceed the na¬
tural size of the pupil. His object is permanently to
destroy this central position of the capsule: merely to
pierce it would not answer his intention, because the
adhesive process will speedily close the wound. Hav¬
ing acted upon the centre of the anterior lamella of the
capsule to the extent which he wishes, he gently sinks
the needle into the body of the lens, and moderately
opens its texture. In doing this he may, if he pleases,
incline the edge of the needle, by which motion the
aqueous humour will escape, and the lens will approach
his instrument; but at the same time his field for ope¬
rating will be diminished by the contraction of the pu-
384
ELEMENTS OF SURGERY.
pil. The needle and speculum are now to be with¬
drawn, the eye is to be lightly covered, and the patient
put to bed.
Inflammation is seldom excited by this operation on
the child; but its first approach, marked by pain and
unusual redness of the conjunctiva, or serous effusion
under it* must immediately be arrested by the applica¬
tion of leeches on the palpebrae; and, in stouter chil¬
dren, by bleeding from the arm, followed by purgatives
and a very low diet. Soon after the operation the ex¬
tract of belladonna should be applied over the eye-brow,
to prevent, by a dilatation of the iris, the adhesion of
the pupillary margin to the wounded capsule. Nature
now performs her part of the cure, and the lens, loos¬
ened in its texture, and through the aperture in the
capsule, subjected to the action of the aqueous humour,
is gradually dissolved and absorbed.
A single operation sometimes suffices, and the cure
is completed in the space of a few weeks; but if the
process should not advance with sufficient rapidity, the
operation may be repeated once or oftener, interposing
at least a fortnight between each operation. If the ad¬
hesive process has counteracted his former operation
on the capsule, he will take care now to effect the per¬
manent aperture in its centre, and he may use greater
liberty than at first in opening the texture of the lens.
Some have supposed that the fluid cataract is not
only the most frequent, but the most manageable of the
congenital cases. Both suppositions are erroneous. It
is not only the least common, but the fluid, when extra-
vasated, sometimes excites a hazardous inflammation.
In these cases, after puncturing the anterior lamella o(
the capsule, and discharging its contents into the ante¬
rior chamber, it will be prudent to desist for the time
ELEMENTS OF SURGERY.
385
and to guard against inflammation: by this operation
the case will be converted into a capsular cataract.
Where the lens is nearly or quite absorbed, and the
capsule only is opaque, the surgeon may use the needle
with more freedom than in the lenticular cataract, but
in other respects he proceeds in the manner above de¬
scribed. If any portion of the lens remain as a small
nucleus or scale, in the centre of the capsule, his ef¬
forts will be exclusively directed to detach this portion,
by which he will fulfil the intention of the operation,
that of effecting a permanent aperture in the centre of
the capsule.
Mr. Saunders in some cases punctured the sclerotica
and perforated the capsule from behind: he observes,
that in this posterior operation the surgeon has more
power, but that the anterior operation excites less pain
and inflammation, and inflicts a slighter injury (if any)
on the vitreous humour; from the facility with which
the cornea heals I should prefer the anterior operation.
The number of operations which may be necessary
to accomplish the cure of a congenital cataract, will de¬
pend much upon the texture of the capsule, and the size
of the lens. It is frequently cured by a single opera¬
tion; more frequently it requires two; often three;
sometimes four; but very rarely five. In sixty patients
Mr. Saunders, (the author of the operation) succeeded
in giving sight to fifty-two. In thirteen he operated on
single eyes. In forty-seven he operated on both eyes.
The ages were as follows: five, from two to nine months;
nine from 13 months to two years; four, from two and
a half to three years; five, from three and a half to four
years; eight, from four to six years. Seven, at seven
years; eight, from seven to nine; ten, from nine to fif¬
teen; and four from twenty to twenty-eight. The
greatest success attended the operation when perform-5
vol. i. 3 c
38t> ELEMENTS OF SURGERY.
ed between the ages of 18 months and four years. The
age of two years is perhaps preferable to any other. It
is extremely important to operate as early as possible,
because, the muscles acquire an inveterate habit of roll¬
ing the eye, so that for a long time, no voluntary effort
can control this irregular motion, nor direct the eye to
objects with sufficient precision, for the purpose of dis
tinct and useful vision.
I cannot refrain in this place from expressing my
high sense of the ingenuity of Mr. Saunders, in the con¬
trivance of the simple and important operation which
has been described. When the advantages of educa¬
tion are considered, and the necessity of sight for this
purpose, the magnitude of the object will appear very
great, and when the success of his practice is recollect¬
ed, (52 cures of 60 patients) his skill and judgment can¬
not be too highly rated. Since Mr. Saunders's publica¬
tion I have met with but one case of congenital cataract,
(which from all the inquiries I can make, I believe to
be extremely rare in America, as from Scarpa's account
it is in Italy) but in that one case I succeeded in re¬
storing vision, and my patient, now four years old, sees
very well.
Before concluding this subject, I beg leave to sug¬
gest the propriety, in cases of cataract where the pupil
is greatly contracted, of using either the belladonna, as
directed by Mr. Saunders, or the extract of stramo¬
nium, which operates in the same manner; great diffi¬
culty sometimes attends the extraction of the lens, ow¬
ing to the contracted state of the pupil, the applications
just proposed will probably be found to obviate this dif¬
ficulty, and perhaps another, the entangling of the iris
on the point of the knife, because the dilatation of the
pupil, occasioned by stramonium and belladonna, is so
A
ELEMENTS OF SURGERY.
387
great, that the iris actually resembles a narrow ring at
the margin of the cornea.
The effect of certain narcotic plants in dilating the
pupil of the eye, both when externally and internally
administered, has been long known, but it is only a
few years since surgeons have availed themselves of it,
in examining cataracts, and facilitating their extrac¬
tion. Mr. Wishart, in a paper published in the Edin¬
burgh Med. and Surg. Journal, for January 1812, re¬
commends very strongly the hyosciamus, and quotes
professor Himly of Gottingen, who has made compa¬
rative experiments with belladonna and hyosciamus,
and prefers on his authority, as well as from his own
observation, the latter article. The mode of using it
is, to dissolve a dram of the extract in an ounce of
water, of which solution a few drops are to be let fall
into the eye. It occasions no pain nor redness. The
effect on the pupil commences in an hour, and continues
five or six hours.
There are several advantages which may be gained
by artificially dilating the pupil. I have known a lady
blind except at noon; her pupil was no larger than a
pin's head, the use of stramonium enabled her to see
tolerably in various degrees of light. In examining
cataracts, the larger the pupil, the more readily we
may ascertain the circumstances of the case. It is
always in the surgeon's power to learn whether the
iris be adherent, in which case no dilatation of the pupil
will be occasioned by the narcotic applications. In
cases of partial opacity in the cornea, the dilatation of
the pupil enables the patient to see by withdrawing the
iris from behind a lucid part of the cornea, and thus
forming a temporary substitute for an artificial pupil:
the advantages of a dilated pupil during the operation
of extracting a cataract, have been already mentioned:
388
ELEMENTS OF SURGERY.
but an inconvenience lias been dreaded from the escape
of the vitreous humour, in consequence of a want of
that support which the iris afforded. The experiments
of Himly quoted by Wishart, appear to prove that this
fear need not be entertained, and the surgeon may
doubtless avail himself safely of the benefits which are
to be derived from the application of these narcotics to
the eye.
Among the consequences of the extraction of cataract,
hypopion and staphyloma are the most formidable;
happily they are of rare occurrence, I have never seen
either. Hypopion is a collection of matter in the ante¬
rior chamber of the eye. The term empyesis signifies
a collection of pus in the posterior chamber, both are
consequences of violent inflammation, and occasionally
occur after ophthalmia.
In cases of hypopion the continued use of the reme¬
dies for inflammation seldom fails of producing an ab¬
sorption of the pus;—as this absorption goes on, the
pus being heavier than the aqueous humour falls to the
bottom of the anterior chamber of the eye, forming a
semicircle of a yellow colour, the circumference of
which is formed by the cornea. It is very seldom
necessary to puncture the cornea for the evacuation of,
the pus; active purges are to be repeatedly administer¬
ed, but if, aided by the usual depleting remedies, they
are unsuccessful, a puncture must be made. These
remarks apply equally to hypopion from inflammation
of the eye arising from other causes.
The staphyloma is a tumour projecting through the
wound of the cornea, formed generally of the iris, but
in some cases of a transparent membrane, which
Wenzel calls the capsule of the aqueous humour.
When upon looking at the eye for the first time, which
is generally done in six or eight days after the opera-
ELEMENTS OF SURGERY.
389
tion, the iris is observed protruding through the wound,
110 attempt should be made to replace it; as the opening
in the natural cornea closes, the iris generally regains
its situation. The tumour formed by a transparent mem¬
brane, is of a very different nature. The membrane
is probably an adhesion formed of coagulating lymph,
distended afterwards by an abundant secretion of
aqueous humour; if cut off or destroyed, it generally
returns again, which would not be the case if it were
formed of an organized capsule. Wenzel recommends
the case to be left to nature; the eye-lids gradually
produce by friction and pressure, an absorption of the
tumour. Staphyloma sometimes results from ulcers of
the cornea; in these cases, if it continue obstinate and
do not subside spontaneously, the lunar caustic must be
applied.
Scarpa denominates the staphyloma formed by the
iris " procidentia iridis," which is surely a more pro¬
per appellation, for it is perfectly distinct from the tu¬
mour just described, which is often pellucid, but when
opaque is of a pearly white colour, and easily distinguish-
ble from the protruded iris.
Staphyloma is sometimes occasioned by small-pox—
in this case the tumour is of a white colour like the
opaque cornea. In general it ulcerates and occasions
inflammation of the eye; in these cases the tumour may
be cut off, and should it reappear lunar caustic is to be
applied.
The term staphyloma has been vaguely applied to
many and various tumours of the cornea. It has been
called total when the whole cornea is morbidly promi¬
nent, and partial when the tumour is confined to a por¬
tion only. For some very interesting remarks on this
subject the reader is referred to Wardrop,and Scarpa.
390
ELEMENTS OF SURGERY.
Since the first edition of the Elements of Surgery,
some very important improvements have been made in
the treatment of cataract, which I shall next relate,
having judged it proper to leave my previous account
of extraction and couching for the information of those
readers who may not have access to other works on
these subjects.
Mr. Saunders's operation of lacerating the capsule and
destroying the texture of the lens, by means of a dou¬
ble-edged needle introduced through the cornea or scle¬
rotica, which succeeds so happily in cases of congenital
cataract, has been found also well adapted to a large
number of cataracts occurring in advanced life. I have
myself employed it in a great many cases with com¬
plete success, and the facility with which it is perform¬
ed, together with the little injury which the eye sus¬
tains from it, give it certainly strong claims to a pre¬
ference over either couching or the former methods of
extraction. When I adopted this mode of treatment,
I commenced a journal of my operations and recorded
the results of eighteen cases, which were published in
the second American edition of Cooper's Surgical Dic¬
tionary, in 1816, viz: between the 25th of April, 1814,
and the 25th of October, 1815, I performed Mr. Saun¬
ders's operation as improved by Mr. (now Sir William)
Adams, in eighteen cases; at the time of the publica¬
tion alluded to, eight of the patients were completely
cured; in two of the cases both eyes were cured, in the
others only one;—two of the patients refused to wait
for absorption, and were cured by extraction;—in two
permanent blindness ensued from violent inflammation,
and the remaining six were under treatment. These
have since been operated on repeatedly, and have all
got well, with one exception; in that case, making the
third out of eighteen, inflammation destroyed the eye.
ELEMENTS OF SURGERY.
391
I have continued to employ this operation, sometimes
passing the needle through the cornea and sometimes
through the sclerotica in a much greater manner of cases,
but of these I have not preserved an entire list: my suc¬
cess, however, has been such as induces me to declare
a decided opinion that it is far preferable to the usual
mode of extraction, or to couching. It has succeeded
partially or totally, in a great majority of cases, since
the publication alluded to, but by no means so generally
as in Sir William Adams's practice; in some it has prov¬
ed exceedingly tedious, and my patients, in one or two
instances, have been twelve months and longer before
absorption has been completed The gradual improve¬
ment of vision, however, satisfies them, and eventually
success appears as certain as from any other operation.
I have now, I believe, operated upon nearly fifty cases,
and in six of these the eye has been destroyed by in¬
flammation. In one of these instances the patient was
very old, the cataract fluid, and immediately on its es¬
caping from the wounded capsule into the anterior
chamber and mixing with the aqueous humour, he com¬
plained of severe pain—this continued and augmented,
and although the operation was performed with as
little violence to the eye as possible, suppuration took
place. I cannot but ascribe this result to some irritating
quality of the fluid lens. In a few other cases in which
the operation has been very cautiously performed, vio¬
lent inflammation has resulted, but has been cured by
copious evacuations.
Sir William Adams has just favoured the world with
his anxiously expected volume on cataract, and his suc¬
cess in treating it seems to exceed any thing which the
most sanguine hopes could have anticipated. Of thirty-
one cases of cataract, at Greenwich hospital, many of
which were complicated with other diseases of the eye,
392
ELEMENTS OF SURGERY.
he completely cured twenty-nine; one only failed, and
one was dismissed for irregular conduct.* The testi¬
monials of accuracy in this statement are from the
governors of the hospital, noblemen and gentlemen of
great respectability, and are entitled to the fullest con¬
fidence. The treatment of Sir William Adams varies
in different cases. I shall proceed to give an outline
of his practice.
" I shall commence with the description and consi¬
deration of the operation for * solid cataract in children
and in adults/ It is an operation, perhaps, more ex¬
tensively applicable, and which has proved more gene¬
rally successful, than any other, either ancient or
modern.
Having secured the eye by making a gentle pressure
with the concave speculum, introduced under the upper
eye-lid, I pass the two-edged needle through the sclero¬
tic coat, about a line behind the iris, with the flat sur¬
face parallel to that membrane; it is then carried cau¬
tiously through the posterior chamber, without in the
slightest degree interfering with the cataract or its cap¬
sule. When the point has reached the temporal mar¬
gin of the pupil, I direct it into the anterior chamber,
and carry it on as far as the nasal margin of the pupil,
in a line with the transverse diameter of the chrystal-
line lens. I then turn the edge backwards, and with
one stroke of the instrument, cut in halves both the
capsule and cataract. By repeated cuts in different di¬
rections, the opaque lens and it capsule, are divided in
* If this be contrasted with the results of the practice at the Hotel Dieu
at Paris, it will be found that the improvements are very striking. In that
celebrated institution one hundred and thirteen cases were operated on
from 1806 to 1810—and of these only forty-three were completely success¬
ful, and ten partially so. And in the very hospital in which Sir William
Adams operated, of twenty-four cases in which extraction was performed
by the usual method, one only succeeded.
ELEMENTS OF SURGERY.
393
many pieces, and at the same time I take particular
care, to detach as much of the capsule as possible from
its ciliary connection. As soon as this is accomplished,
I turn the instrument in the same* direction as when it
entered the eye; and, with its flat surface, bring for¬
ward into the anterior chamber, as many of the frag¬
ments as I am able: by these means, the upper part of
the pupil is frequently left perfectly free from opacity.
By cutting in pieces the capsule and lens at the same
time, not only is capsular cataract generally prevented,
but the capsule is also much more easily divided into
minute portions, than when its contents have been pre¬
viously removed.
The needle which I employ in this operation, is
eight-tenths of an inch long, the thirtieth part of an
inch broad, and has a slight degree of convexity through
its whole blade, in order to give it sufficient strength to
penetrate the coats of the eye without bending. It is
spear-pointed, with both edges made as sharp as possi¬
ble, to the extent of four-tenths of an inch. Above
the cutting part, it gradually thickens, so as to prevent
the escape of the vitreous humour.*
This instrument, it is apparent, is well calculated to
cut in pieces with facility, any cataract whose nucleus
is not too solid to admit of division, and from the pecu¬
liar manner in which it is employed, (by making the
vitreous humour and the attachment of the capsule to
the ciliary processes, a counter-resistance to the cata¬
ract, while acted upon with its edge turned backwards,)
is capable of dividing the nuclei of lenses of a greater
degree of solidity, than could be effected by any other
instrument hitherto used for the same purpose. Most
of these instruments are sharpened, a short way only
from their point, and any attempt to divide with them
■ An engraving is unnecessary from its resemblance to Saunders' needle.
VOL. I.—3 D
ELEMENTS OF SURGERY.
a lens of any considerable degree of solidity, would,
instead of accomplishing the division, detach the lens
from the ciliary processes, when, according to the usual
practice, .no alternative remains but either to depress
the lens in the vitreous humour, or to place it in the
anterior chamber for solution and absorption, whole
and undivided, which latter practice can never be
done with safety, when its nucleus does not admit of
division.
The first step of this operation consists in carrying
the needle through the coats of the eye, winch, from
its spear point and sharp edges, can be effected with a
very slight degree of force, as it penetrates the dense
sclerotic with as much facility as a lancet, while, from
its very small size, it inflicts as little injury upon the
organ as it is possible for any instrument to do. There
is reason to believe, that the degree of force which is
necessary to be used, in effecting this step with a needle
whose blade is round, instead of being flat, is one source
of the inflammation which immediately succeeds to the
operation, while the wound inflicted upon the coats of
the eye, partaking more of a contused than an incised
wound, is not only another source of irritation and in¬
flammation, but also prevents its healing kindly, which
evidently cannot be the case when my sharp-edged
needle is employed. It has, however, been stated, that
the eye sustains less injury from the use of a blunt, than
of a sharp cutting instrument, but this opinion I con¬
ceive to be entirely erroneous; where any part is to be
divided, it can obviously be done with less injury apd
violence, the sharper the instrument employed, provid¬
ed it is used with skill and judgment. H this argu¬
ment applies to operations in general, how* much more
forcibly may it be urged, in regard to those on the eye;
when any considerable degree of force is there em¬
ployed, either from the nature of the operation itself,
ELEMENTS OF SURGERY. 395
or from the instrument with which it is executed, a
degree of inflammation is produced, which too often
baffles the utmost skill of the operator. On this ac¬
count, it is observable, that the most experienced ocu¬
lists are the most particular in their instructions relative
to the form and condition of their instruments, all
agreeing, that the favourable termination of the sec¬
tion of the cornea, greatly depends upon the good con¬
dition of the knife; and surely, if it is the principle of
an operation to divide the cataract, that object can be
more expeditiously accomplished, and with less violence
to the eye, with a sharp-cutting needle, than with a
blunt one, in which latter case, the cataract is torn,
rather than cut; so many movements of the needle are
also required, as not only to prolong the sufferings of
the patient, but the continued action of the instrument
upon that part of the coats of the eye in which it is
inserted, necessarily excites inflammation, and hazards
the total failure of the operation.
From the facility with which my needle penetrates
the coats of the eye, the operator (particularly if he has
been in the habit of employing needles with round
blades) should be careful not to use much pressure, and
should make the puncture at a sufficient distance be¬
hind the iris, and parallel with its plane surface, other¬
wise the point may either pass through that membrane
before it reaches the edge of the pupil, or be carried
too far into the eye towards the nose. In either case,
however, no serious mischief is to be apprehended,
and these accidents can only occur to a very inexpe¬
rienced and unsteady operator, who would probably do
much more mischief to the eye, by any other mode of
operating; the eye being rendered immoveable by
the speculum, and the pupil previously dilated by the
belladonna, the iris is the only part at all likely to
396
ELEMENTS OF SURGERY.
be injured in this step of the operation, unless indeed
the instrument be broken in penetrating the coats of
the eye, an accident which, when the operation is per¬
formed, agreeably to the description of it given at length
in my work on Diseases of the Eye, can only happen
from unskilfulness.
The second step of the operation consists in dividing
both capsule and lens, with the same stroke of the
knife. This may be always accomplished, when the
vitreous humour is in a healthy state, in young, and
frequently in old persons, by turning the edge of the
knife backwards, in the manner directed, provided the
usual degree of firmness, in the attachment of the capsule
to the ciliary processes, exists. In those cases, however,
where the nucleus of the lens is too solid to admit of
division, if an attempt is made immediately to divide the
lens, it will be entirely separated from its natural ad¬
hesions, when, should the vitreous humour be partly
or wholly disorganized, the cataract will immediately
become spontaneously depressed, when it cannot be
extracted, without hazarding a very dangerous escape
of the vitreous fluid. This is the only accident to
which the second step of the operation is liable, when
properly conducted; as, if the iris be wounded with the
point of the needle, it must, as in the first, at all times
be the fault of the operator. Should he not have had
sufficient experience to enable him to'ascertain with pre¬
cision, the nature of the cataract by previous examina¬
tion, he may certainly fall into the error, of attempting
to divide a lens, which is too solid to admit of such
division, when, should the vitreous humour prove to be
in a disorganized state, he necessarily subjects the pa¬
tient to the dangers already detailed, from the depres¬
sion of a solid lens, in a fluid vitreous humour. As
this knowledge can only be acquired by practice, and
ELEMENTS OF SURGERY.
397
observation, the young operator, in all doubtful cases,
should proceed with caution; and, instead of attempt¬
ing to cut the capsule, and cataract in halves, with one
stroke of the instrument, it will be prudent in him, to
act at the first only with its point; by this means, he
will be enabled to ascertain the consistence of the
opaque lens, which will direct him how to proceed, in
the prosecution of this, the most important step of the
operation.
Having effected the division of the nucleus of the
cataract, the operator is then to remove the divided por¬
tions with the point of the needle, through the aperture
of the pupil, into the anterior chamber, which consti¬
tutes the third, and last step of the operation.
When the consistence of the cataract is tolerably
firm, there is no difficulty in placing a part, or even the
whole of the divided lens in the anterior chamber,
should it be adviseable so to do, such is the dilated
state of the pupil; no impediment is presented to the
accomplishing that object: but when, as sometimes
happens, the lens is very soft, and of a jelly-like con¬
sistence, the flat part of the needle, passes through it,
with as much facility, as if it were turned edgeways, in
which case, after freely dividing the capsule, as. well
as the lens, it will be better, to avoid irritating the coats
of the eye considerably, by repeated attempts to pass
the portions of cataract through the pupil, which might
probably produce inflammation, but rather to let it re¬
main in situ, (taking care, however, to prevent its press¬
ing too much against the posterior part of the iris,)
where it will in a few weeks become lessened in quan¬
tity, and acquire a consistence which admits of its being
removed with great readiness into the anterior cham¬
ber, if it be necessary to repeat the operation. In this
stage, also, the iris may be wounded with the point of
398
ELEMENTS OF SURGERY.
the needle., from a want of dexterity in the the operator,
but otherwise that accident will never happen, as, from
the dilated state of the pupil, its circular margin is suf¬
ficiently out of the way of the needle, when the opera¬
tion is skilfully performed.
If the capsule be partially,-and not completely cut in
pieces, during the division of the lens, after placing the
fragments of that body in the anterior chamber, the
capsule should be lacerated to the full extent of the
area of the pupil. In doing this, the iris is alone the
part subjected to injury; whatever injury the ciliary
processes, or vitreous humour, have sustained during
the posterior operation, (ag the introduction of the
needle behind the iris has been called,) being of no mo¬
ment whatever, the uses of the ciliary processes having
ceased, as soon as the chrystalline lens is removed; and
it is evident, from the very little irritation generally ex¬
cited in the eye by the operation for capsular cataract,
that no inflammation is to be apprehended from the la¬
ceration of these processes by the needle; experience
in the operation for couching, (but especially the cir¬
cumstance of the patient's vision not being perceptibly
impaired, when the vitreous humour is in part or wholly
disorganized,) renders it equally certain, that no injury
is occasioned by the needle having lacerated the vitre¬
ous tunic.
The next operation to be considered is that for " cap¬
sular and adherent capsular cataract." , The needle
used in this operation, although slightly curved, is much
less bent at its point, than that recommended by Pro¬
fessor Scarpa, on which account the surgeon can direct
the point of it with greater ease and precision, for the
purpose of separating minute portions of capsule, when
adherent to the iris. In this operation the capsule
should be lacerated very freely, as much as its consis
ELEMENTS OF SURGERY.
399
tence will possibly admit of; but when that membrane
is too thickened to enable the operator to accomplish
this object, he must then detach it, from its ciliary con¬
nexion, except at one small part, as I have already
described, and afterwards place it out of the axis of
vision. In effecting these steps, there is less likelihood
of wounding the iris even than in the operation for
children and young persons, from the point of the
needle, which is introduced at the same distance be¬
hind the iris, being somewhat curved, and directed to¬
wards the bottom of the eye, the pupil being dilated by
the belladonna.
When the capsule adheres to the iris, constituting
u adherent capsular cataract," the operator must pro¬
ceed more cautiously, otherwise, in liberating the adhe¬
sions between the cataract and the iris, the latter mem¬
brane may be injured, and thereby give rise to severe
inflammation; or, should the adhesions be very firm
and extensive, a forcible attempt at separation would
be likely to detach the iris from the ciliary ligament,
and consequently occasion an obliteration of the na¬
tural pupil. In this, as in the operation for capsular
cataract without adhesions, care must be taken not en¬
tirely to detach the capsule from the ciliary processes, as
it would float about in the vitreous humour, and proba¬
bly obstruct the pupil; but, on the other hand, if not
sufficiently detached, it will be likely, particularly if
much thickened, to rise again into its former situation.
Should these accidents occur, the evils resulting from
them may be avoided; the floating portions may be ex¬
tracted through a small puncture in the cornea, and if
the capsule should rise, the operator may again intro¬
duce the needle through the same puncture in the eye,
and detach it still further; or, if the return should not
take place for some time after the operation, it may be
400
ELEMENTS OF SURGERY.
again repeated, and the farther detachment effected, as
may be necessary..
In " adherent lenticular cataract,v when the pupil ia
not too much contracted, provided the nucleus of the
lens is sufficiently soft to admit of division, I employ
the same two-edged needle as in operating for the solid
cataract in young persons. Part of the fragments
should then be carried through the pupil with the point
of the needle into the anterior chamber for solu¬
tion and absorption. In this case, great caution is
necessary on the part of the operator, both from the
small size of the pupil, and from the extensive adhe¬
sion of the capsule of the lens to the iris, affording a
much smaller .area for the action of the needle, and
thereby rendering the iris more liable to be cut or punc¬
tured with the point of the instrument, while dividing
the lens; in effecting this division, unless the surgeon
proceed with similar caution, the iris is put so much
upon the stretch as either to hazard its partial detach¬
ment from the ciliary ligament, or to produce a consi¬
derable degree of inflammation. By proper care and
delicacy in the use of the needle, these dangers may,
however, be wholly avoided, and are to be apprehend¬
ed only, when an injudicious degree of force is employ¬
ed with the instrument. If the pupil be too much con¬
tracted for the purposes of vision, the surgeon, instead
of using the two-edged needle to cut up the cataract,
should, at the first, proceed to the division of the iris,
in order to form an artificial pupil, in a manner which
will presently, be minutely described.
When the lens is hard, and solid, and the pupil suffi¬
ciently large to admit of its free passage, I at once
carry the lens forwards into the anterior chamber, with
the two-edged needle, ready for extraction, but more
commonly the pupil requires enlargement before this
ELEMENTS OF SURGERY.
401
can be effected. The iris scalpel, should in this case
be employed at first, with which the iris should be
divided transversely full two-thirds of its extent, and
the lens afterwards carried through this new opening,
into the anterior chamber, with the point of the same
instrument. Should the lens be soft, and even trans¬
parent, both lens and capsule ought to be cut through
and divided, the capsule being always opaque, which
would intercept the rays of light, equally as if the lens
were in the same state.
In introducing the iris scalpel at the usual distance
behind the iris, its edge should at the first be turned
backwards instead of upwards or downwards; by that
means, the stretching of the aperture in the coats of
the eye, which ensues from subsequently turning its
edge backwards, (as is recommended in the operation
for solid cataract in young persons,) and also the escape
of a portion of the vitreous humour, when partially or
wholly disorganized, will be prevented. It is of great im¬
portance that this escape should not take place in this
particular species of case, for the coats of the eye being
thereby rendered flaccid, a sufficient resistance to the
action of the knife is not afforded in dividing the iris;
whereas, if the operator endeavours to accomplish his
object by increasing the degree of pressure upon the
instrument, he will detach that membrane from its
ciliary ligament, instead of dividing it. It is necessary
not only to divide the iris, but either to detach, or di¬
vide the capsule of the lens, to the full extent of the
opening of the iris, otherwise its radiated fibres cannot
retract the edges of the divided membrane sufficiently
distant from each other, to prevent their reunion by the
first intention, unless indeed some portions of the trag-
ments of the divided lens are interposed between them.
For the purpose of dividing the iris, I introduce the
vor>, r.—3 e
402
elements of surgery.
point of the instrument, through the coats of the eye
about a line behind that membrane. The point is next
brought forward through the iris, somewhat more than
a line from its temporal ciliary attachment, and cau¬
tiously carried through the anterior chamber, until it
nearly reaches the inner edge of that membrane, when
it should be drawn uearly out of the eye, making gen¬
tle pressure with the curved part of the cutting edge
of the instrument, against the iris in a line with its
transverse diameter. If, in the first attempt, the divi¬
sion of the fibres of the iris is not sufficiently exten¬
sive, the point of the knife is to be again carried for¬
ward, and similarly withdrawn, until the incision is of a
proper length. I take care, however, very freely at the
same time to cut the cataract in pieces. Some of these
pieces I bring into the anterior chamber, and leave the
remaining portions in the newly-formed opening of the
iris. These act as a plug in preventing its reunion by
the first intention, and assist the radiated fibres, in keep¬
ing the pupil more extensively open; by the time these
fragments are dissolved, the iris has lost all disposition,
or indeed power, of again contracting, its divided edges
having by that time become callous, and being drawn
considerably apart by the permanent contraction of the
radiated fibres." (Adams.)
In reviewing the innovations introduced within a few
years in the treatment of cataract, every intelligent sur¬
geon will perceive, that they embrace modifications of
every mode of operating hitherto employed, and are to
be regarded more in the light of improvements than in¬
ventions, nor is this conclusion derogatory to the cha¬
racters of those by whom these new modes of operat¬
ing have been introduced—Since his merit is surely
greatest, whose practice succeeds best. Mr. Hey has a
sentence which I shall here transcribe, as proving that
before Mr. Saunders or Sir William Adams were
ELEMENTS OF SURGERY.
40S
known in the medical profession, he had accidentally
performed their operations.
" Though I do not think it advisable to persist in
pressing an entire cataract into the anterior chamber,
when the advance of the cataract causes a large dilata¬
tion of the pupil; yet after the needle has wounded the
capsule, a firm cataract, or at least its nucleus, will
sometimes slip through the pupil without the design of
the operator. This has been considered by some au¬
thors, as a disagreeable circumstance, and has been
ranked amongst the objections to the operation of
couching. On the contrary, it ought to be considered
as a favour able event, since the cataract always dis¬
solves in the aqueous humour, and finally disappears
without any injury to the eye. This, at least, has been
the event in every case of the kind which I have seen.
I have six or seven times seen the whole opaque nu¬
cleus fall into the anterior chamber of the eye, and very
frequently small opaque portions. Indeed, if the cata¬
ract could, in all cases, be brought into the anterior
chamber of the eye, without injury to the ins, it would
be the best method of performing the operation. But
this is not usually practicable; the softness, as well as
the bulk of the cataract presenting an obstacle to this
process/'
It is strange that Mr. Hey should state, that when
the nucleus of a cataract accidentally escapes into the
aqueous humour it is a favourable circumstance, and
should yet never have done by design what succeeded
so well by accident.
Sir William Adams's new mode of extraction I have
too recently been acquainted with to decide upon it.
I think it well entitled to trial, and shall try it impar¬
tially.
One remark I shall make in concluding this article,
404
ELEMENTS OF SURGERY.
which is, tliat it is impossible to anticipate the degree
of inflammation likely to result from any operation on
the eye. In some cases when merely punctured, it in¬
flames very violently, and in others, where the opera¬
tion is difficult and protracted, scarcely any inflamma¬
tion results. This remark must not be construed into
an apology for violence, or for too much effort to de¬
stroy the texture of the lens, for I believe that the
surgeon who treats the organ most tenderly will be
most sure of success.
My own practice at present is to destroy as much as
possible the texture of the lens and capsule in the man¬
ner described by Sir William Adams, and with the
same instruments, and to push the fragments as much
as possible into the anterior chamber for solution and
absorption. When the nucleus remains unabsorbed
and very hard, I propose in future to extract it. I have
in two cases found long continued inflammation to re¬
sult from leaving a large portion of hard cataract in
the anterior chamber; these portions are diminishing
however daily, and f trust will be ultimately removed.
Some of my patients with very tough membranous ca¬
taracts, have as yet, derived ho benefit from the opera¬
tion, and are still under treatment. I have a gouty pa¬
tient thus circumstanced, whose eye occasionally in¬
flames severely during his gouty paroxysms.
Carcinoma ofllte Eye.
' '' J~.ysc.
i
ELEMENTS OF SURGERY.
405
CHAPTER LXI
Extirpation of the eye.
This operation, terrible in its nature, is extremely
simple. The diseases which render it necessary are
not very accurately defined. In general it is perform¬
ed for the removal of a disorganization which com¬
mences, and terminates in a fungous tumour: in some
cases this affection begins without pain, but commonly
it is preceded by head-ache, and itching and watering
of the eye. It is in some cases truly cancerous, but in
others, probably, has no cancerous tendency. It occurs
at all ages, but oftenest in young persons. More than
one-third of D vault's patients were under twelve years
of age. As the disease advances great pain is perceiv¬
ed—sight is lost—the cornea inflames, ulcerates, and
bursts—a fungous red tumour projects through it, dis¬
charging a purulent sanies, fetid and acrid—the size
of the tumour becomes very great. I extirpated a fun¬
gous tumour of this nature from the socket of a boy^s
eye, resembling, except in colour, a cauliflower, its size
and appearance are represented in the annexed plate
—no return of the disease took place. The plate af¬
fords a tolerable idea of the general form of this dread¬
ful malady.
The operation is to be performed, when practicable,
by separating the lid, from the ball of the eye with a
scalpel: but in many cases this is impracticable, and all
that can be done is to save as much of the upper lid
as possible, provided it be sound. A straight bistoury
of sufficient strength is to be passed as quickly as pos¬
sible round the basis of the tumour, the surgeon mak-
406
ELEMENTS OF SURGERY.
ing it revolve upon its point in such a manner as to
keep the edge close to the bony orbit. Having seen
Mr. Dubois at Paris perform the operation in this sim¬
ple manner, I have imitated his example, and in a very
short time the operation is completed. Any portions
of the tumour which remain may be afterwards remov¬
ed, but as the hemorrhagy is always very profuse, what¬
ever cutting is done, should be done quickly. The
orbit is to be filled with lint, and the bleeding soon
ceases. The antiphlogistic regimen should be adhered
to for a few days.
Sometimes the fungus returns, and although often
destroyed, as frequently springs up. In these cases the
event is fatal. But as death is inevitable if the disease
be not extirpated, the attempt ought always to be made.
I have four times performed the operation, and three
of the four patients remain quite free from disease.
The fourth was attended with disease of the absorbent
glands, and terminated fatally, though life appeared to
be prolonged by the operation.
TAPPING THE EYE.
Dropsy of the eye, or hydrophthalmy, sometimes
renders it necessary to evacuate the aqueous humour,
accumulated in too great quantity. Scarpa states that
in the cases of dropsy of the eye which he has dissect¬
ed, the vitreous humour has been in a morbid state of
fluidity, and he was unable to distinguish it from the
aqueous humour. The proper internal remedies hav¬
ing been in vain administered, if the eye-ball continue •
to augment in volume, and protrude from the socket, it
becomes necessary to open the eye by a surgical ope¬
ration. Nuck used to puncture the centre of the cor¬
nea with a small trochar; other writers recommend the
puncture to be made through the sclerotica. Scarpa
ELEMENTS OF SURGERY.
407
advises a small circular incision to be made in the up¬
per part or centre of the cornea, as the best mode of
evacuating the eye. In several cases I have punctured
the cornea by inserting the point of a sharp cataract
knife through it; the evacuation of the aqueous hu¬
mour, although not sudden, was amply sufficient; but if
necessary it is very easy to turn the knife a little, so as
to make the incision somewhat circular, whereby the
fluid will more readily escape.
Dr. Physick, from an idea that gutta serena is in some
cases occasioned by pressure upon the retina and optic
nerve from an over secretion of aqueous humour, has
punctured the eye with a view to relieve this affection,
In some instances the operation has been evidently ad¬
vantageous—in others no benefit whatever has result¬
ed. I have suggested this, because I shall not enter
into the history of this paralytic affection of the eye, as
many excellent histories of it are in the hands of every
medical man. Richter, Scarpa, and Ware are among
the best writers on the subject, and to them I refer,
only suggesting that in very obstinate cases where other
remedies have failed, tapping may be tried, as it has
been sometimes useful, and the repeated application of
blisters directly over the eye-lids, are also occasionally
beneficial
408 ELEMENTS OF SURGERY.
EXPLANATION OF THE PLATES.
Fig. 1. Represents the most usual form of Pterygium
or Unguis.
2. The appearance of an eye, after the excision of
that portion of the palpebra, from which the
cilia project; an operation performed for the
cure of Entropium or Trichiasis.
3. Curved scissors used in various operations on
the eye.
4. Forceps.
5. Saunders's couching needle.
ti. Scarpa's couching needle.
7. Hey's couching needle.
8. Represents the section made in the cornea in
the operation of extracting a cataract
0. An artificial pupil, near the external margin of
the iris.
10. The place of introducing the cornea knife and
the mode of passing it through the anterior
chamber of the eye.
11. This figure represents an accident which some¬
times happens in the operation of Extraction,
the floating of the iris before the blade of the
knife.
12. Tiie forceps contrived by Dr. Physick, with a
circular punch on the extremities of the blades.
13. A small hook useful in the operation of Extrac¬
tion.
14. Wenzel's knife for incising the cornea.
15. Curette and needle.
16. Wenzel's forceps.
17. The nail-headed style used in fistula lachry-
malis.
.//jr .v././"/,/
p
ELEMENTS OF SURGERY.
409
CHAPTER LXII.
Of Polypus.
A polypus is a fleshy excrescence, of various den¬
sity and colour, originating from the lining membrane
of a canal or cavity, as the nose, vagina, rectum, &c.
The nostrils are the most frequent situation of this
complaint. It commences as a small pendulous tumour,
void of pain, accompanied with watering of the eyes,
sneezing, and the usual symptoms of catarrh. The co¬
lour of these tumours is generally a pale red. They
commonly commence from the ossa spongiosa; but^fc
casionally from all the parts concerned in-forming tire
cavity of the nostril. They produce at first no other
effects than have been noticed, but as they enlarge, the
defluxion from the eye increases, sneezing is frequent,
and the tone of voice is much altered. The weather
has a great influence on the patient. In dry weather
the tumour appears to diminish, and it increases in
damp and cold weather—augmenting gradually in size,
it at length obstructs the passage of air through the
nostril, and in this stage produces a very unpleasant
nasal tone of voice. The polypus assumes gradually
the shape of the cavity of the nose, being formed in it
as in a mould. It becomes visible at the anterior nos¬
tril and at the fauces behind, where it may be seen si¬
tuated over the soft palate, and sometimes hanging down
behind the uvula. In this state great inconvenience is
experienced—the eyes are constantly suffused with
tears, from the obstruction to the ductus ad nasum. In
some instances, ulceration takes place, and a fetid mat¬
ter is discharged, attended with great inflammation and
vol. i.—3 F
410
ELEMENTS OF SURGERY.
severe pain. In some cases, however, it is remarka¬
ble that the tumour acquires a great size, and the pa¬
tient suffers no pain. From the nose being stopped
patients generally sleep with the mouth open, and in¬
convenience is sustained from the dryness of the mouth
and throat. Hearing is often injured, probably from
pressure against the Eustachian tube. In swallowing,
some difficulty is experienced from the weight of the
tumour which presses against the velum pendulum pa-
lati. The appearance of the face becomes changed
from one nostril being wider than the other, the root
of the nose appears swelled, and violent head-aches
come oa—the bones eventually become carious and ul¬
cerated—a foul fetid sanies mixed with blood is dis¬
charged—hemorrhage sometimes ensues—the teeth
ftrfl out and a fungus shoots through the sockets. These
symptoms in some cases increase and exhaust the pa¬
tient's strength;—frequent bleedings and an incessant,
discharge of matter take place, and during the last stage
of the disease, stupor and coma come on, and eventu¬
ally death.—Such are sometimes the dreadful effects of
a disease at first trifling, and to all appearance of very
little consequence.
The causes of this complaint are not well understood
Some have supposed picking the nose, or violently
blowing the nose to have produced it; but for this there
is no foundation.
Several species of nasal polypi are described by au¬
thors, one of which is said to be of a malignant nature,
disposed to end in cancer. This, however, 1 believe is
extremely rare; the most common are a fleshy, red vas¬
cular polypus, and a pale tough, firm polypus, neither
of which is of a cancerous nature.
ELEMENTS OF SURGERY.
411
TREATMENT.
The cure of polypi consists in extracting or destroy¬
ing them with caustic.
The extraction may be performed by forceps, or by
passing a ligature round the base of the tumour in such
a manner as to destroy the circulation, after which the
polypus soon falls off. The application of a ligature is
to be preferred in cases where the pedicle by which it
hangs is very small, or in cases where the patient is too
feeble to bear the loss of blood which is apt to follow
the use of the forceps. The mode of applying the li¬
gature must vary in different cases. Sometimes all that
is necessary is to pull the polypus forward with a hook
and pass a silver wire over it—or a waxed ligature may
be formed into a noose and passed round the base of
the tumour in the same way. When the wire is to be
used a double canula is generally the best instrument
for fixing it—it must be drawn very tight, and in a few
days the polypus will fall off. It is of great importance
to watch when the polypus becomes loose, as it has oc¬
casionally separated in the night time and endangered
suffocation by falling over the glottis. A case of this
complaint occurred several years ago, in which Dr.
Physick practised a new mode of extraction that will
probably be found useful in many other instances. A
gentleman having suffered many unsuccessful attempts
for the removal of his polypus, came to Philadelphia
and consulted Dr. Physick—he found a large tumour
projecting behind the soft palate as low as the extre¬
mity of the uvula, and filling completely the posterior
nares and cavity of the nose; after vain attempts to ex¬
tract it in the usual manner with ligature and forceps,
* piece of tape was made stiff by passing silver wire
through it, and this was fixed on the projecting part of
412 ELEMENTS OF SURGERY.
the tumour by a firm knot—the tape was now pulled
forcibly and with it came away Ihe polypus, which was
of prodigious size.
In using the forceps they must be applied as near the
root of the polypus as possible. Hemorrhage generally
attends the operation, but it is not often alarming—cold
water or brandy injected into the nose generally checks
it. If not, a plug of lint may be introduced into the
nostrils so as to press on the part whence the blood
issues. If necessary, the posterior nostrils may be
stopped up by passing a double catgut through the nose
into the mouth, and by means of this a roll of lint is
readily introduced into the posterior nares which inva¬
riably succeeds in putting a stop to the hemorrhage.*
The application of caustic is often requisite to pre¬
vent the growth of the tumour after the greater part of
it has been removed. This is in general easily effected
by means of a bougie, or a roll of waxed linen in which
is included a piece of caustic alkali.
The application may be repeated daily until the tu¬
mour no longer grows up.
* Mr. Samuel Cooper stales that when the usual means for checking he¬
morrhage have failed, he has invariably succeeded by rolling a portion of
lint on a probe, and wetting it with a strong solution of sulphate of zinc,
and applying it to the bleeding surface. When the nostril is sufficiently
dilated, the fingers may be used for this purpose with more advantage than
the probe.
Soft tow pushed into the nostril is found to be extremely convenient, it
is easily applied and readily removed.—Ed.
ELEMENTS OF SURGERY.
413
CHAPTER LXIII.
Of Ranula.
This consists in a tumour under the tongue contain¬
ing a glairy fluid, resembling the white of an egg. It is
supposed to proceed from an obstruction in the salivary
duct. The tumour is generally on one Side of the fras-
num linguse, and varies greatly in size, sometimes ex¬
tending to the very point of the tongue, and elevating it
considerably.* The tumour sometimes contains in¬
stead of the viscid fluid which has been mentioned, a
purulent matter, and sometimes, a calculous concretion.
When uninflamed the disease gives no pain, but from
its bulk is more or less inconvenient; when it inflames
considerable pain is experienced.
TREATMENT.
The remedy for ranula, that is, for a tumour actually
formed by a dilatation of the salivary duct, consists if
possible in dilating the duct by means of a probe, as
recommended by Desault; but it is not often in our
power to effect this, and other measures become neces¬
sary.
The extirpation of the tumour is difficult and dan¬
gerous on account of the large blood-vessels in the vi¬
cinity. The British surgeons are in the habit of laying
open the cavity of the tumour, by a free incision, after
which they apply caustic to its surface. This plan does
not always effect a cure, and is unnecessarily severe; a
simpler and easier method should therefore have the
* I have never seen these tumours very large, but when suppuration
iakes place in them, large abscesses have been formed, and as much as a
pint of matter has been discharged from under the tongue.
414
ELEMENTS OF SURGERY.
preference. In a majority of cases the disease may be
cured, as recommended by Dr. Physick, by passing a
seton through the cavity of the sac; a common curv¬
ed needle armed with a ligature can readily be passed
through the tumour, the needle being cut off, the
string is suffered to remain in the cavity of the tu¬
mour where it excites inflammation and suppuration,
after which a fistulous orifice is established through
cJ
which the saliva afterwards flows, and this is soon fol¬
lowed by a complete obliteration of the cavity. I have
known this simple remedy successful in a great number
of cases, and I believe it will be found to fail in very
'few.
If calculous concretions are found in the sac they
must be removed, and the caustic if necessary can be
applied for the purpose of destroying the sac. I have
met with a very difficult case of ranula attended with a
large calculous concretion, which occasioned an abscess
and salivary fistula in the neck. In this case the cal¬
culus enlarged, and was found in close contact with
the carotid artery and compressing the oesophagus and
trachea. I succeeded in rescuing my patient from his
dangerous condition by injecting into the cavity con¬
taining the calculus, diluted sulphuric acid, which
softened the stone and enabled me to extract it with
forceps through an incision made cautiously down to
-the stone. The aperture of the submaxillary duct
being enlarged by probes and bougies, the external
wound healed up in a short space of time.
It has occasionally happened that a small calculus in
the duct produces the obstruction, in which case all that
is necessary is to remove it, after which the tumour
will subside.
Mr. B. Bell relates such a case which terminated in
ulceration of the cavity. The ulcer could not be heal¬
ed until the calculus was removed.
ELEMENTS FO SURGERY,
4r\5
CHAPTER LXIV.
Of Salivary Fistulas.
In consequence of wounds of the cheek or ulcers,
the duct of the parotid gland is sometimes opened and
discharges its contents externally. When the patient
is eating, the saliva, instead of being poured into the
mouth, flows out upon the cheek. Whether the loss
of this fluid occasions any effect upon the digestive
organs or not, the complaint is found extremely incon¬
venient; two ounces of saliva are said to have flowed
out of such a fistula during a single meal.
In case of a recent wound which opens the parotid
duct, great care should be taken to unite very accu¬
rately the sides of the wound externally; in this way the
probability is, that the duct will either reunite or form
a fistulous orifice internally, either of which occur¬
rences will prevent the formation of an external fistula.
When the fistula has existed for a considerable time,
and attempts have been made by pressure, caustic ap¬
plications, and other means, to heal up the ulcer with¬
out effect, more difficulty is to be anticipated. In these
cases it is necessary in the first place to establish an
opening into the mouth, and afterwards to heal up the
external orifice.
Mr. Charles Bell directs the following measures,
which I believe were contrived by the celebrated Dr.
Monro: u Our first attempt will be to pass a small
silver probe from the mouth into the natural opening
of the duct, and enlarge it, if it shall be found con¬
tracted; then to substitute a small tube, which being
introduced from the mouth shall also pass some way
416
ELEMENTS OE SURGERY.
into that part of the duct which discharges the saliva.
Lastly, while the tube is retained in its place, the out¬
ward lips of the wound are to be made raw, brought
together and healed.
" But the circumstances of the case may be such,
that it will be better to make a new duct, from the
fistulous opening into the mouth. To do this we must
push a straight needle, obliquely from the bottom of
the fistula into the mouth, and draw through a small
seton, which is to be worn until the passage is callous
Then either with or without introducing the tube, we
have to endeavour to unite the edges of the outward
opening."
Desault made use of the seton in the treatment of
salivary fistulas, but instead of introducing it in the
usual manner, he complicated his operation by using
a trochar instead of a needle. His mode of cure which
differs in several particulars from the one just described,
appears to'have no advantages over it.
The patient during the cure, should as much as pos¬
sible avoid speaking, and should be nourished princi¬
pally upon spoon victuals.
ELEMENTS OF SURGERY.
417
CHAPTER LXV
Of Abscess of the Antrum MaxiUare.
This cavity is sometimes the seat of inflammation
and suppuration. The complaint commences like a fit
of tooth-ache, a severe darting pain extending through
the jaw, without any external tumefaction: afterwards
suppuration takes place; the pus flows into the nostril
of the affected side, especially when the head is in¬
clined in such a position as to favour its escape. The
disease even after suppuration is established is not al¬
ways easily known, for the mucus of the nostril often
resembles pus, and the pus is mistaken for the common
secretion of the nostril. In some cases the affection
subsides after suppuration takes place, but more gene-
rall it continues, and occasions caries of the bone.
The absorbents remove portions of bone, and make
outlets for the pus in different places. In some cases
the sockets of the molar teeth are absorbed, the teeth
loosened, and the pus discharged through the openings
thus formed into the mouth.
The cause of the disease is often a caries of the up¬
per molar teeth and consequent inflammation of the
sockets, extending gradually to the antrum.
The treatment of the abscess is to be commenced by
extracting any carious teeth which may exist in its
vicinity; this removes in many instances the remote
cause of the disease, and also affords not unfrequently
a ready outlet for the pus at the most depending part
of the abscess, which is an object of great importance.
If the fang of the tooth should not extend into the
antrum, a perforation is to be made cautiously with the
vol. i.—3 G
418
ELEMENTS OF SURGERY.
stilette of a small trochar, or a common pointed probe.
If, however, the teeth be sound, and pus evidently
exists in the antrum, the third or fourth molar tooth
should be removed, and an aperture made through its
socket into the abscess.
The removal of carious bone should never be at¬
tempted before it is quite loose; this process may be
very safely trusted to the absorbent vessels.
Besides inflammation and abscess, the antrum is oc¬
casionally the seat of fungous tumours. These occasion
an enlargement of the bone, and subsequently an ab¬
sorption of it. The alveolar sockets are protruded
downward, and the teeth pushed out from their sock¬
ets. The nostril becomes filled up; the excrescence
extends in every direction; the eye is pushed upward,
and in some cases the skin ulcerates, and the fungus
protrudes through it.
The only remedy is an early extirpation of the tu¬
mour, by removing a portion of the bone, and dissect¬
ing out the tumour with a knife, and destroying what
may remain with caustic; if the disease have made
much progress before the operation is performed, its
efficacy is very doubtful. In one case I extirpated a
very extensive fungous tumour, extending almost to the
orbitar plate of the upper maxillary bone, in a girl, and
after a cure was apparently nearly effected, the tumour
recommenced its growth, and neither the knife nor
caustic had any effect in arresting its progress. The
disease although not very frequent is extremely formi¬
dable, and'often terminates fatally.
In the collection of Mr. Heaviside at London, there
is a skull exhibiting a very extensive bony excrescence
from the antrum and upper jaw, an engraving of which
may be seen in Mr. Fox's treatise on teeth. The early
extirpation of all such tumours is the only remedy in
which confidence can be placed.
ELEMENTS OF SURGERY.
419
CHAPTER LXVF.
Diseases of the Tongue.
The fraenum linguae is occasionally too short to allow
the free motion of the tongue, and it sometimes ex¬
tends to the extremity of the tongue and thus confines
it. Children suck with great difficulty in these cases,
and it becomes necessary to divide the fraenum. The
operation is extremely easy, and may be performed
either with scissors, or, what is better, a sharp-point¬
ed bistoury. Care should be taken to avoid the ranina
artery.
It is proper to remark that surgeons are often con¬
sulted about children, said to be tongue-tied, in whom
there is no confinement of the tongue, a certain difficulty
in speaking is generally the reason for the supposition;
an inspection of the mouth will readily enable the prac¬
titioner to ascertain whether the tongue is preternatu-
rally confined or not.
Ulcers of the tongue arise from various causes and
are often very difficult of cure. Sometimes a carious
tooth occasions ulceration of the tongue; this ought
certainly to be removed or filed smooth. Slits or fis¬
sures occasionally form in the tongue, which swells and
becomes indurated in their vicinity. The use of caus¬
tic is generally proper in these cases. Dr. Physick has
employed with advantage the actual cautery in a very
obstinate case of this kind,-with a view to change the
nature of the sore into the state of a burn.
Cancer occasionally forms on the tongue;—extirpa¬
tion is the only remedy: and in performing it, all the
diseased parts should be carefully removed. Mr
420 ELEMENTS OF SURGERY:
Home advises in these cases to pass a needle armed
with a strong double ligature through the middle of the
tongue beyond the diseased part, and to tie one ligature
on each side; in this manner the diseased part being
deprived of its circulation, will mortify and drop off
The pain is not very great, and no danger of hemor-
rhagy exists. A salivation in some cases follows, but
soon subsides.
It will be obvious to every one that a little attention
and dexterity will enable the surgeon to remove such
parts only as are diseased, leaving the sound parts of
the tongue uninjured; he should always, however, apply
the ligature in sound parts. If any circumstance should
induce the surgeon to prefer the knife, he should be
careful to take up all the bleeding arteries and to have
at hand a heated iron in case he should be unable to
secure them with ligatures. I particularly urge this
precaution upon the young surgeon because no one
unaccustomed to surgical operations upon the mouth
can be aware of the difficulty of securing a bleeding
artery in these parts.
Ulcers of the tongue are not unfrequently occasion¬
ed by diseases of the digestive organs—here the reme¬
dies must be internally administered, and different cases
call for very opposite medicines. In some, alkalies are
useful, in others, acids. Opium has relieved a number
of these cases. Tartar emetic, in small doses long
continued, has occasionally succeeded. In addition to
these remedies, leeches should be applied in the vicinity
of the ulcer, and various astringent lotions are to be
tried.
Ulcers from the use of mercury, generally get well
when the medicine is discontinued.
ELEMENTS OF SURGERY.
m
CHAPTER LXVIL
Diseases of the Uvula and Tonsils.
Inflammation of the throat and fauces produces
sometimes a considerable elongation of the uvula. In
general it resumes its usual length after the inflammation
subsides, but in some cases it is permanently elongated,
and in these instances should be removed;—a hook
may be inserted into the uvula to prevent its slipping
backwards, and then with a pair of scissors a portion
of it can be easily cut off. There is no danger of
hemorrhagy *
The tonsils in this climate are particularly liable to
v inflammation. In some cases the swelling is very con¬
siderable and breathing and deglutition are greatly im¬
peded. In these cases, in addition to the remedies em¬
ployed by the physician, scarifications become neces¬
sary. A sharp scalpel answers the purpose very well.
A number of small incisions are to be made, and the
vessels suffered to unload themselves; the mouth and
throat should be rinsed with warm water to promote
bleeding. In case of suppuration the abscess may be
opened by a common lancet, and great relief will be
* The irritation produeed by an elongated uvula coming in contact with
the epiglottis and the highly irritable parts in its vicinity, has been so great
as to produce some of the most alarming symptoms of phthisis pulmonalis,
such as distressing cough, hemoptysis, &c. Influenced with this view of a
case which occurred in Dr. Physick's practice, he proposed and per¬
formed the simple operation of removing a portion of the uvula with a pair
of scissors. The result confirmed his most sanguine expectations; the
cough and other symptoms soon subsided, and the patient recovered. He
has since performed this operation on a considerable number of patients, and
most generally with the same success; he has also the satisfaction of hear¬
ing that this operation has been performed by many other physicians with
the same views and the same success — E».
4 22
ELEMENTS OF SURGERY.
immediately perceived. A particular instrument has
been constructed for the purpose of opening abscesses
of the throat, called pharyngotomus, an engraving of
which may be seen in Brambilla's Instrumentarium. It
has no advantage over a common lancet or scalpel.
The tonsils are sometimes enlarged and indurated
trom successive inflammations, and sometimes an en¬
largement occurs without any evident cause. The com¬
plaint is usually, but improperly, denominated scir-
rhus. It has no disposition to terminate in cancer, but
great inconvenience is experienced from the bulk of
the tumour. A part or the whole of the tonsil may be
removed by means of a knife, but in this operation the
bleeding is sometimes troublesome. Caustic may also
be employed, but it is the most tedious and painful
mode of removing the glands. The application of a
ligature around its base, is I believe the safest and best
mode of extirpating scirrhous tonsils; at least I have
never seen any inconvenience from this method, and I
have seen it very frequently performed.
When the base of the tumour is small, a silver wire
in a double canula, is to be applied round it, in the
same manner as around the root of a polypus; this wire
is to be drawn very tight and secured to the shoulders
of the instrument. In a great majority of cases this
operation is very readily performed, and in a few days
the tumour drops off.* Great care is necessary to
* The reader, by referringto vol. 1, p. 17, of Dr. Chapman's Medical and
Physical Journal, will find some valuable observations by Professor Phy-
sick, on the management of the double canula and wire, when employed
tor the removal of Scirrhous Tonsils.
Contrary to the usual method of allowing' the ligature to remain upon
the tumour, until it is separated, and thrown off, " a process seldom corr.-
>leted in less than a week or ten days," it is the custom of the Professor,
to allow it to remain thus applied for twenty-four hours only, and he is of
opinion, that a much shorter time will be sufficient, as eight or twelve
hours.—His objections to the application of the instrument remaining
ELEMENTS OF SURGERY.
423
make the ligature sufficiently tight in order to prevent
all circulation in the tumour, otherwise a portion of it
only will be destroyed, the central part remaining after
the rest had dropped off.
When the base of the tumour is large, it is best to
cut off at least a considerable portion of the gland with
a bistoury; the bleeding may in general be restrained
by washing the mouth with cold water. If the whole
of the tonsil be removed with the knife, it is said that a
great discharge of blood takes place. I believe that no
dangerous hemorrhagy would be likely to occur, for if
the bleeding vessels did not speedily contract, it would
be easy to apply a hot iron and put a check to the dis¬
charge. The great improvements of modern surgery
have almost entirely banished the actual cautery from
practice, but in certain hemorrhages from the fauces,
it is indispensable.
until the tumour is separated, are, that " during the whole of this time the
patient's sufferings have generally been very severe, arising from several
circumstances, next to be mentioned.
And first.—From the presence of the canula in the mouth, resting on the
edge of ihe tongue, and passing out at the corner of the mouth, great irri¬
tation is given to these parts, sometimes occasioning ulceration; and I
have seen the chin also rendered sore, by the constant flow of saliva over
it, passing by the sides of the canula involuntarily.
Secondly.—From the compression of the wire, at the base of the tumour,
on the soft parts, being continued while they are inflaming and swelling.
This ligature increases the tension and pain very much, as may be readih
understood, by any one who reflects for a moment on the effect of any liga¬
ture applied over an inflammation in any other part of the body. In addition
to the pain, a high degree of symptomatic fever sometimes supervenes,
attended with great restlessness and want of sleep, and in one instance
which came under my notice, with delirium.
Thirdly.—From the instrument hanging out of the mouth, irritating by
its weight. It is likewise constantly liable to accidents in wiping the mouth
and hps, and when touched, never fails to occasion great pain.
Fourthly—From swallowing being rendered so difficult and painful,
that the patient is very unwilling to attempt it. When it is effected, great
pain is always experienced."—En.
4 24
ELEMENTS OF SURGERY
CHAPTER LXVIII.
Of Foreign bodies in the (Esophagus.
Substances occasionally become arrested in the oeso¬
phagus, and by pressing forwards the membranous part
of the trachea obstruct respiration. I believe with Mr.
Charles Bell, that the obstruction in these cases is not
purely of a mechanical nature, but that spasm is ex¬
cited by the irritation produced, and the muscles of the
glottis diminish very much the aperture through which
the air passes.
If the substance be not likely to occasion unpleasant
consequences in the stomach, it is generally easier to
push it down than to extract it through the mouth—
pins, needles, sharp bones, or any pointed substance
which would probably wound the oesophagus, or any
portion of the alimentary canal, and also substances
which from their chemical qualities would be likely to
occasion mischief, as copper coins, &c. should if possi¬
ble be extracted through the mouth. This can only be
done when they are situated high up near the fauces.
If near the stomach they must be pushed down, and
the risk of the consequences must be incurred.
To extract substances from the oesophagus the fin¬
gers and forceps are generally the only instruments
which can be employed, and we are very often able to
see the foreign body by pressing down the tongue with
a spoon, even when the sensations of the patient lead
him to suppose that it has descended very low; a hook
of curved wire is also useful in some cases for extract¬
ing foreign matters, especiall) when they are of con¬
siderable size. In two instances I have known the
ELEMENTS OF SURGERY.
425
spasm which had arrested a foreign substance, speedily
relaxed by a solution of emetic tartar. In each of
these cases, a large peach stone had slipped into the
oesophagus, and the patients were of course unable to
swallow, and could not breathe without great difficulty.
They were directed by Dr. Physick to hold in their
mouths a solution of emetic tartar, and attempt to swal¬
low it. Nausea came on, and the spasm relaxing, the
peach stones were readily discharged.
An ingenious mode of extracting small substances, as
needles, fish-bones, &c. is described by Mr. S. Cooper.
" The art of employing compressed sponge in the most
advantageous manner, consists in taking a piece about
the size of a chesnut, and introducing each end of a
strong ligature through it. The ends of the ligature
are then to be passed through a tube, and fastened to
that end of the instrument which the surgeon holds.
The sponge is then to be introduced down the oesopha¬
gus beyond the foreign body, and water is to be inject¬
ed through the tube, in order to moisten the sponge
and make it expand. After this the ends of the liga¬
ture are to be firmly drawn, for the purpose of press¬
ing the sponge against the extremity of the canula to
make it expand still more. Then the tube is to be
withdrawn, together with the sponge, observing to twist
the instrument to the right and left in this part of the
operation.
"When the foreign substance cannot be extracted
with this instrument aprobang may be tried, to the end
of which a bunch of thread, doubled so as to make an
immense number of nooses, is fastened. Little bodies
may frequently become entangled, and be extracted in
this way, when the other one fails."
When the foreign matter cannot be extracted, it be¬
comes necessary to push it forcibly into the stomach;
vol. J.—3 H
426 ELEMENTS OF SURGERY.
this is generally done by means of a probang, a piece ot
sponge tied on the end of a whalebone, or large firm
bougie of waxed linen. In many cases where much
inconvenience has been anticipated from the nature ot
the foreign substance, it has passed through the alimen¬
tary canal, without occasioning any great inconvenience.
I have known, however, a very extensive fistula in ano,
produced by a large fragment of bone accidentally
swallowed.
When the foreign body cannot be either extracted
or pushed down into the stomach, it sometimes occa¬
sions very speedy suffocation. Benjamin Bell relates
two cases of death from this cause, and Desault men¬
tions one instance in which a woman swallowed a bone
with so much voracity that it lodged in the middle of
the pharynx and occasioned suffocation-, she died in
three minutes: numerous accidents of a like nature
have happened.
In other instances the foreign matter remains for
many years, occasioning no inconvenience. A boy
four years old, playing with an English farthing, slip¬
ped it into the oesophagus and was unable to swallow
or eject it. The accident happened in Dublin; Dr.
Dease and several other surgeons of eminence attempt¬
ed to extract it, but without success; the immediate
symptoms of suffocation soon subsided, and the coin,
although very inconvenient to the patient in his attempts
to swallow, remained without occasioning any very
alarming symptoms. He came to America, and was
attacked in this city with a vomiting of blood of which
he died after a few hours illness, at the age of seven¬
teen years. Upon examination after death, I found
the coin lodged vertically in the oesophagus opposite the
bifurcation of the trachea; it was so loose as easily to
move upwards, its motion downwards was more diffi-
ELEMENTS OF SURGERY.
427
cult. The copper was encrusted with a thick coat of
dark greenish matter, which was detached at one part
shewing the metallic surface. How it was detained
thirteen years in this situation I am at a loss to imagine;
certainly it would have been an easy matter to have
pushed it into the stomach, and by no means impracti¬
cable to have withdrawn it through the mouth.
Sometimes pins and needles are swallowed, they oc¬
casion abscesses by sticking in the oesophagus, when
they get into the stomach they are generally evacuated
with the feces. In other instances they travel to
different parts of the body, and ultimately approach
the surface. A case is related in the Memoirs of
the Academy of Surgery, in which a needle remain¬
ed eighteen years before it made its appearance ex¬
ternally, during which time very little sensation was oc¬
casioned by it.
The operation of cutting into the oesophagus in order
to extract foreign bodies, I have never known neces¬
sary, and I believe it ought very seldom to be done.
The memoirs of the French Academy contain, how¬
ever, two cases in which it was successfully performed.
Whenever suffocation is dreaded, and the patient is
unable to breathe in consequence of a foreign body in
the oesophagus, it becomes necessary to maintain the
communication of air to the lungs, by artificial means
hereafter to be described. By these means we have it
in our power to prevent suffocation, and thus to afford
time for the removal of the foreign body.
428
ELEMENTS OF SURGERY.
CHAPTER LXIX.
Of Strictures of the (Esophagus.
The oesophagus being a muscular canal is capable
of contracting at times and of being again dilated. Oc¬
casionally spasm takes place at a particular part of the
oesophagus and produces a spasmodic stricture, similar
to the same disease in the urethra. Permanent stric¬
tures in the oesophagus also occur, producing a nar¬
rowness at the part, with thickening of its substance,
and at length if not prevented, an almost total oblitera¬
tion of the canal. The case in this way proves fatal
by cutting off supplies of food, from the stomach, unless
medical aid is successful in relieving it.
The disease can in no manner be better explained,
than by a history of cases in which it has occurred.
Mr. Home has published several in his second volume
on strictures, to which the reader is referred. The
complaint generally commences with a difficulty of de¬
glutition, gradually increasing until fluids only can be
swallowed, and at last every attempt at deglutition be¬
comes extremely painful and attended with a sense of
suffocation, from the substance passing into the glottis.
Emaciation takes place—hunger is extreme, and the
patieut, unless relieved, is literally starved to death. I
have seen one case in which this actually happened—
upon dissection the oesophagus was found so nearly
obliterated that a probe could not without difficulty be
forced through the stricture.
The treatment recommended by Mr. Home is to
dilate the stricture by introducing bougies of waxed
linen, commencing with such as readily enter it and
ELEMENTS OF SURGERY.
429
gradually enlarging their diameter so as to dilate it.
In some cases this method is ineffectual, and the pro¬
gress made in dilating the passage is too slow. Mr.
Home has employed the caustic in such instances with
advantage, and Dr. Andrews of Madeira, has lately
published some cases in which the same remedy prov¬
ed successful. The lunar caustic is to be preferred. It
must be fastened securely in the extremity of a bougie,
of such a size as to pass readily down to the stricture;
another bougie of a larger diameter is first to be intro¬
duced, and when the resistance of the stricture is felt
the patient by shutting his mouth makes a mark with
his teeth, upon the instrument, by which the precise
distance of the stricture is ascertained. This bougie
being withdrawn, a mark corresponding to it, is to be
made on the bougie, armed with caustic, which is next
to be introduced, and suffered to remain half a minute
in contact with the stricture; this may be repeated as
often as necessary. In passing the bougie, it will be an
advantage to preserve as accurately as possible the curve
which the first instrument had assumed, as this facili¬
tates greatly the operation of introducing it.
430 ELEMENTS OF SURGERY.
CHAPTER LXX.
Of Obstructions in the Glottis and Trachea.
Whenever respiration becomes interrupted in con¬
sequence of obstruction in the trachea either from dis¬
ease, or from foreign substances accidentally introduc¬
ed into it, it becomes necessary to make an artificial
opening into this canal, below the obstructed part, in
order to preserve the free communication of air to
the lungs. This has generally been done by cutting
into the trachea, an operation which may be performed
with great safety and without risk of any permanent in¬
convenience—this truth is established, not only by the
frequency with which the operation has been perform¬
ed, but also by the facility with which even the most
extensive wounds of the windpipe heal up, after unsuc¬
cessful attempts to commit suicide.
Although the operation of cutting into the trachea
may become necessary in a variety of instances, yet the
necessity for performing it has been greatly diminished
by the introduction of apian of treatment in which the
knife is dispensed with: the passage of a flexible tube
through the glottis into the trachea.
The causes which may render one of these operations
necessary are numerous. Inflammatory swellings in the
vicinity of the glottis, as in the tonsils, sometitnes occa¬
sion great difficulty in breathing, and though I have
never known tracheotomy performed in this place in
consequence of an enlargement of the tonsils, yet it may
possibly become necessary.—Tumours sometimes form
in such situations as to impede respiration by pressing
on the trachea.—Substances lodging in the oesophagus.
ELEMENTS OF SURGERY. 431
by pressing forward the membranous part of the trachea
and exciting spasm of the glottis, lessen the size of its
cavity so as to cut off the free access of air to the lungs.
—In some cases the tongue becomes so much swelled
from the use of mercury as to fill up the mouth, and ob¬
struct respiration. In most of the cases which have
been enumerated, we may frequently avail ourselves of
the introduction of a large elastic catheter into the tra¬
chea, and thereby avoid the necessity of tracheotomy.
The introduction of foreign substances into the glot¬
tis occasions always great uneasiness, violent coughing,
and much irritation; hence it would appear from theory,
a most imprudent act to force an instrument into this
passage. Experience, however, proves that no danger
results from it, and many cases have now occurred
which establish the fact, that an elastic catheter may
be left for many days in the trachea without exciting
any other inconvenience than a convulsive cough at its
first introduction. Even in cases where the irritability
of the parts is augmented by inflammation, the intro¬
duction of a canula into the glottis is easily tolerated.
The cough is at first violent, but it soon subsides and
the patient breathes very well through the instrument.
When the tumour exists in the mouth, and the glot¬
tis is not diseased, the canula may be passed through
the nostril, and readily finds its way into the windpipe.
In cases where foreign substances exist in the oeso¬
phagus pressing forward the membranous part of the
trachea, nothing is easier than to pass a catheter into
the glottis, which will prevent the canal from being
closed and allow the patient to respire freely. In these
cases tracheotomy has often been performed—a sur¬
geon once performed the operation to relieve from suf¬
focation a young man, who for fear of being robbed,
had swallowed his money, tied in a rag—it stopped in
43 2
ELEMENTS OF SURGERY.
the pharynx, and would have killed him, had not tra¬
cheotomy been performed: now in this and similar
cases, the operation recommended by Desault would
certainly have prevented suffocation, and afforded time
to extract or force through the oesophagus into the sto¬
mach the substance arrested there.
The advantages of the plan are very considerable.
The operation is not difficult;—there is no danger from
bleeding vessels;—no wound to heal;—no risk of a fis¬
tulous opening;—consequences which sometimes fol¬
low the operation of tracheotomy.
A tube may with great safety be left a considerable
time in the trachea; this fact is established by the case
of a soldier in the hospital at Lyons, who cut his tra¬
chea through, and wounded the oesophagus. His sur¬
geon introduced a large flexible catheter into the tra¬
chea, another into the oesophagus; by means of one he
was nourished, and through the other he breathed dur¬
ing the cure. Although the operation of opening the
trachea may sometimes be dispensed with and the in¬
troduction of a flexible tube substituted, yet this cannot
always be done. Tracheotomy becomes necessary in
certain cases when foreign bodies are lodged in the
trachea and cannot be coughed up. Writers also men¬
tion polypi and other excrescences in the trachea, as
causes .demanding the operation; these are, however,
very rare.
Foreign substances having entered the glottis some¬
times get fixed in the ventricles of the larynx,—this ac¬
cident has often happened; they produce less disturb¬
ance here than in the trachea or glottis, sometimes
remaining many years without occasioning any unplea¬
sant effects: they must of necessity be very small. If
the foreign body should rest in the glottis so as to im¬
pede respiration, no time is to be lost, an opening must
ELEMENTS OF SURGERY. 43S
'*e made below it, and the substance pushed up with
a probe.
When any substance falls into the windpipe, it oc¬
casions violent coughing and difficulty of breathing, at¬
tended with the usual symptoms of suffocation , but if the
foreign body be not discharged by the efforts of cough¬
ing, and death be not occasioned by the obstruction
to respiration, then we are to infer that the substance
has passed through the glottis into the trachea, the ir¬
ritation in this case is greatly diminished, and after a
short time entirely subsides. Heister relates several
instances in which foreign bodies have passed down to
the bifurcation of the trachea, and there remained for
many years.
In consequence of the facility with which the mem¬
branous partition between the oesophagus and trachea
may be pushed forward, so as to diminish the cavity of
the latter canal, and of the spasmodic action of the mus¬
cle of the glottis excited by any irritation of these parts,
it is occasionally difficult to ascertain, whether the fo¬
reign substance be actually in the oesophagus or tra¬
chea. Indeed mistakes have been made, and the tra¬
chea has been laid open in cases where nothing has
been found in it, the obstruction having proceeded from
pressure in the oesophagus. It is of the utmost impor¬
tance before proceeding to such an operation to ascer¬
tain precisely whether the body be in the oesophagus
or not, and this can readily be done by passing a pro-
bang or catheter down the oesophagus, which will re¬
move all doubt.
When the catheter is to be introduced, it should be
one of the largest size in use for the urethra. It is to
be held as a pen, and passed through the mouth, or if
this be inconvenient from the nature of the disease,
through the nostril, at the fauces it readily passes either
vol. i.—3 I
434 ELEMENTS OF SURGERY.
into the larynx or pharynx; at the former it produces,
First, A cough and tickling pain, with desire to vomit,
and a spasmodic elevation of the larynx. Secondly, The
flame of a candle placed before the end of it is blown to
one side. Thirdly, In passing it still further, resistance
is felt at the bronchiae. In the pharynx and oesopha¬
gus there is less irritation—no cough—no blast of air
—but if some fluid is injected through the tube, the
doubt ceases: if it pass into the larynx, violent cough¬
ing is occasioned, and it returns; if on the contrary
into the oesophagus, 110 inconvenience results.
When any difficulty is found in passing the tube into
the glottis, a stilette may be introduced into it properly
curved; by this means it acquires sufficient firmness to
be passed through the glottis. When introduced it is
to be secured to the patient's night cap, and a piece of
gauze must be fastened over the orifice of the tube in
order to prevent the dust and floating matter of the air,
from being drawn into the lungs. The tube is to be
often removed and cleansed, as the apertures at its ex¬
tremity are soon filled with mucus so as to obstruct the
free passages of air.
When the operation of bronchotomy becomes neces¬
sary there are two places of performing it, one at the
lower part of the larynx, the other in the trachea. Tra¬
cheotomy consists in making a puncture between the
rings of the windpipe, or if necessary for the extraction
of foreign matters it may be divided longitudinally, for
a considerable length. But of late the French surgeons
have preferred very much the division of the larynx,
and they state the following advantages which this ope¬
ration possesses.
In dividing the membrane between the cricoid and
thyroid cartilages the skin and a very small portion of
cellular membrane are the only substances met with.
ELEMENTS OF SURGERY. 435
While in tracheotomy, the skin, much cellular sub¬
stance, and generally a part of the thyroid gland, are
divided.
There is never any hemorrhage from the puncture
between the cricoid and thyroid cartilages, whereas the
other operation is almost always followed by more or
less hemorrhage, and this is an important circumstance,
.because it occasions delay, or, by falling into the tra¬
chea, produces unpleasant effects. Desault relates an
instance of a child who died from loss of blood before
the operation could be completed. The larynx is firmly
supported, and the operation is easily performed; in the
trachea, so much motion is allowed that it is often push¬
ed before the knife, and in one case the carotid artery
was opened owing to this circumstance; laryngotomy
is therefore upon the whole to be preferred.
<
OPERATION.
The patient is to be seated, and the head inclined
somewhat backwards, a bistoury and a curved canula
adapted to the larynx are to be provided. The surgeon
placed before the patient searches for the space between
the thyroid and cricoid cartilages, and makes an inci¬
sion with the bistoury an inch long, through the skin and
cellular membrane, from the bottom of the thyroid to
the cricoid cartilage—the edges of this wound being
separated, the bistoury is to be passed through the mem¬
brane of the trachea, low down, so as to avoid a small
artery sometimes found on the lower edge of the thyroid
cartilage. If this be divided, however, it is to be taken
up immediately. The canula is next introduced and
secured by tapes, the angles of the wound covered
with lint, and the end of the canula with gauze.
When a foreign substance is to be extracted, the
436
ELEMENTS OF SURGERY.
aperture may be enlarged, by means of a pair of for¬
ceps and a bistoury; the forceps when introduced into
the wound may be opened so as to stretch the trachea
and liberate the substance, which may then be extract¬
ed, or pushed upwards through the glottis. The cricoid
cartilage, if necessary, may be cut through in this ope¬
ration, and a considerable portion of the thyroid may
be divided.
Where the object has been to remove a foreign sub¬
stance, the wound may be immediately closed, and in
general it soon unites, but it is sometimes necessary to
leave the canula in the wound, and then great attention
must be paid to frequently cleansing it, because the col¬
lection of mucus is so great as to impede the passage
of air when this caution is neglected.
I have sometimes found it necessary to introduce a
canula into the trachea, in cases where it has been
opened by persons attempting to destroy themselves. In
these cases it is difficult to prevent the collection of
blood and mucus in the cavity of the canula, and great
care is necessary to change the tube frequently, in or¬
der to remove the obstructions which may be formed
within it.
J1.ATKJTV.
■ - *
"• - •" . ■
W> r , »
'
.
'
v i-•< ' '"-h ; • ■ygm
. ■ ■
ELEMENTS OF SURGERY.
437
CHAPTER LXXI.
Accidents and Diseases of the Ear.
The meatus auditorius externus is frequently
plugged up in children with foreign substances, as
corn, beads, &c., and in adults with hardened wax.
In these cases a common eyed probe bent so as to form
a hook at the perforated extremity, is a very conve¬
nient instrument for extracting them. The wax if ne¬
cessary may be softened by injections of warm water.
In general the hearing is immediately restored when
the passage is cleared.
Insects sometimes crawl into the ear and excite ex¬
treme pain;—a little olive oil poured into the external
meatus kills them very speedily, and they can be rea¬
dily extracted. Worms have occasionally been found in
this canal, their ova having been previously deposited,
probably during sleep; an infusion of tobacco in these
cases may be poured into the meatui; it does not irri¬
tate the parts, and is fatal to the insects.
Abscesses sometimes form in the vicinity of this canal
and discharge themselves into it—when this is the case,
the hearing is generally unimpaired. Should the tym¬
panum, however, be affected, the bones of the ear are
sometimes discharged through the membrana tympani
and hearing is greatly injured or entirely destroyed.
When the symptoms of inflammation exist in this im¬
portant organ, the usual remedies for it are to be em¬
ployed, with a view to prevent the formation of pus;—
a number of leeches behind the ear and blisters after¬
wards are to be applied. Mr. Saunders observes that
when these remedies are unsuccessful and matter has
438
ELEMENTS OF SURGERY.
formed, it is generally evacuated, as far as lie has ob¬
served, between the auricle and mastoid process, or
into the meatus. If it has been evacuated into the mea¬
tus, the opening is most commonly small, and the spon¬
gy granulations, squeezed through a small aperture,
.assume the appearance of a polypus. Sometimes the
small aperture, by which the matter is evacuated, is in
this manner even closed, and the patient sutfers the in¬
convenience of frequent returns of pain from the re¬
tention of the discharge. When the parts have fallen
into this state, it will be expedient to hasten the cure
by making an incision into the sinus, between'the auri¬
cle and mastoid process.
It occasionally happens that the bone itself dies, in
consequence of the sinus being neglected, or the ori¬
ginal extent of the suppuration. The exfoliating parts
are the meatus extern us of the os temporis or the ex¬
ternal lamina of the mastoid process.
When polypi are found in the external meatus they
are to be removed by the knife or forceps.
The cavity of the tympanum is sometimes, as has
been remarked, the seat of abscess; in these case's the
membrane is destroyed, and air passes through the ear
when the patient closes his mouth and blows forcibly;
these abscesses are sometimes the result of common in¬
flammation, and sometimes follow small-pox and other
diseases. The usual remedies for inflammation are
the only means of preventing suppuration, and where
pus is evidently formed, notwithstanding their exhibi¬
tion. Mr. Saunders advises a puncture to be made
through the merflbrana tympani, in preference to al¬
lowing the abscess to burst. When the discharge of
pus continues a great length of time, astringent injec¬
tions of white vitriol and sugar of lead dissolved in
ELEMENTS OF SURGERY.
439
water may be used. Blisters and setons applied be¬
hind the ear are also advantageous.
The eustachian tube is sometimes obstructed and
occasions a considerable degree of deafness. A severe
catarrh frequently produces a temporary deafness of
this kind. When this tube is obstructed the patient is
unable to inflate the tympanum as in health; the sensa¬
tion attending this inflation is more easily felt than de¬
scribed; to produce it, it is only necessary to make a for¬
cible attempt at expiration while the nostrils and mouth
are closed. Mr. Astley Cooper has proposed, when
permanent obstruction exists in • the Eustachian tube,
to perforate the membrane of the tympanum, an opera¬
tion . which has been repeatedly performed, and some¬
times with success. I have tried it but without any
benefit, though I should have no hesitation in repeating
it, because it can do no harm to a deaf person, and has
in many cases proved beneficial—a couching needle or
sharp pointed probe answers the purpose very well—
when inserted through the membrana tympani a sharp
pain is felt, but it quickly subsides. The instrument
should not be pushed so far as to wound the parts
within the membrane. Air in this manner will be ad¬
mitted to the cavity of the tympanum, and if deafness
should have arisen from a want of it, it will be relieved.
Mr. Saunders in one case by this operation instantane¬
ously relieved a deafness of thirty years standing—he
recommends a large aperture to be made, a small one
being apt to close up.
Diseases of the labyrinth are very generally be¬
yond the reach of surgery. In some cases the parts
upon dissection evince no morbid alteration, and the
want of sensation has probably been owing to the state
of the nerve. In other cases the labyrinth is found
440
ELEMENTS OF SURGERY.
filled with a cheesy concretion, instead of the natural
fluid which should be found.
Mr. Saunders considers most of the diseases of the
internal ear as depending on the nerve of hearing, the
portio mollis of the auditory nerve being probably para¬
lytic. Various noises are generally perceived by pa¬
tients labouring under deafness from the palsy of the
nerve, such as the murmuring of water, the hissing of
a boiling kettle, &c.
The remedies which have oftenest been useful (and
they have been but very rarely so) are long continued
purging, low diet, and the use of mercury, with blisters,
issues, and setons applied in the vicinity of the ear.
Mr. Saunders has known a nervous deafness, origi¬
nating from a syphilitic source, to be relieved com¬
pletely by a mercurial course. Deafness, however, is
a very rare consequence of the venereal disease, unless
when it arises from ulcers, or scabs, in the external
meatus, in which case it is temporary, and amounts
merely to an external obstruction readily removeabte.
END OF VOL. I.