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Surgeon General's Office
ANNEX]
N.
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PRESENTED BY
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DUE
LAST DATE
DECS 1966
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i
V
A SYSTEM
OPERATIVE SURGERY:
BASED UPON THE PRACTICE OF
SURGEONS IN THE UNITED STATES :
BIBLIOGRAPHICAL INDEX AND HISTORICAL RECORD OF
MANY OF THEIR OPERATIONS,
DURING A PERIOD OF TWO HUNDRED AND THIRTY-FOUR YEARS.
BY
HENEY H. |[MITH, M.D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA J
CONSULTING SURGEON AND LECTURER ON CLINICAL SURGERY IN THE PHILADELPHIA HOSPITAL ;
SURGEON TO THE ST. JOSEPH'S HOSPITAL;
FELLOW OF THE COLLEGE OF PHYSICIANS, PHILADELPHIA, ETC.
SECOND EDITION,
WITH
NUMEROUS ADDITIONS IN BOTH THE TEXT AND ILLUSTRATIONS,
MAKING- NEARLY ONE THOUSAND ENGRAVINGS ON STEEL
IN TWO VOLUMES
VOL. I.
PHILADELPHIA:
J. B. LIPPINCOTT AND CO.,
1856.
St>5\s
v. 1
Entered according to the Act of Congress, in the year 1854, by
LIPPINCOTT, GRAMBO, AND CO.,
in the Office of the Clerk of the District Court of the United States, in and for the
Eastern District of the State of Pennsylvania.
TO
CHARLES A. POPE, M.D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY, AND OF CLINICAL SURGERY,
IN THE
MEDICAL DEPARTMENT OF THE ST. LOUIS UNIVERSITY,
ۤi fnllnmiitg ^ago an nsjurtfttllij D*Mnthlt,
AS AN
CKNOWLEDGMENT OF HIS DEVOTION TO THE PROGRESS OF SURGERY IN THE UNITED STATES,
AND AS
A TESTIMONIAL OF THE RESPECT AND ESTEEM OF HIS
SINCERE FRIEND,
THE AUTHOR.
PREFACE TO THE SECOND EDITION.
The constant republication by the American press of the works
of European surgeons, and their general adoption as Text-books
by our medical schools, having tended to instruct the junior mem-
bers of the profession in the results of foreign practice, rather than
in the opinions and acts of their own countrymen, the desire was
excited to counteract this tendency by presenting them with a
treatise on Operative Surgery which should exhibit some of the
more marked proceedings of surgeons in the United States.
These views having led to the publication of the first edition,
have also been adopted as the basis of the present one, the rapid
exhaustion of the work (although from its illustrations it was ne-
cessarily more costly than most medical books) having shown that
the enterprise was favorably received by the Profession.
But, whilst endeavoring to exhibit the results of American ope-
rations, the more valuable portion of those of European surgeons
have received their full share of attention in this as in the former
edition, there being no desire on my part to exclude their acts from
proper consideration.
In the publication of the present edition, the effort has been
made to augment its value by the correction of former errors of
judgment and of the press, as well as by the addition of such
operative proceedings as have been the result of the progress of
surgical science ; and though the period between the publication of
the two editions has been almost too brief to permit the expendi-
ture of a large amount of time, except after attending to the urgent
demands of daily practice, the entire work has been thoroughly
revised, and each subject augmented or remodelled in accordance
with the views and experience of surgeons at the present time.
The additional matter thus introduced having added 269 pages
VI PREFACE TO THE SECOND EDITION.
to the former number, the work has been published in two volumes,
in order to prevent its becoming too cumbrous for daily use at the
dissecting-table.
The first twenty-eight plates have also been handsomely re-
engraved by Mr. Illman, of Philadelphia, and many new illustra-
tions added.
The Bibliographical Index has been brought up to January,
1854, by the addition of 366 new references, and it now includes
the titles of 1,228 works and papers on surgical subjects, as well as
the volume, page, title, and year of the journal, or place in which
they were published.
The principal additions to the text will be found in the articles
on Etherization ; Eesection of both Superior Maxillae ; Tracheotomy
in Epilepsy, &c. ; Polypi in the Larynx ; Pharyngeal Tumors ; Ee-
tro-Pharyngeal Abscess ; Treatment of Aneurism by Compression,
Galvanism, &c. ; Eesection of the Scapula; Hydatids of the Liver;
Hernia ; Stricture of the Urethra ; Puncture of the Bladder ; Lithec-
tasy; Litholiby; Yesico-uterine Fistula; Movable Cartilages in the
Knee-joint ; Ligature of Arteries ; Eesections and Amputations.
"With these modifications of form and substance, the work is
again presented to the Profession, in the hope that its value will be
found to be augmented by the labor bestowed on it.
PREFACE TO THE FIRST EDITION.
To the majority of those commencing the study of medicine, few
subjects are possessed of greater interest, or surrounded by a more
pleasurable excitement, than operative surgery.
"With some few exceptions, every young man, at an early period
of his pupilage, regards the performance of an operation as the
highest test of professional acquirements, and under the impression
that his knowledge of it is to be obtained by observation, is always
anxious to embrace every opportunity of witnessing the efforts of
an operator. Whilst, therefore, chemistry displays her secrets, and
physiology tenders him in vain the principles of his profession, the
surgeon, when limited to the least scientific portion of his duties,
is always sure of a numerous audience, who, under the impression
that they will be fully prepared to follow in his footsteps, simply
by observing his course of proceeding, will readily repeat their
visit whenever he can offer them a similar inducement.
Having, from long intercourse with medical classes, had many
evidences of the existence of this condition of mind, and having,
like many others, learned that seeing an operation and performing
it are very different acts, the author has wished to lead the reader
to a more correct estimate of the means by which operative skill is
to be acquired, and sought, in the following pages, to furnish him
a guide which might also serve as an instructor, whilst performing
for himself the operations which he desires to study. In special
anatomy, few have ever acquired a thorough knowledge of the
structure of the body until, by constant manipulation, they have
been able to separate each portion for themselves; and in surgery,
the same course must certainly be pursued. Study, observation,
and the repeated demonstration of another are, doubtless, valuable
aids to the acquisition of knowledge, but, unless seconded by per-
VU1 PREFACE TO THE FIRST EDITION".
sonal practice, they will all pass away as "the baseless fabric of a
vision."
The following pages are, therefore, presented to the Profession,
in the hope that they may invite more general attention to the ne-
cessity of acquiring a knowledge of operative surgery by practising,
upon the subject, such processes as it is desired to master; while,
at the same time, drawings have been added in order to facilitate
the progress of those who cannot, at the moment, obtain the neces-
sary material for repeating the operation.
In many portions of the work, the descriptions furnished will be
found to be given in as condensed a form as seemed compatible
with clearness, and have been thus presented in order to prevent
the volume becoming too cumbersome for constant use. In addi-
tion to which, the author has not desired to go over ground which
has so recently been well displayed by writers both in Europe and
this country. Many details of history, pathology, physiology, and
surgical proceedings which are essential to a complete treatise upon
the subject have, therefore, been designedly omitted in this as not
coming within the scope of its plan.
Although the idea of an instructor cannot be claimed as a novel
one, having, in the hands of Messrs. Malgaigne and Fergusson,
been most happily illustrated, there has yet been no work issued
by the press which has presented the American practitioner with a
comprehensive view of the opinions, operative methods, and instru-
ments of those of his countrymen who have given to American
surgery a character of its own.
At present, little more than two hundred years have elapsed since
the first surgeon stepped upon our shores ; yet, during that time,
many acts have been performed that will favorably compare with
the brightest achievements of the surgeons of Europe. To record
these points and save them from unmerited oblivion, has been a
pleasant duty in connection with the composition of the volume.
In its formation, the author is under many obligations to various
sources, which he hopes he has suitably acknowledged. Basing
his description of any operation chiefly on the views of his own
countrymen, he has yet felt bound to display along with them the
opinions of such European authorities as are universally received
as sound; and to facilitate a judgment on the part of those whose
knowledge might not be sufficient for the formation of an opinion
of the value of the different methods referred to, he has appended
PREFACE TO THE FIRST EDITION. IX
to the account an estimate of their advantages. This estimate, he
wishes it to be distinctly understood, is founded solely upon his
own opinion, based upon the experience acquired during a devotion
of seventeen years, under auspicious circumstances, to the study
and practice of a favorite branch of his profession.
To the liberality of the publishers, Messrs. Lippincott, Grambo,
& Co., is due the opportunity of presenting a series of illustrations,
that must materially contribute to the reader's comprehension of
descriptions, the details of which might otherwise be difficult to
follow.
For the accuracy and finish of the engravings, he is indebted to
Mr. John M. Butler, of Philadelphia, who has zealously exerted
himself for the perfect execution of- his pari of the undertaking.
To the latter gentleman is also due the author's acknowledgment of
the untiring good nature with which all the alterations and renewed
criticisms on his work have been received during the progress of
the engraving.
In selecting the illustrations, various sources have been resorted
to, but upon none has the author relied more than on the beautifully
finished plates of Messrs. Bernard & Huette. Wherever, in any
instance, previous figures did not present such views as were de-
sired, the aid of the Daguerreotype has been invoked, and original
drawings made with all the accuracy of the scene at the moment.
In employing the illustrations of other writers, the effort has been
made to credit accurately the original authority; but this having
often proved a matter of impossibility, the author has merely at-
tached the name of the work from which he has taken them.
Heister, Froriep, Blasius, Seerig, Dupuytren, Sir Charles Bell,
Labat, Gensoul, Serre, Bourgery, and Jacobson, and Pancoast, have
all drawn, more or less, from the same sources as Messrs. Bernard
& Huette; but most of them have so transferred from work to
work the result of their labors, that, with one or two exceptions, it
is not easy to trace their origin.
For an opportunity of consulting the many works required in
connection with the Bibliographical Index, as well as with the mat-
ter embodied in the text, the author is indebted to the valuable
libraries of the Pennsylvania and New York Hospitals, to the
Loganian portion of the Philadelphia Library, and to the private
collections of many friends. . To the Librarian and Library Com-
mittee of the Pennsylvania Hospital he is under especial obliga-
X PREFACE TO THE FIRST EDITION.
tions for the free use, at all hours, of their valuable and extensive
collection.
To Dr. John C. Warren, of Boston, and also to his son, Dr. J.
Mason Warren, is due the acknowledgment of the aid afforded by
an extended manuscript, as well as by a collection of pamphlets
which have furnished much valuable information in connection with
the surgery of Boston. From the American Journal of Medical
Sciences, edited by Dr. Isaac Hays, there has also been gained many
scattered facts connected with the doings of the surgeons of this
country.
In describing the anatomical relations of the various parts con-
cerned in the different operations, reliance has been chiefly placed
upon the accounts furnished in the Anatomie Topographique of
Blandin, as well as on that given in the Special Anatomy and His-
tology of Dr. Wm. E. Horner, of the University of Pennsylvania.
In bringing his labors to a close, the author also recalls many
acts and suggestions on the part of friends which he cannot pro-
perly specify, and which he regrets he did not note at the moment.
Hoping, at some future time, to have the opportunity of remedy-
ing this, as well as some other omissions connected with the press,
he cheerfully submits the volume to the judgment of the Profession
in the belief that it will be received as a contribution to facilitate
the progress of those who have yet to acquire their surgical expe-
rience.
TABLE OE CONTENTS.
VOLUME I.
Dedication ....
Preface ....
General History op Surgery .
History of Surgery in the United States
Bibliographical Index
List of American Journals
PAGE
iii
v
17
25
41
48
INDEX OF SPECIAL PAPERS.
Papers on the Elementary Operations
54
Papers relating to Operations on the Head and Face
58
Tumors and other Diseases of the Head
59
Hydrocephalus
Trephining .
Affections of the Eyelids
" " Eyeball
Operations on the Face
" " External Nose
60
60
63
65
66
67
Polypi in the Nose .
Operations on the Lips
" " Upper Jaw
Immobility of the Jaw
Operations on the Lower Jaw
-
68
69
69
71
72
" " Face
76
" " Tongue .
76
" " Throat .
77
" " Tonsils .
78
Staphyloraphy
Operations on the Ear
Papers relating to Operations on th]
g Neck
AND TR
DNK
79
80
81
Extirpation of the Parotid Gland
81
XII
TABLE OF CONTENTS.
PAGE
Deformities of the Neek .
82
Operations on the (Esophagus
83
On Tracheotomy .....
84
(Edematous Laryngitis .
84
Operations for Tumors on the Neck
89
Ligature of the Innominata and Carotid Arteries
91
" " Subclavian and Axillary Arteries
95
Extirpation of the Clavicle ....
97
Operations on the Breast ....
97
Tumors of the Chest ....
98
Operations on the Chest ....
98
Empyema ......
99
Operations on the Abdomen .
101
Hernia ......
103
Artificial Anus .....
106
Ligature of the Iliac Arteries
107
Operations on the Back ....
110
Spina Bifida .......
111
Papers on the Genito-Urinary Organs and Rectum
113
Operations on the Penis ....
113
Affections of the Male Urethra
113
Operations on the Testicle and Cord
115
Hydrocele .......
116
Operations on the Bladder .
117
Lithotomy .......
117
Lithotripsy .......
123
Operations on the External Female Organs .
124
" " Female Perineum
125
" " Vagina .
125
" " Uterus .
127
Polypus Uteri ......
128
Ovariotomy and Gastrotomy .
129
Caesarean Operation ......
133
Affections of the Rectum .
134
Papers relating to Operations on the Extremities
137
General Operations on the Extremities
137
Club-Foot .......
139
Ligature of the Arteries in the Extremities .
140
Pseudarthrosis ......
144
Resection of the Bones of the Extremities
145
Amputations ......
147
Alphabetical List of American Surgeons
155
TABLE OF CONTENTS.
xni
PART I.
GENERAL DUTIES AND ELEMENTARY OPERATIONS.
Introduction ......
PAGE
175
CHAPTER I.
GENERAL DUTIES OF AN OPERATOR
Sect. I. Attention to the patient
§ 1. Duties of a surgeon before operating .
§ 2. Duties " " during the operation
§ 3. Duties " " after the operation
Sect. II. Preparation of instruments
§ 1. Action and selection of instruments .
§ 2. Preparation and sharpening of instruments
§ 3. Manipulation of instruments .
§ 4. Preservation of instruments .
Sect. III. The operator's duties to his assistants .
§ 1. Selection and instruction of assistants .
CHAPTER II.
ELEMENTARY operations
Sect. I. Incisions with the scalpel and bistoury
Sect. II. Dissections .....
Sect. III. Punctures or incisions with pointed instruments
178
178
180
190
193
196
196
197
200
203
204
205
207
207
213
214
CHAPTER III.
MEANS OP ARRESTING HEMORRHAGE .
Sect. I. Compression .....
Sect. II. Arrest of hemorrhage by ligatures
Sect. III. Styptics, cauteries, and other means of arresting hemor
rhage .....
215
217
218
221
CHAPTER IV.
DUTIES OP A SURGEON IMMEDIATELY AFTER OPERATING 222
Sect. I. Dressings ...... 223
§ 1. Closing of parts after an operation . . 224
§ 2. After-treatment as one of the means employed
to favor union .... 229
XIV
TABLE OF CONTENTS.
PART II.
OPERATIONS ON THE HEAD AND FACE.
CHAPTER I.
SURGICAL ANATOMY OF THE HEAD
CHAPTER n.
OPERATIONS UPON THE HEAD
Sect. I. Operations upon the scalp
§ 1. Encysted tumors
§ 2. Aneurism by anastomosis, or erectile tumors
i. Treatment by exciting inflammation
II. Operation of excision .
§ 3. Cephalaematoma
§ 4. Division of the supra-orbitar nerve
§ 5. Tumors of the scalp .
§ 6. Venous tumors of the scalp
Sect. II. Operations upon the bones of the cranium
§ 1. Operations for caries and necrosis of the cranium
§ 2. Trephining the cranium
I. Instruments required in trephining
II. Trephining the frontal sinus
§ 3. Puncturing the head for hydrocephalus
§ 4. Removal of fungoid tumors of the dura mater
PAGE
231
234
235
235
236
237
240
242
242
243
244
244
244
246
248
254
255
257
CHAPTER III.
OPERATIONS ON THE FACE
Sect. I. Anatomy of the face ....
§ 1. Anatomy of the appendages of the eye
§ 2. Anatomy of the lachrymal apparatus .
261
261
263
264
CHAPTER IV.
OPERATIONS ON THE APPENDAGES OF THE EYE
Sect. I. Operations practised on the eyelids
§ 1. Tumors of the eyelids
§ 2. Encanthus ....
§ 3. Epicanthus ....
266
266
266
267
267
TABLE OF CONTENTS.
. XV
Sect. II.
PAGE
§ 4. Ankyloblepharon
269
§ 5. Symblepharon
269
§ 6. Ptosis ....
270
§ 7. Blepharoplasty
271
§ 8. Ectropium ....
272
i. Blepharoplastic operation for ectropium
273
§ 9. Entropion .
276
I. Operation by excision of the lid
276
Operations on the lachrymal apparatus
279
CHAPTER V.
OPERATIONS ON THE EYEBALL . . 285
Sect. I. Operations on the coats or external parts of the eyeball 286
Sect. II. Operations on the muscles of the eyeball . . 286
§ 1. Anatomy of the muscles concerned in squinting 287
§ 2. Operation for strabismus — incision . . 288
I. Operation by the ligature . . 290
§ 3. Extirpation of the eyeball . . .292
§ 4. Tumors in the orbit . . . .293
CHAPTER VI.
OPERATIONS ON THE HUMORS OF THE EYE
Sect. I. Anatomy of the eyeball
Sect. II. Operations for cataract
§ 1. Preliminary treatment
§ 2. Dilatation of the pupil
§ 3. Operations by absorption, couching, and extrac
tion
I. Operation by absorption
II. Operation by depression or couching
in. Operation by extraction
Sect. III. Anatomical relations of the iris
§ 1. Formation of an artificial pupil
I. Coretomia
II. Corectomia
III. Coredialysis
IV. Distortion of the natural pupil .
294
294
297
299
300
303
303
305
307
312
312
313
315
315
317
XVI
TABLE OF CONTENTS.
CHAPTER VII.
PLASTIC OPERATIONS ON THE FACE
Sect. I. Metoplasty, or restoration of the integuments of the fore-
head ...•••
PAGE
318
319
CHAPTER VIII.
OF THE EXTERNAL NOSE
Sect. I. Anatomy of the external nose
Sect. II. Operation on the external nose
Sect. III. Rhinoplasty .
§ 1. Indian or Brahmin method
§ 2. Taliacotian operation .
§ 3. Restoration of the columna nasi
322
322
322
325
328
333
337
CHAPTER IX.
OF THE INTERNAL NOSE
Sect. I. Anatomy of the internal nose
Sect. II. Operations on the nasal cavities
§ 1. Arrest of hemorrhage from the nostrils
§ 2. Polypi in the nostrils
339
339
340
341
342
CHAPTER X.
OF THE MOUTH
Sect. I. Anatomy of the external portion of the mouth
Sect. II. Operations on the lips
§ 1. Simple harelip
§ 2. Double harelip
§ 3. Cancer of the lip
§ 4. Enlargement of the mouth
§ 5. Cheiloplasty .
§ 6. Genioplasty .
§ 7. Removal of tumors from the cheeks
§ 8. Salivary fistula
Sect. III. Division of the masseter muscle for false anchylosis of
the jaw ......
347
347
349
349
353
355
356
357
361
362
363
364
TABLE OF CONTENTS.
XV11
CHAPTER XL
OPERATIONS PRACTISED WITHIN THE MOUTH
Sect. I. Anatomy of the parts within the mouth
Sect. II. Operations upon the tongue and throat
§ 1. Cancer of the tongue .
§ 2. Hypertrophy of the tongue
§ 3. Excision of the uvula
§ 4. Excision of the tonsils
PAGE
366
366
369
369
371
373
374
CHAPTER XII.
RESECTION OP THE BONES OF THE FACE. . 376
Sect. I. Anatomy of the bones of face . . . 377
Sect. II. Operation on the jaw-bones . . . .379
§ 1. Resection of the upper jaw-bone . . 379
§ 2. Resection of both superior maxillae . . 389
§ 3. Resection of the inferior maxilla . . 393
I. Resection of half the inferior maxilla . 393
II. Resection of the inferior maxilla entire . 397
Sect. III. Operation on the palate .... 401
§ 1. Stapbyloraphy .... 401
§ 2. Staphyloplasty . . . .409
CHAPTER XIII.
OPERATIONS PRACTISED UPON THE EAR. . 411
Sect. I. Anatomy of the ear . . . . . 413
Sect. II. Operations on the ear .... 414
§ 1. Otoplasty ..... .414
§ 2. Foreign bodies in the meatus externus . 416
I. Extraction of foreign bodies . . 416
II. To wash out foreign bodies . . 416
§ 3. Polypi in the meatus externus . . 417
§ 4. Perforation of the membrane of the tympanum 418
§ 5. Catheterism of the Eustachian tube . . 420
XV111
TABLE OF CONTENTS.
PART III.
OPERATIONS PRACTISED ON THE NECK AND TRUNK.
CHAPTER I.
SURGICAL ANATOMY OF THE NECK.
Sect. I. The supra-hyoid or glosso-hyoid region of the neck
Sect. II. The parotid region .
Sect. III. The laryngo-tracheal and supra-sternal regions
Sect IV. The supra-clavicular region
CHAPTER II.
OPERATIONS PRACTISED ON THE PORTION OP THE NECK "WHICH
IS ABOVE THE OS HYOIDES.
Sect. I. Of the diseases of the parotid gland .
§ 1. Extirpation of the parotid gland
§ 2. Relief of enlargement of the parotid gland by
obstructing the circulation
Sect. II. Operations practised on the sub-maxillary gland
CHAPTER III.
OPERATIONS PERFORMED ON THE LARYNX AND TRACHEA.
Sect. I. Surgical anatomy of the larynx and trachea
Sect. II. Operations upon the larynx
§ 1. Cauterization of the larynx
§ 2. (Edema of the glottis
§ 3. Polypi in the larynx .
§ 4. Tracheotomy ....
I. Tracheotomy for croup .
II. Tracheotomy for the removal of a foreign
body
III. Tracheotomy for epilepsy
IV. Laryngotomy .
V. Laryngotomy in polypi laryngis
§ 5. Estimate of these different operations .
§ 6. Statistics of the operation of tracheotomy
I. " tracheotomy for croup
ii. " tracheotomy for the removal of
foreign bodies
PAGE
425
427
429
431
435
437
437
439
447
448
449
451
451
453
458
459
459
462
464
465
465
467
472
472
474
TABLE OF CONTENTS.
XIX
CHAPTER IV.
PAGE
OPERATIONS UPON THE PHARYNX AND (ESOPHAGUS 475
Sect. I. Surgical anatomy of the pharynx and oesophagus . 476
§ 1. Of the pharynx .... 476
§ 2. Of the oesophagus .... 476
Sect. II. Operations upon the pharynx . . . s . 477
§ 1. Hypertrophy of the follicles of the pharynx . 477
§ 2. Tumors in the pharynx . . . 478
§ 3. Foreign bodies in the pharynx . . 479
§ 4. Retro-pharyngeal abscess . . . 480
Sect. III. Operations upon the oesophagus . . .481
§ 1. Removal of foreign substances from the oesopha-
gus and stomach . . . 482
I. Effects of the introduction of a foreign
body into the oesophagus . . 482
§ 2. Extraction of noxious substances from the sto-
mach .... 486
§ 3. Stricture of the oesophagus . . . 488
I. Dilatation of the stricture . . 489
II. Application of caustic . . . 490
in. (Esophagotomy . . .491
CHAPTER V.
OPERATIONS FOR THE RELIEF OF DEFORMITIES OF THE NECK
Sect. I. Deformities from burns ....
Sect. II. Torticollis, or wry-neck ....
495
496
501
CHAPTER VI.
TUMORS of the neck ,
Sect. I. General pathology of tumors of the neck
§ 1. Diagnosis of the character and position of tumors
of the neck .
I. Character of tumors
II. Position of tumors
Sect. II. Operations for the removal of tumors of the neck
§ 1. Removal of large lymphatic glandular tumors
§ 2. Extirpation of a large malignant tumor
Sect. III. Bronchocele, or goitre
§ 1. Pathology of goitre .
505
506
509
509
5.11
514
517
518
522
522
XX
TABLE OF CONTENTS.
§ 2. Treatment of goitre by compression .
§ 3. Ligature of the thyroid arteries
§ 4. Subcutaneous ligature of goitre
I. Dissection of the skin and ligature
Sect. IV. Hydrocele of the neck
PAGE
525
527
527
528
530
CHAPTER VII.
ANEURISMS IN GENERAL.
Sect. I. General diagnosis of aneurisms . . . 532
Sect. II. Treatment of aneurism without an operation . . 534
§ 1. Plan of Valsalva . . . .535
§ 2. Treatment by compression . . . 535
§3. " by galvanism and acupuncture needles 537
Sect. III. General principles of the ligature of arteries . . 538
CHAPTER VIII.
ANEURISM OF THE CAROTID ARTERIES.
Sect. I. Anatomy of the bloodvessels of the neck
Sect. II. Ligature of the carotid arteries
§ 1. Ligature of the primitive carotid
§ 2. Effects of ligature of the carotid
§ 3. Statistics of the operation on the carotid
§ 4. Ligature of the lingual and facial arteries
I. Ligature of the lingual artery .
II. Ligature of the facial artery
542
544
546
548
551
552
553
553
CHAPTER IX.
LIGATURE OP THE INNOMINATA AND SUBCLAVIAN ARTERIES.
Sect. I. Surgical anatomy of these arteries . . . 554
§ 1. The innominata artery . . . 555
§ 2. The subclavian artery . . . 555
Sect. II. Ligature of the innominata .... 556
Sect. III. Ligature of the subclavian artery . . . 560
§ 1. Of the subclavian on the first rib . . 562
§ 2. Between the scaleni muscles . . . 563
§ 3. Within the scaleni .... 564
§ 4. Ligature of the left subclavian within the scaleni 565
§ 5. Statistics of the ligature of the subclavian artery 568
§ 6. Anatomical phenomena consequent on the liga-
tion of the subclavian artery . . 569
TABLE OF CONTENTS.
XXI
VOLUME II.
PART III.— Continued.
CHAPTER X.
OPERATIONS UPON THE CHEST.
Sect. I. Surgical anatomy of the chest
§ 1. Anatomy of the portion of the chest about the
clavicles
Sect. II. Resection of the clavicle
§ 1. Resection of the entire clavicle
§ 2. Resection of a portion of the clavicle
Sect. III. Resection of the scapula
§ 1. Resection of the entire body of the scapula
§ 2. Resection of the acromion process of the scapula
Sect. IV. Operations on the parts about the clavicle
§ 1. Ligature of the axillary artery below the clavicle
CHAPTER XI.
OPERATIONS ON THE MAMMARY GLAND OP THE FEMALE
Sect. I. Pathology and diagnosis of mammary tumors
1.
§2.
Tumors dependent on hypertrophy
Tumors due to degeneration of tissue
i. Ligneous or wood-like scirrhus
II. Fibro-scirrhous degeneration
III. Ordinary cancerous tumor of the breast
§ 3. Abnormal productions
Sect. II. Extirpation of the mammary gland
§ 1. Statistics of these operations
Sect. III. Removal of tumors of the chest
§ 1. Congenital encysted tumor
PAGE
17
18
19
20
25
26
26
29
29
29
31
31
34
36
36
37
37
38
39
44
49
50
CHAPTER XII.
OPERATIONS ON THE WALLS OF THE THORAX.
Sect. I. Surgical anatomy of the thorax
Sect. II. Operations on the chest
§ 1. Resection of the ribs .
51
52
53
xxn
TABLE OF CONTEXTS.
§ 2. Paracentesis thoracis .
I. Statistics of the operation
§ 3. Effusions in the pericardium .
CHAPTER XIII.
OPERATIONS UPON THE ABDOMEN.
PAOE
55
60
61
Sect. I.
Paracentesis abdominis
63
Sect. II.
Hepatic abscesses
65
Sect. III.
Hydatids of the liver .
69
Sect. IV.
Gastrotomy and enterotomy
70
§ 1. Gastrotomy
71
§ 2. Enterotomy .
72
Sect. V.
Gastric and intestinal fistulae
76
CHAPTER XIV.
WOUNDS IN THE ABDOMEN
77
Sect. I.
"Wounds causing protrusion of intestine
s . . 78
Sect. II.
Wounds of the intestine
79
§ 1. Sutures employed in longitudinal wounds . 82
§ 2. Sutures of transverse t
rounds
83
CHAPTER XV.
HERNIA IN GENERAL . . . 86
Sect. I. General pathology of hernia .... 88
§ 1. Envelops of hernia .... 89
§ 2. Seat of hernia .... 91
§ 3. Effects of the formation of hernia . . 93
§ 4. Reducible hernia «... 94
§ 5. Irreducible hernia .... 94
§ 6. Strangulated hernia .... 95
Sect. II. Treatment of hernia ..... 98
§ 1. Reduction of hernia .... 98
§ 2. Palliative treatment of reducible hernia . 101
I. General character of trusses . . 102
II. Fitting of trusses . . . 102
CHAPTER XVI.
OF INGUINAL HERNIA . . . 105
§ 1. Radical cure of inguinal hernia . . 105
§ 2. Observations on the radical cure of inguinal
hernia ..... 113
TABLE OF CONTENTS.
XX111
CHAPTER XVII.
STRANGULATED INGUINAL HERNIA.
Sect. I. Surgical relations of inguinal hernia .
Sect. II. Operations for strangulated inguinal hernia
§ 1. Taxis ....
§ 2. Reduction of strangulated hernia in mass
§ 3. Herniotomy in strangulated inguinal hernia
§ 4. Remarks on herniotomy
§ 5. Statistics of the operation
PAGE
118
121
121
125
126
131
134
CHAPTER XVIII.
FEMORAL OR CRURAL HERNIA.
Sect. I. Anatomical relations of femoral hernia . . 135
Sect. II. Operations for the relief of strangulated femoral hernia 139
§ 1. Taxis in femoral hernia . . . 139
§ 2. Trusses in femoral hernia . . .140
§ 3. Herniotomy in strangulated femoral hernia . 141
§ 4. General remarks on strangulated femoral hernia 144
§ 5. Statistics of the operation . . . 145
CHAPTER XIX.
UMBILICAL HERNIA.
Sect. I. Surgical anatomy ...
Sect. II. Means of treating umbilical hernia
§ 1. Palliative treatment .
§ 2. Radical cure .
§ 3. Herniotomy in umbilical hernia
§ 4. Statistics of herniotomy for umbilical hernia
§ 5. Summary of the operations of herniotomy in
all kinds of hernia .
§ 6. Frequency of the different forms of hernia
147
148
148
149
150
151
151
152
CHAPTER XX.
ARTIFICIAL ANUS.
Sect. I. Artificial anus from mortified intestine
§ 1. Statistics of the operation
Sect. II. Formation of an artificial anus
§ 1. Anus formed at the groin
§ 2. Formation of an anus in the lumbar region
§ 3. Statistics of the operation
152
157
160
160
162
163
XXIV
TABLE OF CONTENTS.
CHAPTER XXI.
LIGATURE OF THE ILIAC ARTERIES.
Sect. I. Surgical anatomy of the iliac arteries
Sect. II. Operations upon the iliac arteries
§ 1. Ligature of the external iliac artery .
§ 2. Statistics of the application of a ligature to the
external iliac artery
Sect. III. Ligature of the primitive iliac artery .
§ 1. Surgical anatomy
§ 2. Operation of ligating the primitive iliac
§ 3. Statistics of ligating the primitive iliac
§ 4. Ligature of the internal iliac .
TACTS
165
166
166
171
172
172
173
175
176
CHAPTER XXII.
OPERATIONS PRACTISED ON THE BACK.
Sect. I. Superficial tumors of the back
Sect. II. Tumors of the spinal canal, or spina bifida
§ 1. Operations for the cure of spina bifida
181
182
183
PAET IV.
OPERATIONS ON THE GENITO-URINARY ORGANS AND RECTUM.
CHAPTER I.
OPERATIONS ON THE MALE GENITO-URINARY ORGANS.
Sect. I. Surgical anatomy of the male organs . . . 189
§ 1. The penis ..... 190
§ 2. The urethra ..... 190
§ 3. The testicles ..... 192
Sect. II. Operations on the penis .... 192
§ 1. Phymosis ..... 193
i. Circumcision . . . .193
n. Incision .... 193
§ 2. Paraphymosis .... 196
i. Compression .... 197
II. Incision . ... . 197
§ 3. Division of the fraenum . . . 198
§ 4. Amputation of the penis . . . 198
Sect. III. Operations on the urethra .... 201
TABLE OF CONTENTS.
XXV
§2.
Catheterism .
i. Catheters
II. Ordinary operation of catheterism
in. Obstacles to catheterism
Strictures of the urethra
I. Dilatation
II. Internal incisions
in. External incisions
IV. Caustic .
§ 3. Summary of the treatment of strictures
§ 4. Puncture of the bladder
I. Puncture through the perineum
II. Puncture through the rectum
in. Puncture above the pubes
IV. Puncture of the bladder in the female
§ 5. Fistula in perineo
§ 6. Hypospadias and epispadias
Sect. IV. Operations on the spermatic cord
§ 1. Ligature of the spermatic artery
§ 2. Ligature of the spermatic veins
§ 3. Operations on the scrotum
Sect. V. Operations on the testicle
§ 1. Hydrocele
I. Treatment of hydrocele by injectic
II. Cure of hydrocele by the seton
in. Treatment by incision .
IV. Treatment by excision .
§ 2. Castration
PAGE
201
201
202
204
206
209
211
212
214
219
221
222
222
223
224
224
227
228
228
228
233
234
234
234
236
236
236
237
CHAPTER II.
STONE IN THE BLADDER
Sect. I. Surgical anatomy of the male perineum
Sect. II. Operation of perineal lithotomy
§ 1. Preparatory steps
I. Diagnosis of stone in the bladder
§ 2. Constitutional treatment
§ 3. Local preparatory means
Sect. HI. The lateral operation
§ 1. Instruments that may be wanted during the ope
ration .
§ 2. Lateral operation with the cutting gorget
239
241
243
244
245
246
247
249
249
250
XXVI
TABLE OF CONTENTS.
§ 3. Operation with the single lithotome cache of
Frere Cosme . . . .254
Sect. IV. The bilateral operation . . . .254
Sect. V. The median operation . 260
§ 1. Lithectasy . 261
Sect. VI. Of the supra-pubic operation . . • 262
§ 1. The quadrilateral operation . . • 263
Sect. VII. General remarks on perineal lithotomy . • 263
§ 1. Extraction of the stone . • • 264
§ 2. Accidents connected with lithotomy . . 266
I. Ligature in hemorrhage . . 266
II. Plugging to arrest hemorrhage . . 267
in. Wound of the rectum . . . 267
Sect. VIII. After-treatment of the operation of perineal lithotomy 269
§ 1. Putting to bed . . . . 270
§ 2. Treatment of the wound . . .271
§ 3. Constitutional treatment . . . 271
Sect. IX. General estimate of the value of the different methods
of operating for lithotomy, with statistics . 272
CHAPTEE III.
LITHOTRIPSY, OR CRUSHING OF STONE IN THE BLADDER 274
Sect. I. Preliminary treatment necessary in lithotripsy . 275
Sect. II. Operation of lithotripsy .... 277
Sect. III. Cases adapted to lithotripsy . . . .280
Sect. IV. Litholiby ...... 281
CHAPTER IV.
OPERATIONS ON THE FEMALE GENITO-URINARY ORGANS.
Sect. I. Surgical anatomy of the female perineum
Sect. II. Operations on the external organs of the female
§ 1. Occlusion of the vulva
§ 2. Hypertrophy of the nymphae and clitoris
§ 3. Catheterism .
§ 4. Imperforate hymen
§ 5. Occlusion of the vagina
Sect. III. Laceration of the perineum
§ 1. Atresia of the vagina .
282
284
285
285
285
287
287
289
292
TABLE OF CONTENTS.
XXV11
CHAPTER V.
OPERATIONS FOR VAGINAL FISTULA.
Sect. I. Vesicovaginal fistula .
§ 1. Palliative treatment .
§ 2. Operations for vesico-vaginal fistula
Sect. II. Vesico-uterine fistula .
Sect. III. Recto-vaginal fistula .
PAGE
293
295
295
303
304
CHAPTER VI.
OPERATIONS PRACTISED ON THE DEEP-SEATED ORGANS OF THE FEMALE.
Sect. I. Lithotomy and lithotripsy in the female
§ 1. Lithotripsy in the female
Sect. II. Operations upon the uterus
§ 1. Puncture of the uterus
§ 2. Polypi of the uterus .
I. Ligature
§ 3. Amputation of the neck of the uterus .
§ 4. Extirpation of the womb
§ 5. Removal of fibrous tumors from the uterus
Sect. III. Extirpation of the ovary, or ovariotomy
§ 1. The major operation .
I. Are ovarian tumors proper subjects for an
operation ?
II. Is the removal of the ovarian tumor
attended by any extraordinary diffi-
culty or danger during or after the
operation ?
§ 2. Report of American operations
Sect. IV. On the Caesarian operation
Sect. V. Excision of the neck of the womb
306
307
307
308
308
309
309
311
312
312
313
318
319
321
323
325
CHAPTER VII.
OPERATIONS PRACTISED ON THE RECTUMT.
Sect. I. Surgical anatomy of the rectum
Sect. II. Operations on the rectum
§ 1. Removal of foreign bodies
§ 2. Encysted rectum
§ 3. Fissure of the anus
§ 4. Imperforate anus
326
328
328
329
330
331
XXV1U
TABLE OF CONTENTS.
§ 5. Prolapsus ani .
I. To restore the prolapsed portion
II. Operation of Dupuytren
in. Excision of a portion of the sphincter
ani muscle
IV. Cauterization
V. Excision of the tumor
Sect. III. Hemorrhoids, or piles .
§ 1. Treatment of hemorrhoids
I. Application of nitric acid
II. The ligature
in. Excision
iv. Incision and ligature
Sect. IV. Fistula in ano
§ 1. Operation by the ligature
§2. " " knife
PAGE
333
334
334
335
335
335
336
337
338
339
339
339
341
341
343
PAET V.
OPERATIONS ON THE EXTREMITIES.
CHAPTER I.
GENERAL OPERATIONS ON THE EXTREMITIES
Sect. I. Of inverted toe-nail
§ 1. Removal of the nail and its matrix
Sect. II. Cure of paronychia, or whitlow
Sect. III. Enlarged bursa
§ 1. Subcutaneous puncture
§ 2. Puncture and injection of iodine
§ 3. Incision
§ 4. Movable cartilages in the knee-joint
Sect. IV. Painful condition of the nerves
Sect. V. Varicose veins
Sect. VI. Tenotomy, or division of the tendons .
345
346
346
347
348
349
349
349
350
351
351
354
TABLE OF CONTENTS.
XXIX
CHAPTER II.
PAGE
LIGATURE OP THE ARTERIES OF THE EXTRExMITIES . 355
Sect. I. Ligature of the axillary artery in the axilla . . 357
§ 1. Anatomical relations of the axillary artery . 357
§ 2. Ligature of the axillary artery . . 358
Sect. II. Ligature of the brachial artery . . .359
§ 1. Anatomical relations of the brachial artery . 360
§ 2. Ligature of the brachial artery at the middle of
the arm ..... 361
§ 3. Ligature of the brachial near the elbow . 362
Sect. III. Ligature of the radial artery .... 363
§ 1. Anatomical relations of the radial artery . 363
§ 2. Ligature of the radial artery . . . 363
I. Malgaigne's operation at the upper third
of the forearm . . .363
II. Ligature of the radial at the wrist . 365
in. Ligature of the radial artery at the thumb 365
Sect. IY. Ligature of the ulnar artery .... 366
§ 1. Anatomical relations of the ulnar artery . 366
§ 2. Ligature of the ulnar artery . . .366
I. Ligature of the ulnar artery at the middle
third of the forearm . . . 366
II. Ligature of the ulnar artery above the
wrist ..... 367
CHAPTER III.
LIGATURE OF THE ARTERIES OF THE LOWER EXTREMITY 367
Sect. I. Ligature of the femoral artery . . . - 369
§ 1. Anatomical relations of the femoral artery . 369
§ 2. Ligature of the femoral artery . . 370
I. Ligature of the femoral artery at the
upper part of the thigh . . 370
II. Ligature of the femoral artery in the
middle of the thigh . . .371
Sect. II. Ligature of the popliteal artery . . . 372
§ 1. Anatomical relations of the popliteal artery . 372
§ 2. Ligature of the popliteal artery . . 373
Sect. III. Ligature of the posterior tibial artery . . . 375
§ 1. Anatomical relations of the posterior tibial artery 375
§ 2. Ligature of the posterior tibial artery . . 375
XXX
TABLE OF CONTENTS.
I. Operation at its upper third
II. Operation at its middle third
III. Operation behind the malleolus internus
Sect. IV. Ligature of the anterior tibial artery .
§ 1. Anatomical relations of the anterior tibial artery
§ 2. Operations for the ligation of the anterior tibial
artery .
I. Ligature of the anterior tibial artery at
its middle third
II. Ligature of the anterior tibial artery on
the dorsum of the foot
PAGE
375
37G
377
377
377
378
378
379
CHAPTER IV.
OPERATIONS ON THE BONES OP THE UPPER EXTREMITY 379
Sect. I. Resections in general ..... 380
Sect. II. Resection of the bones of the upper extremities . 381
§ 1, Resection of the shoulder-joint . . 382
§ 2. Resection for false joint of the humerus . 383
§ 3. Resection of the elbow-joint . . . 386
§ 4. Resection of the bones of the forearm and hand 387
I. Resection of both the radius and ulna . 387
II. Resection of the body of the ulna . 388
in. Resection of the inferior extremity of the
ulna ..... 389
IV. Resection of the wrist-joint . . 390
v. Resection of the metacarpus . . 391
vi. Resection of the bones of the hand . 391
CHAPTER V.
OPERATIONS ON THE BONES OP THE LOWER EXTREMITY . 391
Sect. I. Resection of the femur .... 392
§ 1. Resection of the head of the femur . . 392
§ 2. Resection of the femur for anchylosis, and
formation of a new joint at the hip . 392
Sect. II. Introduction of a seton for false joint in the femur . 393
Sect. III. Resection of the knee-joint .... 395
§ 1. Removal of a portion of the patella, condyles,
and articulating surfaces of the tibia . 397
§ 2. Resection of the bones of the leg . . 399
§ 3. Extraction of the fibula . . . 400
TABLE OF CONTEXTS.
XXXI
Sect. IV. Resection of the ankle ....
§ 1. Resection of the inferior extremity of the tibia
and fibula .....
§ 2. Resection of the astragalus
§ 3. Resection of the os calcis
§ 4. Resection of the metatarsal bones and phalanges
PAGE
400
400
401
402
403
CHAPTER VI.
GENERAL REMARKS ON AMPUTATIONS
Sect. I. Cases for amputation ....
§ 1. Gunshot wounds
§ 2. Railroad accidents
§ 3. The period for amputating
Sect. II. Points for the performance of amputations
§ 1. The place of election .
Sect. III. The different kinds of amputation
§ 1. The circular operation
§ 2. The oval method
§ 3. The flap operation
Sect. IV. Estimate of the different forms of amputation .
Sect. V. General measures requisite in amputation
§ 1. Preparatory measures .
§ 2. Employment of anaesthetics in amputations
§ 3. Duties of assistants
§ 4. After-treatment
§ 5. Accidents that may occur either during or after
an amputation .
403
404
404
405
408
412
431
414
414
415
416
416
419
419
421
424
424
427
CHAPTER VII.
AMPUTATIONS OF THE UPPER EXTREMITY.
Sect. I. Amputation at the shoulder-joint
§ 1. Of the operation at the shoulder-joint .
I. Amputation of the arm above the shoul
der-joint
II. Amputation of the arm at the shoulder
joint .
Sect. II. Amputation of the arm
Sect. III. Amputation at the elbow-joint
Sect. IV. Amputation of the forearm
Sect. V. Amputation of the fingers
429
430
430
431
435
437
439
440
XXX11
TABLE OF CONTENTS.
CHAPTER VIII.
AMPUTATIONS OF THE LOWER EXTREMITY.
Sect. I. Amputation at the hip-joint .
§ 1. Surgical anatomy of the hip-joint
§ 2. Operation at the hip-joint
§ 3. Statistics of amputation at the hip-joint
Sect. II. Circular amputation of the thigh
§ 1. Circular operation of Alanson
§ 2. Flap operations
§ 3. Statistics of amputation of the thigh .
Sect. III. Amputation at the knee-joint
§ 1. Statistics of amputation at the knee-joint
Sect. IV. Amputation of the leg .
§ 1. Circular amputation of the leg
§ 2. Flap operation on the leg
§ 3. Oval method ....
Sect. V. Amputation at the ankle-joint
Sect. VI. Amputation of the foot at the tarsus
Sect. VII. Amputation of the toes
Sect. VIII. Organic changes resulting from amputations .
Sect. IX. Substitutes for the natural limb
PAGE
441
442
443
447
449
449
451
452
452
454
456
457
458
458
459
460
463
465
467
GENERAL HISTORY OF SURGERY.
A BRIEF HISTORICAL SKETCH OF SURGERY, ARRANGED CHRO-
NOLOGICALLY.*
The origin of Surgery, being coeval with that of Medicine, dates
from the earliest periods of the human race, the reception of injuries
naturally requiring that some effort should be made to alleviate
them. That surgical operations were performed, at a very remote
period, cannot be doubted, the laws of Moses, describing minutely
the operation of circumcision (an operation yet practised among the
Jews, according to ancient usages), and the embalming of Joseph,
indicating the possession of at least such surgical knowledge as was
necessary for the opening of bodies.
The earliest individual, directly spoken of in connection with the
practice of surgery, and the reputed originator of the science, is the
myth named Chiron, the Centaur, who was supposed to have been
born in Thessaly, at some unknown period.
Next, we find mention made of J3sculapius, a son of Apollo,
B.C. 1142, who was believed to have been a pupil of Chiron; and
then we have more positive information, in the account by Homer
of the events of the Trojan war, in which he describes Podalirius
and Machaon as sons of -ZEsculapius, and as surgeons in this war,
B.C. 1184.
Podalirius is reported to have been the first bleeder, having
opened a vein in either arm of the daughter of the King of Caria,
and received her hand in marriage as his recompense.
The Asclepiades, or reputed descendants of iEsculapius, consti-
tute the only surgeons spoken of during the ensuing 500 years.
* The facts here stated have been chiefly collected from Miller, Richerand, Sharp,
Black. Chelius. and the Dictionary of Antiquities, by William Smith, LL.D,
2
18 GENERAL HISTORY OF SURGERY.
After these came Pythagoras, B.C. 608; and, after him, the
following may be briefly mentioned in the natural order of time.
Damocedes, a contemporary of Pythagoras, treated King Darius
for a sprained ankle; and his queen, Atossa, for cancer of the breast.
After him came Hippocrates, the great father of medicine and
surgery, from whom all the rest may be traced.
Hippocrates, B.C. 460, or 357, was among the first of the distin-
guished surgeons, and practised many operations, often claimed as
modern inventions. He employed the actual cautery of various
shapes; used moxa made of rolls of flax; resorted to issues and tents
as counter-irritants ; and operated for calculi in the kidney by incision,
though he did not cut for stone, lithotomy being then confined to a
special class of practitioners. He also reduced dislocations and frac-
tures by means yet resorted to; employed the obstetrical forceps for
delivering the foetus; frequently employed the trepan in depressed
fractures of the skull ; resorted to percussion to prove the presence
of fluid in the thorax, and performed empyema or paracentesis
thoracis. He also wrote many excellent surgical treatises.
After him, Diocles Carystius invented an instrument for ex-
tracting darts, and bandaged the head for wounds, &c. 7 by bandages
often employed at the present time.
Praxagoras, of Cos, who followed in his footsteps, also proved
himself an accomplished surgeon, and some of his operations are
yet resorted to. He incised the fauces freely in cases of inflamma-
tion; excised the uvula, and made an artificial anus, or opening into
the bowels, in cases of obstruction or ilius. He also first observed,
the difference between the arteries and veins, and noted the pulse,
though this fact has also been claimed for Aristotle.
Aristotle gave the name to the aorta, and showed that all the
bloodvessels centred in the heart. After him came the anatomist
and surgeon, Herophilus, about B.C. 320, though the exact year
is unknown. He was the first surgeon who practised dissections.
Erasistratus, his contemporary, also dissected and invented many
surgical instruments. This surgeon is reported to have reduced a
dislocated humerus for Diodorus Cronus, and by this operation, to
have convinced him of the possibility of the existence of motion, a
fact which he had previously denied.
Xenophon, his follower, was the first to arrest hemorrhage from
the extremities, by a tourniquet, having recommended the encircling
of the limb with a cord, in order to check the flow of blood.
GENERAL HISTORY OF SURGERY. 19
Lithotomy, at this period, as during the time of Hippocrates, was
avoided by the surgeons, and performed entirely by a special class
of individuals who devoted themselves to this one operation.
Ammonius, surnamed A^oro/xoj, devoted much time to the study
of calculous affections, employing an instrument to crush calculi,
and thus becoming the first surgeon who operated for lithotripsy.*
Cassius, B. C. 96, exhibited considerable knowledge of the phy-
siological action of the brain, having described the paralysis of one
side of the body as induced by injuries of the opposite portion of
the head.
Celsus, the contemporary of Horace, Virgil, and Ovid, practised
surgery at Eome in the beginning of the Christian era, upwards of
150 years before Galen. He was the first to describe lithotomy,
and his mode of performing it (central incision), as well as numerous
other operations, is sometimes resorted to by surgeons of the present
day. He described the operation of removing cataract by depres-
sion; mentions the subject of artificial pupil; gave accurate and
judicious rules for the application of the trepan; was the first to
notice that there might be an effusion and compression within the
head without fracture; first recommended the application of liga-
tures to wounded arteries; improved the operations of amputation;
applied caustics to the treatment of carbuncle; described several
species of hernia; and operated for hare-lip, &c, by methods yet
in use and often claimed as modern improvements.
Aretvetjs, A. D. 54, reign of Nero, first employed blisters and
resorted to cantharides as a vesicating agent. This surgeon con-
demned the operation for tracheotomy, lest the cartilages should
not heal.
Eufus, the Ephesian, A.D. 98 — 117, reign of Trajan, wrote on
diseases of the kidneys and bladder, and operated by ligating the
brachial artery for varicose aneurism at the bend of the arm.
Heliodorus, the physician to Trajan, about A. D. 120, and
contemporary with Juvenal, wrote on injuries of the head.
Antyllus, about A. D. 840, recommended tracheotomy, which
had been previously practised by the Asclepiades in threatened
suffocation from diseases of the throat ; he practised arteriotomy in
great emergencies, and showed the importance of dividing an artery
entirely across, in order to arrest hemorrhage, instead of incising it
* Smith's Diet. Greek and Roman Antiquity — Art. Chirurgie.
20 GENERAL HISTORY OF SURGERY.
obliquely. In the treatment of aneurism, he tied the artery above
and below the sac, and, opening the latter, allowed the wound to
heal by granulations ; he also alluded to the operation of cataract
by extraction, and reported cures of hydrocele by incision.
Claudius Galen, born in the autumn of A. D. 130, wrote upon
luxations of the femur backwards, a variety not mentioned by Hip-
pocrates; he also described spontaneous luxations of the femur,
and trepanned the sternum in empyema.
^Etius, about A. D. 475, scarified the legs in anasarca; employed
the cautery; excised hemorrhoidal tumors; employed lithontriptics
to dissolve calculi, and wrote on hernia, diseases of the testicle, and
castration.
Alexander, of Trallis, a surgeon of the time of Justinian, A. D.
545, wrote on diseases of the eye, and on fractures.
Paulus JEgineta, about A. D. 670, is reported to have bled freely
in cases of gravel. He opened abscesses by caustics ; defined the
points for paracentesis abdominis; sounded the bladder by the finger
in the rectum, in cases of stone ; cut on the left side of the raphe
(lateral operation) in lithotomy, and believed aneurism to be caused
by rupture of the coats of the artery. He extirpated the breast
by a crucial incision; performed laryngotomy, and is said by some
to have been the first to perform tracheotomy, though the Ascle-
piadese had also the credit of the same operation. His incision was
made transversely, instead of longitudinally, as practised at the
present day. He performed the operation for strangulated hernia ;
was the first to treat of fracture of the patella, and originated
embryotomy.
Caliph Haroun, among the Arabians, had charge of a hospital
at Bagdad, about A. D. 790, where no fewer than six thousand stu-
dents, chiefly Christians, are said to have attended the practice of
the house, a number that has not been equalled by any of the more
modern schools.
Khazes, about A. D. 924, first described spina ventosa and
spina bifida; he opposed all operations for cancer when the tumor
was not entirely free from the surrounding parts, and cauterized
poisonous wounds.
Haly Abbas, A. D. 980, advised the application of caustics to
hydrocele, and punctured the linea alba a little below the umbilicus
in cases of ascites.
Avicenna, A. D. 1000, distinguished between closure of the pupil
GENERAL HISTORY OF SURGERY. 21
and cataract; preferred depression in cataract to extraction; first
resorted to the flexible catheter, and also employed a saw similar to
that now named after Hey.
Albucasis, A. D. 1100, is supposed to have been the first who
noticed the effect of a clot in the arteries in arresting hemorrhage ;
he describes an instrument of his own for curing fistula lachrymalis,
and also the cataract needle of his own period. He also reports
having operated for hydrocephalus, but with doubtful success ; he
removed tumors by the ligature, and first described lithotomy as per-
formed on the female; in the male, he practised the lateral operation.
He also excised the tonsils and uvula; extracted polypous tumors
from the fauces; objected to any attempt at extirpating goitrous
tumors; invented the probang; employed sutures in wounds of the
intestines; condemned tracheotomy in acute inflammation of the
windpipe, and when it had reached the bronchia, and strongly
doubted the propriety of operating in cancerous tumors ; declaring
that he never cured, or saio cured, a single case. He also advised the
partial evacuation of large abscesses, as subsequently practised in
England by Abernethy and others, whose names were given to this
plan of treatment.
Pope Innocent II., A. D. 1139, retarded the progress of surgery,
by describing its practice as degrading, and forbidding the clergy
to pursue it.
Pitard, A. D. 1271, established the College of Surgeons in Paris.
Gilbertus Anglicanus and John of Gaddesden, two surgeons
of distinction, practised in England A. D. 1800, 1320.
Guy de Chaulsac, A. D. 1360, first described the Caesarian
operation.
John of Arden, A. D. 1370, operated very successfully for fistula ;
improved the trepan, and added the centre pin.
Valasco de Taranta, A. D. 1410, practised at Montpellier, and
first proposed the application of arsenic to the cure of cancer.
Germain Colot, surgeon of Louis XI., A. D. 1460, restored the
operation of lithotomy to the medical profession by an act of the
law.
A. D. 1440-1450 was distinguished by the discovery of Print-
ing, which had a marked influence on the progress of medicine and
surgery. ,
A. D. 1492, Discovery of America. It may, perhaps, specially
interest the American student to know that syphilis was described
22 GENERAL HISTORY OF SURGERY.
by Albucasis, Avicenna, Yalasco, and John of Gaddesden, nearly
100 years before this period * and that its origin in conneetion with
the expedition of Columbus is by no means established.
Vesalius, in A.D. 1550, taught anatomy; and Eustachius, in
A. D. 1560, did the same.
Ambrose Pare, in France, A. D. 1560, created a new period in
surgery, both by his practice and writings. He wrote on gunshot
wounds, firearms being first introduced at this period; employed
ligatures more than the actual cautery, and first resorted to the
twisted suture in hare-lip, copying the mode in which the ladies and
tailors carried the thread and needle in their cuffs.
Taliacotius, an Italian, in A. D. 1597, revived and systematized
the class of plastic or "Taliacotian" operations which had previously
been practised in a very irregular manner by empirics.
Fabricius ab Aquapendente, A.D. 1610, the preceptor of Har-
vey, introduced the modern trephine, or the instrument now gene-
rally employed both in England and America; he also invented the
the curved canula, which is employed after the operation of trache-
otomy.
Wiseman of England, A.D. 1676, the surgeon to Charles II., ad-
vocated immediate amputation in military surgery, and especially
before fever set in.
James Young, of Plymouth, A.D. 1679, first proposed the flap
amputation, since claimed by Verduin and Sabaurin, and first
recommended that compression should be limited to the artery, in
amputation.
Fabricius Hildanus, A.D. 1653, of Germany, and Scultetus,
each wrote an Armamentarium Chirurgicum, which includes a large
number of surgical instruments illustrative of the practice of their
own and preceding periods.
Dionis, Belloste, Saviard, and Morel, in France, all practised
surgery during the seventeenth century.
Heister, A. D. 1710, was highly distinguished as a surgeon, and
wrote a voluminous and excellent work on the Practice of Sur-
gery, to which modern surgeons are largely indebted.
Desault, of France, A.D. 1730, first taught surgical anatomy.
This distinguished surgeon made many improvements in surgery;
among others, he changed the curved amputating knife to the present
* See Lectures of Sir A. Cooper, by Lee.
GENERAL HISTORY OF SURGERY. 23
straight one; first suggested the cure of artificial anus, by removal
of the septum between the ends of the bowel, and also first proposed
ligating the distal side of the tumor in aneurism.
Petit, A. D. 1740, did much to advance French surgery ; he in-
vented the screw tourniquet, and was the first who operated for
fistula lachrymalis by transfixing the sac.
Le Dran, Sabatier, Garrangeot, Louis, and Frere Cosme
were also eminent French surgeons during the eighteenth century.
HISTORY
SURGERY IN THE UNITED STATES
HISTORICAL RECORD OF SOME OF THE PRINCIPAL FACTS CON-
NECTED WITH THE ORIGIN AND PROGRESS OF MEDICINE AND
SURGERY IN THE UNITED STATES, ARRANGED CHRONOLOGI-
CALLY.*
The history of Surgery in the United States is so closely identi-
fied with that of Medicine, as to render it useless to attempt to
separate them ; nor is it desirable to do so, the existence of surgery,
as a distinct branch, being only the result of violence, both having
naturally a common trunk. In practice, in the United States, any
effort to accomplish this separation is also futile, the most distin-
guished surgeons having been, and yet being, in many instances,
the most accomplished physicians of their respective localities.
As the United States of America, in their earliest periods, were
colonized chiefly from Great Britain, the medical wants of the settlers
were necessarily supplied by practitioners who emigrated with
* For the facts and dates furnished in this synopsis, I have drawn upon various
authorities, but especially upon the following writers : —
American Medical Biography, or Memoirs of Eminent Physicians who have flou-
rished in the United States, by James Thacher, M. D., Boston, 1828.
Annual Address ("On American Medicine before the Revolution"), delivered before
the Medical Society of the State of New York, Feb. 1842, by John B. Beck, M. D.,
President of the Society.
A Review of the Improvements of Medicine in the Eighteenth Century, by David
Ramsay, M. P., Charleston, 1800.
American Medical Biography, or Memoirs of Eminent Physicians, &c. &c, by
Stephen Williams, M. D., Greenfield, Mass., 1845.
History of Kentucky Surgery, by S. D. Gross, M. P., Louisville, Ky., 1853.
26 HISTORY OF SURGERY
them from Europe. A large number of the first emigrants being
also those who left their homes on aceount of religious persecutions,
we find that many of our early physicians united the clerical func-
tion with the practice of medicine, or were colonial officers, who,
whilst regulating the body politic, also undertook the treatment of
the physical derangements of the hardy colonists.
The following facts, though mainly of local interest, and specially
connected with the origin of the profession in particular towns, are
yet deemed worthy of general notice, as showing the condition of the
medical profession in this country during a period of over 200 years.
In 1620, the United States of America was a wilderness. In
1850, it had more than 40,000 practitioners of medicine, and a
population of 25,000,000 souls. As this population in many of
the States is very widely scattered, the practice of medicine in some
sections of the country frequently occupies so much time, as to
leave the practitioner comparatively little for such labor as would
tend to the formation of a National Medical Literature. Notwith-
standing this, an examination of the medical and scientific journals
will clearly show that, though often overtaxed corporeally, Ameri-
can physicians have made a creditable effort to record and publish
the results of their individual observations; so that those, who in
our large cities were more favorably situated for mental labor, have
been able to collect and exhibit such an amount of facts, as has
given to the American profession the credit of having originated
some most useful plans of treatment.
In surgery, especially, do we notice the suggestion of operations
of an original character, which, whilst benefiting the community at
large, have also tended to advance the interests of the profession,
by leading to the development of other operations of an analogous
character. As examples of these, I would cite the operations of
Ovariotomy, by McDowell, of Kentucky; of Bisections of the Lower
Jaw, by Deaderick, of Tennessee ; of Anchylosis of the Knee and
Hip- Joint, by Barton, of Philadelphia; of Extirpation of the Parotid
Gland, by Warren, McClellan, &c., all of which have been operations
of sufficient brilliancy and utility to have invited the attention of
foreign surgeons.
Although the engagements of the American practitioner have
often been constant and onerous, the profession appears to have
enjoyed its full share of health and long life, as compared with that
obtained by those engaged in other pursuits. From an examination
Hff THE UNITED STATES. 27
of some of the statistics furnished by Dr. Stephen Williams, and
published in his Medical Biography, it appears that the practice of
medicine in the United States, though very laborious, is not un-
favorable to a long life. Out of 1060 practitioners, who had been
Fellows of the Massachusetts Medical Society, 1 died at the age of
100 years, 34 were upwards of 80, and 119 were between 50 and 80.
Thacher, in his Biography, also reports 3 who died between 90
and 100 years of age, 23 between 80 and 90, 7 between 85 and 90,
27 between 70 and 80, and 29 between 60 and 70 years of age — so
that out of 148, whose names he has collected, almost one-half have
lived over the period of threescore years and ten, or that usually
allotted to man. Nor has this advanced age been always accom-
panied by mental debility ; on the contrary, many of the American
physicians have possessed active minds to the last. Thus, Dr. John
Huss, of Durham, N. H., who died at the age of 108, was very
vigorous ; and Dr. Holyoke, of Mass., retained his intellectual vigor
until his one hundredth year, having, in 1821, when 92 years old,
operated for paracentesis abdominis.*
The first record of the presence of a physician, as a resident of
this country, is found in the settlement of Virginia, where, in 1608,
one year after the settlement of the colony, Dr. Walter Eussel
arrived from England.
In 1620, Dr. Samuel Fuller, a deacon in the church of the
Eev. John Eobertson, arrived at Plymouth in the first ship with
the Puritans.
In 1635, Dr. Thomas Thacher came over from England, and
subsequently published the first American medical work.
In 1637, Dr. John" Fisk arrived and settled at Salem as a clergy-
man and physician.
In 1638, Harvard University, of Massachusetts, was founded.
Many of its early collegiate graduates, after obtaining medical de-
grees in Europe, returned to practice their profession in their native
country, bringing with them the views and practice of their Euro-
pean teachers, and thus establishing the practice of medicine in this
country on the basis of that taught during their pupilage in the
European schools.
In 1642, Samuel Bellingham and Henry Saltonstall gra-
duated in the arts at Harvard University, but took their degree of
M. D. in Europe.
* Williams's Biography.
28
HISTORY OF SURGERY
In 1644, we notice that Dr. Thomas Oliver is spoken of, in the
Journal of Governor "Winthrop, as " a skilful surgeon."
In 1649, a law was passed in Massachusetts, "regulating the
practice of chirurgeons, midwives, and physicians."
In 1650, Dr. John Glover graduated at Harvard, and obtained
a medical degree at Leyden. Dr. Howard did the same.
In 1651, Dr. Isaac Chauncey graduated at Aberdeen, Scotland,
and then settled in Massachusetts.
In 1662, Dr. John Winthrop was made Governor of Connecticut.
He was one of the founders of the Koyal Society of England, being
in London at that time as an agent for the colony.
In 1667, Dr. Thomas Thacher, of Massachusetts, published a
medical tract, entitled " A Brief Guide in the Smallpox and Mea-
sles," being the first medical publication in the country.
In 1669, Dr. Henry Taylor, of Boston, practised surgery in
that town, and "had his rate remitted for attending the poor."
In 1673, Dr. Samuel Fuller was appointed Surgeon-General to
the Forces.
In 1674, Dr. Edmund Davie, of Harvard, obtained the degree
of M. D. at Padua.
In 1682, Dr. Thomas Wynn and brother, Welsh physicians,
located themselves in Philadelphia, and were the earliest practition-
ers in this city.
In 1691, William and Mary College, in Yirginia, was founded for
the education of young men, but without any medical department.
In 1700, Dr. John Nicoll, a graduate of Edinburgh, located in
New York city.
In the same year, Dr. Hamilton, a Scotch physician, settled in
Maryland.
At the same period, Dr. John Mitchell, of England, settled in
Yirginia.
In 1700, Yale College, Connecticut, was founded.
In 1704, the first American Newspaper (the Boston Neivs Letter)
was published in the United States, and doubtless had its influ-
ence on the profession, in disseminating general information. The
first printed newspaper (the English Mercurie) was published in
England, in the reign of Queen Elizabeth, July 23, 1588, and a
copy of it is now in the library of the British Museum. The Boston
News Letter, which as just stated, was the first in the United States,
was published 116 years subsequent to this. The second journal
IN THE UNITED STATES. 29
in the United States was the Boston Gazette, and the third the
Philadelphia Weekly Mercury; the latter two being published in
1719. The first number of the Philadelphia Mercury may be seen
in the Loganian portion of the Philadelphia Library, Philadelphia.
In 1705, Dr. John Clayton, of England, settled in Virginia.
In 1707, Dr. Grceme came over with the governor, and settled
in Philadelphia.
In 1712, Dr. Gustavus Brown, of Scotland, located himself at
Port Tobacco, Maryland, and was the most distinguished practi-
tioner of this and the adjoining State.
In 1716, Dr. William Douglass, of Scotland, emigrated to New
England.
In 1718, Dr. Colden, of Scotland, settled in New York.
In 1720 or 1730, Dr. Lloyd Zachary, one of the founders of the
Pennsylvania Hospital, commenced practice in Philadelphia.
In 1720, Dr. Colden wrote an account of the climate and dis-
eases of New York city, recommending it as especially favorable to
consumptive patients.
In 1721, Dr. Benjamin Colman, a clergyman of Boston, pub-
lished a pamphlet on Inoculation, defending the practice as intro-
duced by Dr. Boylston. of that place.
In 1721, Dr. Cotton Mather introduced Inoculation in Boston.
Experiments were also made by Dr. Boylston in June, 1721, upon
his own family. This practice created such inflammatory conduct
on the part of the other physicians and the populace as to endanger
their lives. The first case, Lady Mary Wortley Montague, was in-
oculated in England, in April, 1720, only one year previously.
In 1725, Dr. Boylston was handsomely received at court in Lon-
don, and was the first American who was elected a fellow of the Royal
Society. The ensuing year, he published in England, at the request
of the Royal Society, "An Historical Account of the Smallpox, as
inoculated in New England."
In 1730, Dr. Nath. Williams wrote on the Practice in Smallpox.
In 1732, Dr. Walton published an essay on Fever.
In the same year, Dr. Thomas Howard published a treatise on
Pharmacy.
In 1734, Dr. William Bull, of North Carolina, after studying
under Boerhaave, graduated at Leyden, and wrote on Lead Colic.
In 1736, Dr. William Douglass published "The History of a
new Epidemical Eruptive Fever" which prevailed in New England
in 1735, 1736.
30 HISTORY OF SURGERY
In 1736, Dr. Douglass employed Calomel in the treatment of In-
flammation. This practice has been claimed for Dr. Kobert Hamil-
ton, of England, but his attention, it is well known, was not called
to it until 1764.
In the same year, Dr. John" Tenent, of Virginia, published an
account of the Polygala Senega.
In 1737, 1741, 1742, Dr. John Mitchell, of Virginia, treated
Yellow Fever by copious bleedings.
In 1740, Dr. Magraw, of Scotland, settled in New York city.
In the same year, Dr. Thomas Cadwalader, of Philadelphia,
published an "Essay on the Iliac Passion," recommending mild
purges and opiates instead of the violent treatment previously pur-
sued.
In 1741, Dr. Colden published an account of the Fever which
prevailed in New York ; also, a paper on Cancer.
In 1743, Dr. John Mitchell, of Virginia, published letters on
the Yellow Fever of 1741, in Virginia; also, on "The Causes of
different Colors of People in different Climates."
In the same year, Dr. Clayton published the "Flora Virginiana,"
which was deemed so valuable that it was republished by Grono-
Vius, at Leyden, in 1762.
In 1746, Dr. Colden, Lieutenant-Governor of New York, gave
Madeira wine freely in Yellow Fever, with much success.
In 1746, Princeton College, New Jersey, was founded.
In 1748, Dr. John Lining, of Charleston, published a description
of the American Yellow Fever.
In 1749, Dr. John Moultrie, of Charleston, graduated at Edin-
burgh, being the first native Carolinian who obtained this honor.
In 1750, Drs. John Bard and Peter Middleton injected and
dissected the body of a criminal for the instruction of the students,
being the first Dissection recorded in the United States.
In 1752, the Pennsylvania Hospital was established in Philadel-
phia, being the first general hospital in this country. Its surgical
wards, under the charge of Drs. Physick, Hartshorne, Parrish,
Barton, and others, has always largely contributed to the advance-
ment of surgical practice.
In the same year, patients were received into "its wards.
In 1753, Dr. James Lloyd, after enjoying the instruction of
Warner, Sharpe, Smellie, and Hunter, of London, settled in Boston,
and was the first systematic practitioner of Midwifery, &c. in that
section.
IN THE UNITED STATES. 31
In 1754, Dr. Lionel Chalmers, of Charleston, wrote a paper on
Tetanus, then very prevalent in that city, recommending bleeding,
the warm bath, and opiates.
In the same year, Dr. Thomas Bond, of Philadelphia, wrote an
Account of a Worm found in the Liver.
At the same period, Dr. Bond was actively engaged as a medical
officer in the Pennsylvania Hospital.
In 1755, Drs. Andrew Robinson and James Craik came over
as surgeons to Braddock's army, and settled in Virginia.
In 1756, Dr. William Shippen, Jr., of Philadelphia, returned
from Europe, and commenced practice in his native city. In 1765,
he was elected Professor of Surgery in Philadelphia, and was the
first Professor of Surgery in the United States.
In 1759, inoculation was generally adopted in Philadelphia.
In the same year, Dr. John Bard, of New York, published seve-
ral papers on Yellow Fever, and on the Pleurisy, which prevailed
on Long Island in 1749.
In 1759, Dr. Bond wrote on the Use of Bark in Scrofula.
In 1760, the General Assembly of the Province of New York
ordained that no person should practice in the city of New York as
a physician or surgeon before he had been examined and approved
by one of his majesty's council. During the same year, Dr. Wil-
liam Douglass published a summary of the progress and planting
of the British settlements in America, which contained a notice of
the state of the medical profession.
In 1763, Dr. John Morgan, of Philadelphia, graduated at Edin-
burgh, and maintained in his inaugural essay that Pus was a Secre-
tion. The credit of this doctrine has usually been assigned to Mr.
John Hunter, but there is no doubt of his having been anticipated
by Dr. Morgan.*
In 1765, the Medical Department of the University of Pennsyl-
vania was organized and located in Philadelphia. No school of
* Dr. James Curry, Lecturer at Guy's Hospital, in referring to the priority of this
opinion of Dr. Morgan, says: "I cannot avoid giving the merit to Dr. Morgan, who
discussed the question with great ingenuity in his Inaugural Dissertation on taking
his degree at Edinburgh in 1763, and I can find no proof that Dr. Hunter taught, or
even adopted such an opinion until a considerably later period."
See also Cullen's "First Lines," by Charles Caldwell, M. D., vol. i. p. 225, note
by Dr. Caldwell.
Also, Lond. Med. and Phys. Journ. for 1817, and New England Journ. of Med. and
Surgery, vol. vi. p. 401. (Quoted from Dr. Beck.)
32 HISTORY OF SURGERY
medicine bad existed in the United States prior to this period,
though Dr. Wm. Shippen, of Philadelphia, lectured in Philadelphia,
on Anatomy, during the three preceding years. Dr. Shippen was the
first Professor of Surgery in this school, which in 1768, furnished
ten graduates in medicine. Since then it has contributed largely
to the medical education of the whole country ; very many of the
Professors in the numerous schools now scattered over the United
States, looking back to this school as their Alma Mater.
In the same year, Dr. Morgan delivered an address on "The
Institution of Medical Schools in America," at the first commence-
ment of the University.
In 1768, Columbia College, New York (then King's), was founded.
In the same year, Dr. Chalmers, of Charleston, published an
"Essay on Fevers," and in 1776, "Meteorological Observations
taken at Charleston, from 1750 to 1760."
In 1769, Dr. Kearsley, of Philadelphia, wrote a paper on
Angina Maligna.
In the same year, Dr. Peter Middleton, of New York, delivered
an address "On the State of Medicine," at the opening of King's
College, New York. Dr. John Jones was the first Professor of
Surgery in this college.
In 1769, Dr. Samuel Bard suggested the establishment of the
New York Hospital. The building was erected in 1773, but de-
stroyed shortly afterwards by fire when nearly completed, and did
not receive patients until 1791. It is now, 1854, possessed of very
extensive surgical wards, and contributes its full quota to the pro-
gress of surgical science.
In 1770, Dr. Bayley, a surgeon of New York, described*
the False Membrane in Croup as the result of inflammation, and
treated it by bleeding, tartar emetic, and calomel. The credit of
this practice was incorrectly claimed for Dr. Cheyne more than
twenty years subsequently to Dr. Bay ley's publication.
In 1771, Dr. Samuel Kissam, of New York, published an in-
augural essay "On the Anthelmintic Virtues of Cowhage."
In 1775, Dr. Samuel Adams, of Massachusetts, attended the
soldiers wounded at Lexington, and Dr. Miles Wentworth, of
Boston, was surgeon to the American prisoners wounded at the
battle of Bunker Hill.
* New York Medical Repository, vol. xiv. p. 136.
IN THE UNITED STATES. 33
In the same year, Dr. Jos. Warren, an eminent surgeon of Bos-
ton (then a General), fell at the battle of Bunker (Breed's) Hill.
In 1775, Dr. James Thacher, of Massachusetts, commenced his
duties as Assistant-Surgeon among the wounded at Bunker Hill.
In 1776, Dr. Jno. Morgan, of Philadelphia, received from Con-
gress the appointment of Director-General of the U. S. Hospitals.
In 1776, Dr. John Jones, Professor of Surgery in New York,
published a volume on Wounds and Fractures, which was of much
service to the army surgeons during the Eevolution.
In the same year, Dr. Benjamin Eush of Philadelphia, was a
member of Congress, and one of the signers of the Declaration of
Independence.
In 1777, Dr. Crosby, a graduate of the University of Pennsyl-
vania, was surgeon to General Washington's lifeguard.
In the same year, Dr. Mercer (then General) fell at the battle
of Princeton.
In 1780, Dr. John Warren, surgeon of a military hospital in
Boston, commenced a course of Anatomical Lectures, which are
thought to have been the first given in that city.
In 1780, Dr. Jas. Thacher, of Massachusetts, was on duty as an
army surgeon, at West Point, and witnessed the execution of the
unfortunate Major Andre. He was also present at the surrender
of Cornwallis in the same year.
In 1781, Dr. Jno. Warren amputated at the Shoulder-joint, being
the first operation of the kind recorded in the United States. This
amputation was also successfully performed by Dr. Bayley, of N.
Y., assisted by Dr. Wright, in 1782. His operation has been often
referred to* as the first amputation of the kind performed in this
country, but that of Dr. Warren preceded it.
In 1786, the Philadelphia Dispensary was established, being the
first institution of the kind in the United States.
In 1787, the Philadelphia College of Physicians was established.
In 1792, Dr. Physick, afterwards the most distinguished surgeon
in this country, graduated at Edinburgh.
In 1794, Dr. Physick was elected one of the surgeons of the
Pennsylvania Hospital.
In 1795, he invented the Stylet for cutting strictures of the
urethra, and first operated for Lithotomy in 1797. In this operation,
* Thacher's Biography of Bayley.
34 HISTORY OF SURGERY
lie cut the internal pudic artery, and the difficulty of arresting the
hemorrhage led, in 1802, to the invention of his needle and forceps
for the ligature of this and other deep-seated vessels. Previous to
this time, surgeons had deemed the ligature of the internal pudic a
matter that was almost impossible.
In 1796, Dr. Wright Post, of New York, tied the Femoral ar-
tery successfully for Aneurism, the patient living about thirty years
subsequently.
In 1798, Dr. John Warren, of Boston, extirpated the Parotid
gland, being the first operation of the kind known.
In the same year, Dr. Nathan Smith, who was celebrated for his
surgical abilities, founded Dartmouth College, and was the sole pro-
fessor for twelve years, lecturing on all the different branches; thus
exhibiting a degree of industry and energy that has never been
surpassed, all his courses of lectures being spoken of as "complete."
In 1800, Dr. Waterhouse, of Cambridge University, was the
first who vaccinated in the United States ; being one year after the
discovery of Jenner.
In Augus|, 1801, Dr. Jos. Glover, of South Carolina, who had
graduated the previous year at the University of Pennsylvania, ex-
cised a large portion of the Spleen, which had protruded through a
wound, and the patient rapidly recovered.
In 1802, Dr. John C. Warren, of Boston, commenced practice
as a surgeon, and after fifty-two years of active life, still continues
to take an interest in professional duties.
The same year, Dr. Physick operated for the cure of False-joint,
by introducing a seton between the ends of the bones. He ligated
the brachial artery for varicose aneurism at the bend of the arm,
in 1803.
In the same year, Dr. Mason F. Cogswell, of Hartford, Conn.,
ligated the Carotid artery, in removing a scirrhous tumor from the
neck ; the patient, however, died on the nineteenth day. This is
believed to be the first operation on this artery ever practised in
the United States, and among the first three ever performed; He-
berstreit, Abernethy, Cogswell, and Fleming being the first four
surgeons who attempted the operation. The operation of Sir Astley
Cooper was performed in 1805 for aneurism, and his patient also
died on the nineteenth day.
In this year, Dr. John C. Warren ligated the Femoral artery.
' Previous to 1800, capital operations seem to have been rare or were
IN THE UNITED STATES. 35
unrecorded, though, doubtless, the Eevolution afforded many occa-
sions for their performance by the surgeons of that period.
In 1805, Dr. McClellan, of Franklin Co., Pa., extirpated the
Parotid gland.
In 1806, Dr. "Walter Brashears, of Kentucky, amputated at
the Hip-joint successfully. This was the first operation of the
kind known to have been performed in the United States.
In 1807, Dr. Samuel White, of Hudson, New York, removed
a Teaspoon from the Intestines, by incising the abdomen and open-
ing the bowel; the patient recovered. In 1808, he also successfully
extirpated the Parotid gland.
In 1809, Dr. Physick operated for Artificial Anus, by inducing
adhesion between the two sides of the bowel, and then dividing the
septum.
In December, 1809, Dr. McDowell, of Kentucky, removed a large
Ovarian Tumor through the abdominal parietes of three different
patients, all successfully. This operation was the first of the kind
ever performed in any quarter of the world, and was repeated by
Dr. McDowell thirteen times*
In 1810, Dr. Dorsey, of Philadelphia, tied the External Iliac,
being the first time this operation was performed in America.
In the same year, Dr. Deaderick, of Tennessee, amputated half
of the Lower Jaw, being the first resection of this bone ever per-
formed.
In 1811, Dr. Moses Sweat, of Maine, also extirpated a Parotid
gland.
In 1812, Dr. Stevens, of New York, ligated the External Iliac
artery successfully.
In the same year, Dr. ¥i. Gibson, then of Baltimore, ligated
the Primitive Iliac in the case of a wound in the groin ; and Dr.
Wright Post, of New York, about the same period., tied the Primi-
tive Carotid artery, being the second or third time the operation
was repeated in this country.
In 1812, Dr. Ephraim McDowell, of Kentucky, successfully
Lithotomized James K. Polk, who was then a poor boy, though sub-
sequently President of the United States.f
In 1813, Dr. Charles McCreary, of Kentucky, resected and
excised the entire Clavicle successfully, the patient living thirty -five
* Gross, History of Kentucky Surgery,
f Ibid., Report on Kentucky Surgery.
36 HISTORY OF SURGERY
years after the operation, and having the use of the limb. This
was the first operation of the kind performed in the United States.
Dr. Mott's operation was performed fourteen years subsequently,
without his being aware of Dr. McCreary's operation.
In 1814, Dr. Bowen, of Providence, amputated at the Shoulder-
joint.
In 1815, Dr. Hubbard, of Connecticut, ligated the Axillary artery
successfully.
In the same year, Dr. Whitridge, of Sackett's Harbor, ligated
the External Iliac artery. At the same period, Dr. Whitridge
also amputated, successfully, at the Shoulder-joint.
In 1816, Dr. Hunt, of Washington, excised the Head of the
Humerus, and Dr. Physick published an Account of the Ad-
vantages of Animal Ligatures in ligating arteries.
In 1817, Dr. Wright Post, of New York, tied the Subclavian
artery externally to the scaleni muscles, being the first successful
operation performed on this vessel in the United States.
In 1818, Dr. Valentine Mott, of New York, tied the Innomi-
nata, his patient living twenty-six days subsequently.
In 1818, Dr. Glover, of Charleston, performed the operation of
tapping the head in a case of Hydrocephalus. This operation is
believed to have been the only case published, either by English
or American surgeons, since 1778.
In 1820, Dr. Physick invented his instrument for Excision of
the Tonsils. This instrument was so well adapted to the operation,
that it has retained its position before the profession notwithstand-
ing the introduction of numerous others.
In the same year, Dr. John C. Warren, of Boston, operated suc-
cessfully for Staphyloraphy, being the first time it was performed
in America.
In 1821, Dr. Mott, of New York, amputated half the Lower Jaw
after ligating the Carotid; being the second case in the United
States, but the first published.
In the same year, Dr. Antony, of Georgia, resected the fifth and
sixth ribs nearly entire.
In 1822, Dr. Newman, of Pennsylvania, amputated the Tongue
successfully for Lingua Vitula.
In 1823, Dr. A. II. Stevens, of New York, resected nearly the
entire Upper Jaw successfully ; and in the same year, Dr. George
* Gross, Report on Kentucky Surgery.
IN THE UNITED STATES. 37
McClellan, of Philadelphia, removed all the Lower Jaw from its
angles forwards, for the relief of an osteo sarcomatous tumor. The
specimen is now in the Museum of the Pennsylvania College of
Philadelphia.
In 1824, Dr. David L. Kogers, of New York, also removed nearly
the entire Upper Jaw.
In 1825, Dr. Dudley, of Kentucky, tied the Subclavian artery
successfully.
In 1825, Dr. Geo. McClellan, of Philadelphia, ligated the Carotid
artery in three children, five, nine, and sixteen years old.
In the same year, he extirpated the Parotid gland, and repeated
the operation on another patient in 1829.
In 1825, Dr. Butt, of Virginia, resected and removed the entire
Radius successfully.
In the same year, Dr. Bright, of Kentucky, is reported to have
successfully removed nearly the entire Eectum.
In 1826, Dr. Khea Barton, of Philadelphia, resected the Femur
near the Hip-joint for Anchylosis, and established a false joint, upon
which the patient walked.
In 1827, Dr. Mott, of New York, ligated the Primitive Iliac ar-
tery successfully, and in another case removed the entire Clavicle.
In the same year, Dr. S. Pomeroy White, of New York (for-
merly of Hudson), tied the Internal Iliac artery.
In this year, Dr. Amasa Trowbridge, of New York State,
cured a case of Spina Bifida, by ligating the base of the tumor
with a wire ligature.
In 1828, Dr. John C. Warren, of Boston, removed half of the
Lower Jaw.
In 1829, Dr. J. Kearny Eodgers, of New York, successfully
straightened an anchylosed hip, by resection of the Femur.
In the same year, Dr. Mott, of New York, relieved an Anchy-
losed Jaw by dilatation and incision of the soft parts.
At the same period, Dr. Thomas Harris amputated half the
Tongue successfully, and
Dr. Gillespie, of Virginia, successfully resected the Astragalus
in a compound dislocation.
In 1831, Dr. Depeyre, of New York, operated for Lithotripsy,
being the first surgeon who performed the operation in the United
States*
* N. Y. Med. Journ., Feb., 1851.
38 HISTORY OF SURGERY
In 1831, Dr. Barton removed nearly half of the Lower Jaw, but
left the base of the maxilla as a rim of bone to preserve the outline
of the face.
In 1833, Dr. Mott ligated the right Subclavian artery within the
scaleni muscles.
In the same year, Dr. Hall, of Baltimore, ligated the Innomi-
nata, but without success.
In 1834, Dr. Thomas Harris resected the Elbow-joint.
In 1835, Dr. Barton resected the Femur above the knee in a
case of anchylosis, where the leg was bent at a right angle to the
thigh, and straightened the limb so that the patient could walk.
In 1837, Dr. J. Mason Warren, of Boston, successfully performed
the Taliacotian operation for the restoration of a nose, being the
first surgeon who performed this operation in the United States.
In the same year, Dr. Mussey removed the entire Scapula and
Clavicle, in a case in which he had amputated the arm at the shoul-
der-joint six years previously.
In 1838, Dr. Geo. McClellan removed the Scapula and Clavicle,
as well as the entire limb of the same side. ,
In 1841, Dr. Gurdon Buck, Jr., of New York, resected the
Elbow-joint.
In 1842, Dr. Schmidt, of New York, relieved Anchylosis of the
Lower Jaw by a subcutaneous division of the masseter muscle.
In the same year, Dr. John C. Warren removed the Upper Jaw
bone.
In 1844, Dr. Jno. Watson, of New York, operated successfully
for ffisophagotomy.
In 1845, Dr. Buck, of New York, resected the Knee-joint, by
excising a wedge-shaped portion of the patella, condyles, and arti-
culating surfaces of the tibia.
In the same year, Dr. J. Kearny Eodgers, of New York, tied
the left Subclavian artery within the scaleni muscles.
In 1846, Dr. J. Kearny Eodgers ligated the Internal Iliac
artery successfully.
In the same year, the Inhalation of Ether for the purpose of de-
stroying sensibility in surgical operations, was discovered by Dr.
Morton, of Boston, and brought into use by Dr. John C. Warren,
of the same city.
In 1847, Dr. Sweat, of Maine, amputated at the Hip-joint suc-
cessfully.
IN THE UNITED STATES. 39
In 1850, Dr. William E. Horner resected the entire half of
the Upper Jaw, without making any external incision in the cheek.
In the same year, Dr. Paul F. Eve, of Georgia, extirpated the
entire Womb successfully.
In the same year, Dr. Gross, of Louisville, resected nearly the
entire Scapula.
In 1851, Dr. Carnochan, of New York, resected (for necrosis)
the entire Lower Jaw successfully, disarticulating it at both con-
dyles.
In the same year, Dr. Peaslee, of New York, performed Ovario-
tomy, and removed loth ovaries successfully, by the large peri-
toneal section.
In the same year, Dr. Geo. Hayward, of Boston, published an
account of several cases of Yesico-Vaginal Fistula successfully
treated by his own method of operating.
In 1852, Dr. J. M. Carnochan, of New York, cured, in six
months, a case of Elephantiasis Arabium by ligating the femoral
artery of the same limb.
In the same year, Dr. J. Marion Sims, of Alabama (now of
New York), reported several cases of Yesico-Vaginal Fistula cured
by means of ingenious instruments, of his own inventing, closing
the wound by the " Clamp Suture."
A
BIBLIOGRAPHICAL INDEX
OF
AMERICAN WRITERS,
SUBJECTS CONNECTED WITH OPERATIVE SURGERY, FROM THE
YEAR 1783 TO THE COMMENCEMENT OF THE YEAR 1854— BEING
A PERIOD OF 70 YEARS— ARRANGED CHRONOLOGICALLY.
A System of Surgery extracted from the Works of Benjamin
Bell, of Edinburgh; by Nicholas B. Waters, M. D.; with Notes and
copper-plate engravings. 8vo. Philadelphia, 1791.
The Surgical Works of the late John Jones, M. D., 3d edition —
to which is added a Short Account of the Life of the Author, by
James Mease, M. D. 8vo. Philadelphia, 1795.
A Dissertation on the Properties and Effects of the Datura Stra-
monium, or Common Thorn Apple, and on its Uses in Medicine;
by Samuel Cooper, M. D. 8vo. Philadelphia, 1797.
A Eeview of the Improvements of Medicine in the Eighteenth
Century, by David Ramsay, M. D. 8vo. Charleston, 1800.
A Memoir concerning the Disease of Goitre, by Benjamin S.
Barton, M. D. 8vo. Philadelphia, 1800.
Physical Investigations and Deductions from Medical and Surgi-
cal Facts relative to the Causes, &c. of the Diseases of a warm and
vitiated Atmosphere, &c. &c, by William Barnwell, M. D. 8vo.
Philadelphia, 1802.
A Treatise on Fractures, Luxations, "and other Affections of the
Bones. Edited by Xavier Bichat, with plates. Translated from
the French by Charles Caldwell, M. D., with Notes, &c. 8vo. Phi-
ladelphia, 1805.
42 BIBLIOGRAPHICAL INDEX.
The Lectures of Boyer upon the Diseases of the Bones, arranged
by A. Richerand, translated with Notes and additional plates by
Joseph Hartshorne, M. D. 8vo. Philadelphia, 1805.
The Principles of Surgery, by John Bell, Surgeon, abridged by
J. Augustine Smith, M. D. 8vo. New York, 1810.
A Dictionary of Practical Surgery, by Samuel Cooper, Surgeon ;
with Notes by John Syng Dorsey, M. D. 8vo. 2 vols. Philadelphia,
1810.
A Treatise on Ruptures, containing an Anatomical Description
of each Species, with an Appendix, by Jos. Parrish, M. D. 8vo.
Philadelphia, 1811.
The same, edited by Isaac Hays, M. D. 8vo. Philadelphia, 1843.
Elements of Surgery for the Use of Students; with plates, by
John Syng Dorsey, M. D. 8vo. 2 vols. Philadelphia, 1813.
Observations on the Surgery of the Ancients, by David Hosack,
M. D. 8vo. New York, 1813.
Memoirs of Military Surgery and Campaigns of the French
Armies on the Rhine, in Corsica, &c. &c, from the French of D. J.
Larrey. Translated by R. Wilmott Hall, M. D. 2 vols. 8vo. Bal-
timore, 1814.
A Treatise on Surgical Diseases, and of the Operations suited to
them, by Boyer. Translated from the French by Alexander H.
Stevens, M. D. 8vo. 2 vols. New York, 1815.
Medical Sketches of the Campaigns of 1812, '13, '14, on the
Canadian frontier of the United States ; to which are added Surgi-
cal Cases, Observations on Military Hospitals, &c, by James Mann,
M. D. 8vo. Dedham, Mass., 1816.
A System of Surgical Anatomy. Part I. On the Structure of
the Groin, Pelvis, and Perineum, by William Anderson, M. D. 4to.
New York, 1822.
First Lines of the Practice of Surgery, by Samuel Cooper, Sur-
geon; from the fourth London edition, with Notes by Alexander
H. Stevens, M. D. 8vo. 2 vols. New York, 1822.
A short Treatise on Operative Surgery, describing the Principal
Operations, by Charles Averill; with Additions by John Bell,
M. D. 12mo. Philadelphia, 1823.
Observations on the Surgical Anatomy of the Head and Neck,
illustrated by Cases and Engravings by John Burns, London. Edited
by Granville S. Pattison, Surgeon. 8vo. Baltimore, 1823.
BIBLIOGRAPHICAL INDEX. 43
Manual of Surgical Operations, by J. Coster, M. D. P. Trans-
lated by John D. Godraan, M. D. 16mo. Philadelphia, 1825.
The Institutes and Practice of Surgery, being Outlines of a
Course of Lectures by William Gibson, M. D. 8vo. 2 vols. Phila-
delphia, 1824. (Various editions since.)
A Treatise on Strictures of the Urethra, by Theodore Ducamp.
Translated from the French by William M. Herbert, M. D. 8vo.
New York, 1827.
On the Treatment of Anchylosis by the formation of Artificial
Joints, by John Ehea Barton, M. D. 8vo. Philadelphia, 1827.
The First Lines of the Practice of Surgery, by Samuel Cooper,
Surgeon ; with Notes by Alexander H. Stevens, M. D., New York ;
with Additional Notes by a Physician in Philadelphia. 8vo. 2 vols.
Philadelphia, 1828.
An Essay on the Diseases of the Internal Ear. Translated from
the French, by N. E. Smith, M. D., with a Supplement by the
Translator. 8vo. Baltimore, 1829. .
Elements of Operative Surgery. Translated from the French of
A. Tavernier, M. D., with copious Notes and Additions by S. D.
Gross, M. D. Philadelphia, 1829.
A Treatise on Surgical Anatomy ; or the Anatomy of Eegions
considered in its Eelations with Surgery, &c, by Alfred A. L. M.
Velpeau, M. D., &c. Translated from the French, with an Appen-
dix, by John W. Sterling, M. D. 8vo. 2 vols. New York, 1830.
Drawings of the Anatomy of the Groin ; with Anatomical Ee-
marks, by William Darrach, M. D. Folio, Philadelphia, 1830.
The Anatomy, Physiology, and Diseases of the Bones and Joints,
by Samuel D. Gross, M. D. 8vo. Philadelphia, 1830.
A Dictionary of Practical Surgery, by Samuel Cooper, Surgeon,
&c. ; with Notes, by D. M. Eeese, M. D. 8vo. 2 vols. New York,
1830.
The same, from the seventh London edition, with a full Supple-
mentary Index, containing much that is valuable in connection with
American Surgery; as well as the modern European improvements.
Two vols, in one, New York, 1849.
Medical and Surgical Memoirs, by Nathan Smith, M. D., late
Professor of Surgery in Yale College. Edited, with Addenda, by
N. E. Smith, M. D. 8vo. Baltimore, 1831.
Observations on Wounds and their Complications by Erysipelas,
Gangrene, and Tetanus, and on the principal Diseases of the Head,
44 BIBLIOGRAPHICAL INDEX.
Eye, and Ear, by the Baron D. J. Larrey. Translated from the
French, by E. F. Eivinus, M. D. 8vo. Philadelphia, 1832.
Surgical Anatomy of the Arteries, with plates and illustrations,
by Nathan R Smith, M.D. 4to. Baltimore, 1832.
A condensation of matter on the Anatomy, Surgical Operations,
and Treatment of Diseases of the Eye, with remarks and plates, by
John Mason Gibson, M. D. 4to. Baltimore, 1832.
The American Cyclopedia of Practical Medicine and Surgery.
Edited by Isaac Hays, M. D. 8vo. 2 vols. Philadelphia, 1833-35.
Lecons Orales de Clinique Chirurgicale, faites a l'Hotel Dieu de
Paris, par M. le Baron Dupuytren. Translated from the French
by A. Sidney Doane, M. D. Part I. 8vo. New York, 1833.
A Treatise on Topographical Anatomy, or the Anatomy of the
Eegions of the Human Body, comprising an Atlas of 12 plates, by
Ph. Fred. Blandin. Translated by A. S. Doane, M. D. 8vo. and
4to. New York, 1834.
The Minor Surgery of Bourgery. Translated from the French,
by William C. Eoberts, M. D., and J. B. Kissam, M. D. 8vo. New
York, 1834.
A Compendium of Operative Surgery, intended for the Use of
Students, and containing Descriptions of all Surgical Operations.
Illustrated by Engravings, by Thos. L. Ogier, M. D., and Thos. M.
Logan, M. D. No. 1, 4to. and four colored lithographic plates,
Charleston, 1834.
Medical and Physical Researches, or Original Memoirs in Medi-
cine, Surgery, Physiology, &c. &c, by P. Harlan, M. D. 8vo.
Philadelphia, 1835.
A Manual of the Diseases of the Eye, or a Treatise on Ophthal-
mology, by S. Littell, Jr., M. D. 12mo. Philadelphia, 1836, 1846.
Practical Observations on Strangulated Hernia and some of the
Diseases of the Urinary Organs, by Joseph Parrish, M. D. 8vo.
Philadelphia, 1836.
Surgery Illustrated, compiled from the Works of Cutler, Hind,
Yelpeau, and Blazius ; 52 plates, by A. Sidney Doane, M. D. 8vo.
New York, 1836.
A Treatise on the Malformations, Injuries, and Diseases of the
Rectum and Anus. Illustrated with plates, by George M. Bushe
M. D. 8vo. New York, 1837.
The final report of a Committee of the Philadelphia Medical
Society, on the construction of instruments and their mode of action
BIBLIOGRAPHICAL INDEX. 45
in the Radical Cure of Hernia, &c, by Heber Chase, M. D. 8vo.
Philadelphia, 1837.
Surgical Observations on Tumors, with Cases and Operations, by-
John C. Warren, M. D. 8vo. Boston, 1837, and London, 1839.
(Illustrated.)
Essay on Cataract, by Theodore Maunnoir, M. D. Geneva.
Translated from the French, by Henry J. Bowditch, M. D. Boston,
8vo. 1838.
On the Application of the Ligature to Arteries or their Trunks,
at a distance from the wounded part and nearer the heart, a Contri-
bution to Traumatic Hemorrhages, by Charles J. Beck, M. D. Frie-
burg. Translated from the German, by Edward G. Davis, M. D.
Philadelphia, 1838.
Practical Surgery, by Robert Liston, M. D., with Additional Notes
and Illustrations, by George W. Norris, M. D. 8vo. Philadelphia,
1838, 1842.
Boylston Prize Dissertations (On Cancer of the Mammae), by
Usher Parsons, M. D. 8vo. Boston, 1839.
On the Enlisting, Discharging, and Pensioning of Soldiers, by
Henry Marshall, F.R.S.E., with the Regulations for the Recruiting
Service in the U. S. Army and Navy, with a Preface, by W. S. W.
Ruschenberger, M. D. 8vo. Philadelphia, 1840.
A Treatise on the Diseases of the Breast, by Velpeau. Trans-
lated from the French, by S. Parkman, M. D. 8vo. Philadelphia,
1840.
Lectures on Retention of Urine caused by Stricture of the Ure-
thra, and on the Diseases of the Prostate, by M. Amussat. Trans-
lated by J. P. Jervey, M. D. (Charleston). 8vo. Philadelphia, 1840.
Memoir on the Radical Cure of Club-Foot, by H. Scoutetten,
M. D. Translated by F. Campbell Stewart, M. D. 8vo. Philadel-
phia, 1840.
On the Medical and Prophylactic Treatment of Stone and Gravel,
with a Memoir on the Calculi of Cystine, by Civiale, D. M. P.
Translated from the French, by Henry H. Smith, M. D. 8vo.
Philadelphia, 1841.
Remarks on the Surgical Practice of Paris, illustrated by Cases
(Thesis), by W. D. Markham, M. D. 8vo. Philadelphia, 1841.
Practical Surgery, by Robert Liston, Surgeon. 2d American
from 3d London edition, with Additional Notes and Illustrations,
by George W. Norris, M. D. 8vo. Philadelphia, 1842.
46 BIBLIOGRAPHICAL INDEX.
Elements of Surgery, by Robert Liston, with Copious Notes and
Additions, by Samuel D. Gross, M. D. 8vo. Philadelphia, 1842 and
1846.
Minor Surgery, or Hints on the Everyday Duties of the Sur-
geon, by Henry H. Smith, M. D. 12mo. Philadelphia, 1843, 1846,
and 1850.
A Practical Treatise on the Diseases of the Testis and of the
Spermatic Cord and Scrotum, by T. B. Curling. Edited by Paul
B. Goddard, M. D. 8vo. Philadelphia, 1843.
A System of Practical Surgery, by William Fergusson, F. R. S.,
with Notes and Additional Illustrations, by Geo. W. Norris, M. D.
8vo. Philadelphia, 1843. The same, 4th edition, 1853.
A Treatise on the Diseases of the Eye, by W. Lawrence, F.R.S.
Edited, with numerous Additions, by Isaac Hays, M. D. 8vo.
Philadelphia, 1843, 1847, and 1854.
New Elements of Operative Surgery, by Velpeau. Translated
from the French, by P. S. Townsend, M. D. Augmented by the
addition of several hundred pages of entirely new matter, com-
prising all the latest improvements, and discoveries in Surgery, in
America and in Europe, up to the present time, under the super-
vision of, and with notes by Valentine Mott, M. D. 3 vols, grand
8vo. New York, 1844.
The Principles and Practice of Modern Surgery, by Robert
Druitt, Surgeon. Edited, with notes and comments, by Joshua B.
Flint, M. D. 8vo. Philadelphia, 1844.
The same, edited by F. W. Sargent, M. D. 1848.
A Treatise on Operative Surgery, comprising a Description of
the various Processes of the Art, including all the new Operations
(with lithographic plates), by Joseph Pancoast, M. D. 4to. Phila-
delphia, 1844.
The same, 3d edition, revised and enlarged. Philadelphia, 1852.
Manual of Orthopcedic Surgery, being a Dissertation which ob-
tained the Boylston Prize for 1844, on the question, u To what
extent is the division of muscles, tendons, or other parts proper for
the relief of deformities or lameness ?" by Henry J. Bigelow, M. D.
8vo. Boston, 1845.
American Medical Biography, or Memoirs of Eminent Physi-
cians (and Surgeons), embracing those principally who have died
since the publication of Dr. Thacher's work on the same subject,
by Stephen W. Williams, M. D. Greenfield, Mass., 1845.
BIBLIOGRAPHICAL INDEX. 47
Lectures on the Operations of Surgery, and on the Diseases and
Accidents requiring Operations, by Eobert Liston, F. R. S., with
numerous Additions, by Thomas D. Mutter, M. D. 8vo. Philadel-
phia, 1846.
A System of Surgery, by J. 1ST. Chelius. Translated from the
German, and accompanied with Additional Notes and Observations,
by John F. South (with additional references to the Surgical Lite-
rature of the United States, by G. W. Norris, M. D.). 8vo. Phila-
delphia, 1847.
On Bandaging and other.Operations of Minor Surgery, by F. W.
Sargent, M. D. 12mo. Philadelphia, 1847.
The Principles and Practice of Surgery, by George McClellan,
M. D. Edited by his son, John H. B. McClellan, M.D. 8vo. Phila-
delphia, 1848.
On Etherization with Surgical Remarks, by John C. Warren.
M. D. 12mo. Boston, 1848.
Effects of Chloroform and of strong Chloric Ether as narcotic
agents (with statistics, post-mortem examinations, &c), by John C.
Warren, M. D. Boston, 1849.
The Practice of Surgery, embracing Minor Surgery, by John
Hastings, M. D. 12mo. Philadelphia, 1850.
On the Physiological Effects of Sulphuric Ether, and its Supe-
riority to Chloroform, by Wm. T. G. Morton, M. D. 8vo. Boston,
1850.
A Practical Treatise on the Diseases and Injuries of the Urinary
Bladder, the. Prostate Gland, and the Urethra, by S. D. Gross, M.D.
8vo. Philadelphia, 1851.
The Principles and Practice of Surgery, by Wm. Pirrie, Sur-
geon. Edited with Additions, by Jno. Neill, M. D. 8vo. Philadel-
phia, 1852.
The Principles of Surgery, by Jas. Miller, 3d American from the
2d and enlarged Edinburgh edition. Revised with Additions, by
F. W. Sargent, M. D. 8vo. Philadelphia, 1852.
Illustrated Manual of Operative Surgery and Surgical Anatomy,
by MM. C. Bernard and C. Huette, D. M. P. Edited with Notes
and Additions, &c, by Wm. H. Van Buren, M.D., and C.E.Isaacs,
M.D. 8vo. (with beautiful plates), New York, 1852 (2 parts).
On the Surgical Treatment of Polypi of the Larynx and ffidema
of the Glottis, by Horace Green, M. D. 8vo. New York, 1852.
Hydatids of the Liver, Operation and Cure, by J. M. Weber.
M. D. 8vo. New York, 1852.
48 BIBLIOGRAPHICAL INDEX.
Eeport of a Committee appointed by the American Medical Asso-
ciation on the Permanent Cure of Eeducible Hernia, by George
Hayward, M.D., Chairman, &c. 8vo. 1852.
Operative Surgery, illustrated, with explanatory text, by E. U.
Piper, M.D. 8vo. Boston, 1852.
History of Kentucky Surgery, read before the Kentucky State
Medical Society, at its annual meeting at Louisville, by Samuel D.
Gross, M. D. 8vo. 1853.
A Treatise on Operative Ophthalmic Surgery, by H. Haynes
Walton, Surgeon, first American from the first London edition.
Edited by S. Littell, M. D. 8vo. Philadelphia, 1853.
The Practice of Surgery, by Jas. Miller, 3d American from the
2d Edinburgh edition. Edited with Additions, by F. W. Sargent,
M.D. 8vo. Philadelphia, 1853.
The Surgical Treatment of Fibrous Tumors of the Uterus, here-
tofore considered beyond the resources of art, by Washington L.
Atlee, M. D., Philadelphia (Prize Essay of the American Medical
Association). 8vo. 1853.
Practical Observations on Aural Surgery, and the Nature and
Treatment of Diseases of the Ear, with Illustrations, by Wm. E.
Wilde. Edited by Addinell Hewson, M. D. 8vo. Philadelphia,
1853.
AMEEICAN MEDICAL JOUENALS
FROM THE YEAR 1785 TO 1854.
The following list includes only such Journals as were accessible,
and contained Surgical papers. Although it exhibits very many
of the medical journals of this country, it is probable that it does
not include all ; editorial changes, and the irregular distribution of
some of them, rendering it difficult for any individual to obtain ac-
curate information respecting them, especially in relation to the
western journals. The matter in parenthesis () is introduced as
explanatory of the paper, and will not always be found in the origi-
nal title.
Memoirs of the American Academy of Arts and Sciences. 4to.
Boston, 1785—1793.
Medical Papers, Communications and Dissertations, communicated
to the Massachusetts Medical Society. To which are subjoined,
MEDICAL JOURNALS. 49
extracts from various authors, containing some of the improvements
which have lately been made in Physic and Surgery. Published by
the Society, in 2 vols. 8vo. Boston, 1790—1813.
Transactions of the College of Physicians, of Philadelphia. 8vo.
Philadelphia, 1793—1850.
The Medical Repository of Original Essays and Intelligence rela-
tive to Physic, Surgery, Chemistry, and Natural History; with a
critical Analysis of recent publications on these departments of
knowledge, and their auxiliary branches. 8vo. New York, 1797 —
1821. This was the first medical journal published in the United
States, though the Transactions of the American Academy of Arts
and Sciences, of the Massachusetts Medical Society, and of the Col-
lege of Physicians, Philadelphia, which preceded it, published medi-
cal cases in connection with their proceedings.
The Philadelphia Medical and Physical Journal. Collected and
arranged by Benjamin Smith Barton, M. D. 8vo. Philadelphia,
1804—1805.
The Philadelphia Medical Museum, conducted by John Redman
Coxe, M. D. 8vo. Philadelphia, 1805—1811.
The Medical and Agricultural Register for the years 1806, 1807,
by Daniel Adams, M. D. 8vo. Boston.
The Baltimore Medical and Physical Recorder, conducted by
Tobias Watkins, M. D. 8vo. Baltimore, 1809.
The New York Medical and Philosophical Journal and Review.
8vo. New York, 1809—1811.
The American Medical and Philosophical Register; or Annals of
Medicine, Natural History, Agriculture, and the Arts. Conducted
by a Society of Gentlemen. 8vo. New York, 1811 — 1814.
The Eclectic Repertory and Analytical Review, Medical and
Philosophical. Edited by a Society of Physicians. 8vo. Philadel-
phia, 1811—1820.
The New England Journal of Medicine and Surgery, and the
collateral branches of Science. Conducted by a number of Physi-
cians. 8vo. Boston, 1812—1827.
Transactions of the Physico-medical Society of New York. 8vo.
New York, 1817.
The Medical and Surgical Register ; consisting chiefly of Cases
in the New York Hospital. By John "Watts, Jr., M. D., Valentine
Mott, M. D., and Alexander H. Stevens, M. D. 8vo. N. York, 1818.
4
50 BIBLIOGRAPHICAL INDEX.
The American Medical Recorder. Conducted by several respect-
able Physicians of Philadelphia. 8vo. Philadelphia, 1818, 1829.
The Philadelphia Journal of the Medical and Physical Sciences.
Supported by an Association of Physicians, and edited by N. Chap-
man, M. D. 8vo. Philadelphia, 1820—1827.
The Journal of Foreign Medical Science and Literature, being a
continuation of the Eclectic Repertory. Conducted by Samuel
Emlen, M. D., William Price, M. D., and John D. Godman, M. D.
8vo. Philadelphia, 1821—1824.
The New York Medical and Physical Journal. Edited by John
W. Francis, M. D., Jacob Dyckman, M. D., and John B. Beck, M. D.
8vo. New York, 1822—1829.
The Philadelphia Journal of the Medical and Physical Sciences.
New Series. Edited by N. Chapman, M. D., and William P. De-
wees, M. D. 8vo. Philadelphia, 1825—1827.
The North American Medical and Surgical Journal. Conducted
by Hugh L. Hodge, M. D., Franklin Bache, M. D., Charles D.
Meigs, M. D., B. H. Coates, M. D., and RenC La Roche, M. D. 8vo.
Philadelphia, 1826—1831.
The American Journal of the Medical Sciences. Edited by Isaac
Hays, M. D. 8vo. Philadelphia, 1827—1854. This journal con-
tains the largest number of valuable papers of any Journal in the
U. States.
The Boston Medical and Surgical Journal. (Published weekly.)
8vo. Boston, 1828—1850.
The Transylvania Journal of Medicine, and the Associate Sci-
ences. Edited by John Esten Cooke, M. D., and Charles W. Short,
M. D. Lexington, Ky., 1828—1837.
The same, edited by Ethelbert L. Dudley, M. D., and H. M.
Bullitt, M. D. 1850.
The same, edited by L. J. Frazee, M. D. Louisville, 1853.
The Monthly Journal of Foreign Medicine. Conducted by Squire
Littell, Jr., M. D. Philadelphia, 1828, 1829.
The New York Medical and Physical Journal. New Series.
Conducted by Daniel L. M. Peixotto, M. D. 8vo. New York,
1829—1831.
The Maryland Medical Recorder. Conducted by Horatio G.
Jameson, M. D. Baltimore, 1829—1832.
The New York Medical Inquirer and the American Lancet (late
MEDICAL JOURNALS. 51
Medical Inquirer), by an Association of Physicians and Surgeons.
New York, 1830.
New York Medico-Chirurgical Bulletin. Edited by George
Bushe, M. D. New York, 1831, 1832.
The Baltimore Medical and Surgical Journal and Eeview. Edi-
ted by E. Geddings, M. D. Baltimore, 1833—1835.
The Medical Magazine. Conducted by A. L. Pierson, M. D.,
J. B. Flint, M. D., and E. Bartlett, M. D. Boston, 1833—1835.
The American Lancet. Edited by F. S. Beattie, M. D. Phila-
delphia, 1833.
Southern Medical and Surgical Journal. Edited by Paul F.
Eve, M. D. Augusta, Georgia, 1836.
The United States Medical and Surgical Journal. Conducted by
a number of respectable Physicians in various parts of the United
States. New York, 1834—1837.
The same. Edited by L. A. Dugas, M. D. Augusta, Georgia,
1853.
Bulletin of Medical Science. Edited by John Bell, M. D. Phi-
ladelphia, 1837.
The American Medical Intelligencer. Edited by Eobley Dungli-
son, M. D. (Containing reprints, translations, &c, of many excel-
lent works.) Philadelphia, 1837—1842.
Medical Examiner and Record of Medical Science. Edited by
M. Clymer, M. D., and J. B. Biddle, M. D. Philadelphia, 1837.
The same. Edited by F. G. Smith, M. D., and J. B. Biddle, M. D.
Philadelphia, 1850.
New York Journal of Medicine and Surgery. Edited by S. Forry,
M. D. New York, 1839—1841.
New Orleans Medical and Surgical Journal. Edited by A. Hes-
ter, M. D. New Orleans, 1844.
Illinois Medical and Surgical Journal. Chicago, 1844.
Buffalo Medical and Surgical Journal. Edited by Austin Flint,
M. D. 1845. *
New York Medical Gazette. Edited by D. M. Reese, M D
LL.D. New York, 1849.
New York Journal of Medicine and Collateral Sciences. Edited
by S. S. Purple, M. D. New York, 1849.
St. Louis Medical and Surgical Journal. Edited by Drs. Linton
Moore, McPheeters, and Jos. N. McDowell. 1849.
52 BIBLIOGRAPHICAL INBEX.
The Charleston Medical Journal and Review. Edited by P. C.
Gaillard, M. D., and II. W. De Saussure, M. D. Charleston, 1849.
The Western Lancet and Hospital Eeporter. Edited by L. M.
Lawson, M. D., and John P. Harrison, M. D. Cincinnati, Ohio, 1849.
New York Register of Medicine and Pharmacy. Edited by C.
D. Griswold, M. D. New York, 1850.
1 The Ohio Medical and Surgical Journal. Edited by S. Hanbury
Smith, M. D. Columbus, Ohio, 1850.
The same. Edited by Richard L. Howard, M. D. Columbus,
Ohio, 1853.
The New Jersey Medical Reporter, and Transactions of the New
Jersey Medical Society. Edited by Joseph Parrish, M. D. Bur-
lington, N. J., 1850.
Western Journal of Medicine and Surgery. Edited by Lunsford
P. Yandell, M. D. Louisville, 1850.
The Stethoscope and Virginia Medical Gazette. Edited by P.
Claiborne Gooch, A. M., M. D. Richmond, Va., 1851.
The North- Western Medical and Surgical Surgical Journal.
Edited by W. B. Herrick, M. D., assisted by H. A. Johnson, M. D.
Chicago, 1852.
The New York Medical Times. Edited by Henry D. Bulkley,
M. D. New York, 1852.
Nashville Journal of Medicine and Surgery. Edited by W. R.
Bowling, M. D., and Paul F. Eve, M. D. Nashville, Tenn., 1852.
The New Orleans Monthly Medical Register. By A. Forster
Axson, M. D. New Orleans, 1852.
The New Orleans Medical and Surgical Journal, devoted to
Medicine and the Collateral Sciences. Edited by A. Hiester, M.D.
New Orleans, 1852.
American Lancet and Monthly Journal of Practical Medicine.
Edited by Horace Nelson, M.D. Plattsburg, N.Y., 1853.
The New Hampshire Journal of Medicine. Edited by Edward
H. Parker, A. M., M. D. Concord, N. H., 1853. '
The East Tennessee Record of Medicine and Surgery. Edited
by Frank A. Ramsay. A. M., M. D. Knoxville, Tenn., 1853.
The Virginia Medical and Surgical Journal. Edited by George
A. Otis, M. D., and Howell L. Thomas, M. D. Richmond, Va., 1853.
Southern Journal of Medical and Physical Sciences. Edited by
Drs. King, Jones, Ramsey, Currey, Wood, Atchison, and Scruggs.
Nashville, 1853.
MEDICAL JOURNALS. 53
American Lancet and Monthly Journal of Practical Medicine.
Edited by Horace Nelson, M. D. Plattsburg, N. Y., 1853.
Peninsular Journal of Medicine and Collateral Sciences. Edited
by E. Andrews, A. M., M. D. Ann Arbor, Michigan, 1853.
Kentucky Medical Eecorder. Edited by H. M. Bullett, M. D.,
and E. J. Breckenridge, M. D. New Series, Louisville, Ky., 1853.
54: BIBLIOGRAPHICAL INDEX.
INDEX OF SPECIAL PAPERS
PUBLISHED BY
AMERICAN SURGEONS FROxM THE YEAR 1783 TO THE YEAR 1854.
The papers included in the following index exhibit, it is thought,
a fair statement of those published by American surgeons since the
year 1783. It has been composed with great care and with much
labor, in the hope of enabling the reader to form a correct estimate
of the published acts of such surgeons as have aided in illustrating
the surgical practice of the United States. Its deficiencies may
doubtless be noticed, but they must be ascribed mainly to the fact
that the circulation of many of the journals has either been limited
to certain States, or that they have been imperfectly preserved both
in our public and private libraries. The revision of this list for
the present edition has, however, satisfied the author that the num-
ber of papers that have been omitted must bear a very small ratio to
those that are reported ; and the index is, therefore, presented with
considerable confidence in the belief that it is as complete as is
possible for so long a period as the term of seventy years, the
period which it now represents. The matter in ( ) is not in the
original title, but is added as indicating points of interest, and as
explanatory of the case.
PART I.
PAPERS ON THE ELEMENTARY OPERATIONS, ETC.
Experiments on the Coagulation of Blood when out of the Body
(showing that the air is a strong coagulant of blood, and that it is
not owing to cold), by Thomas Hewson, M. D. Philadelphia.
Eclectic Repertory, vol. i. p. 230, 1811.
On the employment of Animal Ligatures, by Philip Syng Physic,
M. D. Philadelphia.
Electic Repertory, vol. vi. p. 389, 181G.
ELEMENTARY OPERATIONS. 55
Observations on Traumatic Hemorrhage, illustrated by Experi-
ments on living Animals, by Horace G. Jameson, M.D. Baltimore.
American Med. Recorder, vol. xi. p. 3, 1827.
On the Use of the Bandage (to arrest hemorrhage and supersede
the use of the knife and saw), in Gunshot Wounds, Fractures, &c,
by Benjamin Winslow Dudley, M. D. Lexington.
Transylvania Journ. of Medicine, vol. i. p. 501, 1828.
Utility of the Bandage in Wounds of the Arteries, by K Gaither,
M. D. Kentucky.
Transylvania Journ. of Medicine, vol. ii. p. 143, 1829.
Experiments on the Use of Metallic Ligatures as applied to Arte-
ries, by Henry S. Levert, M. D. Mobile, Ala.
Am. Journ. Med. Sciences, vol. iv. p. 17, 1829.
Aneurism of the Brachial Artery, cured by Compression, by J.
W. Heustis, M. D. Cahawba, Ala.
Am. Journ. Med. Sciences, vol. ix. p. 261, 1831.
Torsion of Arteries (practised in Dec. 1826, in presence of Sur-
geons Eogers and Ford, British army; three years before Amussat),
by George Bushe, M. D. New York.
2f. Y. Medico- Chirurgical Bulletin, vol. ii. p. 212, 1832.
Two Cases of Accidents from admission of Air into the Veins
during Surgical Operations, by John C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. x. p. 545, 1832.
Also, article Air, by J. C. Warren, M. D. Boston.
Amer. Cyclopedia of Practical Medicine and Surgery, vol. i. p. 263, 1834.
Entrance of Air into the Vein whilst ligating the Subclavian
Artery (recovery), by R. D. Mussey, M. D. Fairfield, New York.
Am. Journ. Med. Sciences, vol. xxi. p. 377, 1837.
Report of five cases of Wounds of Arteries, treated by Compres-
sion, by T. S. Kirkbride, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxiii. p. 324, 1839.
Wounds of Arteries, successfully treated by Compression, by
George Thompson, M. D. Tennessee.
Am. Journ. Med. Sciences, vol. iii. N. S. p. 262, 1842.
On the Use of Sutures in Surgery, and their Advantages over
Adhesive Strips, and other modes of Coaptation of the Edges of
Wounds, by W. T. Wragg, M. D.
Charleston Med. Journ., vol. iii. p. 633, 1848.
On Collodion, or new Liquid Adhesive Plaster, by John P. May-
nard. Boston.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 577, 1848.
56 BIBLIOGRAPHICAL INDEX.
On the Advantages of Simple Dressings in Surgery, by E. R.
Squibb, M.D., U.S. Navy.
Am. Joiirn. Med. Sciences, vol. xvii. N. S. p. 17, 1849.
On Cold Water as a Surgical Dressing, by J. C. Warren, M. D.
Boston.
Address of Dr. Warren before Am. Med. Association at Cincinnati, 1850.
ON ETHERIZATION.
Inhalation of Ethereal Yapor, for the prevention of Pain in Sur-
gical Operations (being the first cases in which it was used), by John
C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxxv. p. 375, 1846, and Am. Journ. Med.
Sciences, vol. xiii. p. 260, 1847.
Inhalation of Ether, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 522, 1847.
On Anaesthetic Agents, with Statistics from various Hospitals in
the United States, by Drs. Isaac Parrish, and Henry J. Bigelow.
Transactions Am. Med. Association, vol. i. p. 174, et seq., 1848.
Report of Operations performed under Anaesthetic Agents, by
Paul F. Eve, M. D. Georgia.
Southern Med. and Surg. Journ., vol. v. p. 278, 1849.
On Anaesthetics, (see Report of Committee on Surgery, American
Medical Association.)
Transactions Am. Med. Association, vol. ii. p. 211, 1849.
On Anaesthesia, by R. D. Mussey, M. D., Cincinnati, Chairman
of the Committee on Surgery, American Medical Association.
Transactions Am. Med. Association, vol. iii. p. 321, 1850.
Ether and Chloroform, by John C. Warren, M. D. Boston.
Address, by Dr. Warren, before Am. Med. Ass. at Cincinnati, Boston, 1850.
On the Use of Anaesthetics, by J. C. Warren, M. D. Boston.
Transactions Am. Med. Association, vol. iii. p. 385, 1850.
The Influence of Chloroform in increasing Hemorrhage after
Amputation, by Kirtley Ryland, M. D. St. Louis, Mo.
St. Louis Med. and Surg. Journ., vol. xi. p. 208, 1853.
Clinical Remarks on a Case of Death from Chloroform, accident-
ally administered (inhaled) in the Massachusetts General Hospital,
by J. C. Warren, M. D. Boston.
New York Journ. Med., vol. x. N. S. p. 121, 1853 ;
also Boston Med. and Surg. Journ., vol. xlvii. p. 353, 1852.
ELEMENTARY OPERATIONS. 57
On the Test for the Safety-Point of Anaesthesia, by James Bol-
ton, M. D. Eichrnond.
Stethoscope and Virginia Med. Gazette, vol. ii. p. 681, 1852.
On Anaesthetic Agents, by Charles T. Jackson, M. D. Boston.
Southern Med. and Surg. Journ., vol. ix. N. S. p. 5, 1853.
Bemarks on Chloroform, by Samuel A. Cartwright, M. D. New
Orleans.
Boston Med. and Surg. Journ., vol. xlvii. p. 254, 1852.
Eemarks on the Comparative Yalue of the Different Anaesthetic
Agents, by George Hayward, M. D. Boston.
Western Lancet, vol. xi. p. 375, 1850, from Boston Med. and Surg. Journ.
Remarks on the Importance of Anaesthesia from Chloroform in
Surgical Operations, Illustrated by two Cases, by Valentine Mott,
M. D. New York.
X. Y. Journ. Med., vol. vii. p. 9, 1851, from Trans. N. Y. Acad. Med.
Report of the Committee of the Medical Society of Virginia on
the Utility and Safety of Anaesthetic Agents (a valuable and ex-
tended Report), by Drs. Bolton, Gibson, Cunningham, and Parker.
Stethoscope, vol. i. p. 181, 1851.
Non-Fatal Accidents from Anaesthetic Agents, with Observa-
tions, by Wm. H. Mussey, M. D. Cincinnati.
Western Lancet, Nov. 1853.
58 BIBLIOGRAPHICAL INDEX.
PART II.
PAPERS RELATING TO OPERATIONS ON THE HEAD AND FACE.
ON ANASTOMOSING ANEURISM AND N.EVUS MATERNUS.
Case of Aneurism by Anastomosis on the Scalp, in which both
primitive Carotid arteries were tied (and the Tumor dissected out
successfully), by R. D. Mussey, M. D. New Hampshire.
Am. Journ. Med. Sciences, vol. v. p. 316, 1829.
Ligature of the Carotid for Anastomosing Aneurism (of the face)
in a Child three months old (cured), by Valentine Mott, M. D. New
York.
Am. Journ. Med. Sciences, vol. vii. p. 271, 1830.
Case of Naevus Maternus terminating in Aneurism by Anasto-
mosis, cured by an Operation (extirpation), by Horatio G. Jameson,
M.D.
Maryland Med. Record, vol. ii. p. 105, 1831.
Telangiectasis, being a Report of Cases treated (by white-hot
needles, ligature, &c.,) by George Bushe, M. D. New York.
N. Y. Medico- Chirurgical Bulletin, vol. i. p. 49, 1832.
Observations on the Nature and Treatment of Telangiectasis, or
that morbid state of the Bloodvessels which gives rise to Naevus
and Aneurism from Anastomosis, by John Watson, M. D. New
York.
Am. Journ. Med. Sciences, vol. xxiv. p. 24, 1839.
Treatment of Vascular Naevus by Caustic Threads, by N. R.
Smith, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 260, 1843.
Naevi Materni, treated by needles and ligature, by George Hay-
ward, M. D. Boston.
Boston Med. and Surg. Journ., vol. xix. p. 157, 1838.
Ligature of both Carotids for a remarkable Erectile Tumor of
OPERATIONS ON THE HEAD AND FACE. 59
the Mouth, Face, and Neck (cured), by J. Mason "Warren, M. D.
Boston.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 281, 1846.
Erectile Tumor of the Face, successful ligature of the Primitive
Carotid, use of thirty needles heated to a red heat (relieved), by
James D. Trask, M. D. White Plains, New York.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 86, 1849.
On the Use of Collodion in the Cure of Erectile Tumors, without
Operation, by Daniel Brainard, M. D., Chicago.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 515, 1849.
Two Cases of Morbid Erectile Tissue, treated successfully by
heated needles, by J. W. Schmidt, M. D. New York.
N. Y. Journ. of Medicine, vol. iv. N. S. p. 66, 1850.
ON TUMORS AND OTHER DISEASES OF THE HEAD.
Two Cases of Tumors on the Head of New-Born Children (Ce-
phalhematoma), treated by Puncture, successfully, by E. N. Allen,
M. D. Maryland.
Maryland Med. Record, vol. iii. p. 257, 1832.
Case of Extraordinary Tumor attached to the Occipital Eegion of
the Head (length 24J inches), communicating with the Cavity of
the Cranium, by E. S. Bennet, M. D. Charleston.
Baltimore Med. and Surg. Journ., vol. i. p. 351, 1833.
Observations on Sanguineous Tumors of the Head, which form
spontaneously ; sometimes denominated Cephalsematoma and Ab-
scessus Capitis Sanguineus Neonatorum, by E. Geddings, M. D.
Baltimore.
North American Archives, vol. ii. p. 217, 1835.
Exostosis of the Frontal Bone removed, by R. D. Mussey, M. D.
New Hampshire.
Am. Journ. Med. Sciences, vol. xxi. p. 377, 1837.
On Extirpation of Encysted and other Tumors, by Alexander H.
Stevens, M. D. New York.
Boston Med. and Surg. Journ., vol. xxii. p. 53, 1840.
Operation for the removal of a large bony Tumor, called Spina
Ventosa, by George McClellan, M. D. Philadelphia.
Medical Examiner, vol. iv. p. 44, 1841.
Anaplastic Operation for removal of a Deformity caused by a hole
60 BIBLIOGRAPHICAL INDEX.
in the forehead, left by Syphilitic Neerosis of the whole external
table of the Os Frontis, by John Watson, M. D. New York.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 537, 1844.
Report of two Cases of Cephalannatoma, with some Remarks
on Diagnosis and Treatment, by Lewis Shanks, M. D. Tennessee.
Ohio Med. and Sunj. Journ., vol. ii. p. 537, 1850.
ON HYDROCEPHALUS.
Case of Hydrocephalus tapped, by P. S. Physick, M. D. Phila-
delphia, 1801.
Philadelphia Journ. Med. and Phys. Sciences, vol. iv. p. 316, 1826.
Case of Congenital Hydrocephalus, forming a cyst on the back
of the head, containing the posterior lobes of the cerebrum, in
which the water was evacuated by puncturing the brain (died), by
Wm, E. Horner, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iv. p. 530, 1829.
Case of Hydrocephalus treated by tapping (operation performed
seven times, and sixty-one ounces of fluid drawn off; patient lived
near two months after the first tapping), by L. A. Dugas, M. D.
Georgia.
Am. Journ. Med. Sciences, vol. xx. p. 536, 1837.
Case of Hydrocephalus (repeatedly tapped — died), by J. B.
Whitridge, M. D. Charleston.
Am. Journ. Med. Sciences, vol. xx. p. 538, 1837.
Account of an accumulation of eight ounces of fluid between the
Cranium and the Scalp, by Robert Lebby, M. D.
Am. Journ. Med. Sciences, vol. xvi. p. 250, 1835.
Operation of Paracentesis Capitis (relieved) in a case of Hydro-
cephalus, by M. Howard, M. D. Louisville.
Transylvania Med. Journ., vol. iii. p. 373, 1852.
Case of Hydrocephalus (tapped— died), with Remarks on Nature
and Treatment of this Disease, by H. L. Byrd, M. D. Savannah,
Georgia.
Charleston Med. and Surg. Journ., vol. viii., p. 774, 1852.
ON TREPHINING AND INJURIES OF THE HEAD.
Fracture of the Skull and Wound of the Brain (cured after the ap-
plication of the Trephine), by John Syng Dorsey, M. D. Philadelphia.
Philadelphia Med. Museum, vol. ii. p. 282, 1806.
OPERATIONS ON THE HEAD AND FACE. 61
Memoir on the Subsequent Treatment of Injuries of the Head,
illustrated by Cases, by Valentine Mott, M. D. New York.
Transactions of the Physico-Ned. Society of New York, vol. i. p. 223, 1817.
Fungus Cerebri, successfully treated by Excision, by Jonathan
A. Allen, M. D. Brattleboro' Vermont.
New England Med. Journ., vol. viii. p. 323, 1819.
Fractured Skull, successfully Trephined, by Andrew Park, M. D.
Eaton, Georgia.
Philadelphia Journ. of Med. and Phys. Sciences, vol. viii. 1824.
Epilepsy from Depressed Bone, cured by Trephining, by David
L. Rogers, M. D. New York.
N. Y. Med. and Phys. Journ., vol. v. p. 79, 1826.
Observations on Injuries of the Head, by Benjamin W. Dudley,
M. D. Lexington.
Transylvania Journ. of Med., vol. i. p. 9, 1828.
Case of Epilepsy cured by Trephining, by James Guild, M. D.
Alabama.
Am. Journ. Med. Sciences, vol. iv. p. 96, 1829.
Chronic Injuries of the Brain relieved by an Operation with the
Trephine, by William Judkins, M. D. Mount Pleasant, Ohio.
Transylvania Med. Journ., vol. ii. p. 135, 1829.
Case in which the Osseous Disk, removed by a Trephine, was
regenerated.
Maryland Med. Recorder, vol. i. p. 152, 1829.
Case of Hernia Cerebri, cured by Sponge Compress, by J. "W.
Heustis, M.D. Mobile.
Am. Journ. Med. Sciences, vol. iii. p. 349, 1829.
A Case of Depressed Fracture of the Cranium, successfully treated
without resorting to the Trephine* by Thomas F. Dale, M.D. Pitts-
burg.
North American Med. and Sure/. Journ., vol. x. p. 164, 1830.
Report of Cases of Injuries of the Head, treated in the Pennsyl-
vania Hospital, by George W. Norris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. ix. p. 304, 1831.
Use of the Trephine in Epilepsy, being the sixth successful case,
by Benjamin "W. Dudley, M. D. Lexington, Kentucky.
Am. Journ. Med. Sciences, vol. xi. p. 542, 1832.
Compound Camerated Fracture of the Cranium, successfully
treated by the removal of three pieces of the external table of the
Skull, by Paul F. Eve, M. D. Georgia.
Am. Journ. Med. Sciences, vol. xii. p. 549, 1833.
62 BIBLIOGRAPHICAL INDEX.
Epilepsy successfully treated by Trephining, by George Hay ward,
M. D. Boston.
Am. Joitm. Med. Sciences, vol. xxii. p. 517, 1838.
Eesearches on Hernia Cerebri following Injuries of the Head.
Essay, read before N. Y. Med. and Surg. Society, by Gurdon Buck,
Jr., M. D. New York.
Neio York Journ. Med. and Surg., vol. iv. p. 348, 1840.
Cases of Injury of the Head, by A. B. Shipman, M. D. Cortland
County, New York.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 66, 1841.
Cases of Injury of the Head, by A. B. Shipman, M.D.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 373, 1841.
Cases of Injury of the Head, by A. B. Shipman, M. D. Indiana.
Boston Med. and Surg. Journ., vol. xxxviii. pp. 353, 373, 1848.
Trephining for Epilepsy (of twenty years' standing), successful,
by J. G. F. Holston, M. D. Ohio.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 541, 1849.
Compound Comminuted Fracture of Skull, removal of a large
portion of the right Parietal Bone (Kecovery), by George Fox, M.D.
Philadelphia.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 43, 1849.
Fracture of the Cranium with Depression ; Epilepsy ; Operation ;
Eecovery, by Charles A. Pope, M.D. St. Louis.
St. Louis Med. and Surg. Journ., vol. vii. p. 298, 1850.
Trephining for an old Depression of the Cranium causing Idiocy
(died on the ninth day from hemorrhage from longitudinal sinus),
by J. M. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 72, 1850.
Surgical Treatment of Epilepsy (7 cases operated on by trephine,
&c), by John G. F. Holston, M. D. New Concord, Ohio.
Western Lancet, vol. xi. p. 700, 1850.
A Case of Epilepsy cured by Trephining the Skull, by E. L.
Dudley, M.D. Lexington, Kentucky.
Transylvania Med. Journ., vol. i. N. S. p. 84, 1851.
Epilepsy (cured by dissecting cicatrices in scalp free from cra-
nium), by F. H. Hamilton, M. D. Buffalo.
Western Lancet, vol. xi. p. 321, 1850, from Buffalo Med. Journ.
Abscess in the Substance of the Brain, Hernia Cerebri, the Late-
ral Ventricles opened by an Operation (died), by William Detmold
M.D. New York.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 86, 1850.
OPEKATIONS ON THE HEAD AND FACE. 63
Fracture of the Cranium; Depression; Epilepsy — trephined,
cured, by Charles A. Pope, M. D. St. Louis.
St. Louis Med. and Surg. Journ., vol. vii. p. 293, 1850.
Injuries of Cranium — trepanning, by Henry F. Campbell, M. D.
Augusta, Georgia.
Southern Med. and Surg. Journ., vol. vii. p. 279, 1851.
Eeport of Trephining for Compression of the Brain (cured), by
J. W. H. Trugien, M. D. Portsmouth, Virginia.
Stethoscope, vol. i. p. 647, 1851.
Case of Fracture of the Cranium, with Depression, followed by
Traumatic Tetanus, in which Trephining was successfully practised,
by E. Geddings, M. D. Charleston.
Charleston Med. Journ., vol. vii. p. 505, 1852.
Trephining the Cranium and Ligature of the Carotid Artery in
Epilepsy (but little relieved), by "Willard Parker, M. D. New
York. •
New York Journ. Med., vol. viii. N. S. p. 418, 1852.
Eemarks on Fracture of the Cranium (6 Cases showing Eesults of
trephining) by John Harden, M. D. Louisville, Kentucky.
Western Journ. Med. and Surg., vol. ix. 3d series, p. 203, 1852.
The Surgical Treatment of Epilepsy, with Statistical Tables of
all the recorded cases of Ligature of the Carotid Arteries, and also
Trephining the Cranium, as performed by American Surgeons, by
Stephen Smith, M. D. New York.
New York Journ. Med., vol. viii. p. 220, 1852.
A Description of, and Eemarks upon a newly constructed Tre-
phine (with a Cut), by Samuel S. Purple, M. D. New York.
New York Journ. Med., vol. x. N. S. p. 419, 1853.
ON AFFECTIONS OF THE EYELIDS.
Eemarks on Encysted Tumors of the Eyelids, with a Case, by E.
J. Davenport, M. D. Boston.
Boston Med. and Surg. Journ., vol. xviii. p. 413, 1838.
Case of Irritation of Tarsi Cartilages, caused by Pediculus Pubis,
by J. D. Godman, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. i. p. 241, 1827.
Encysted Tumor of the Orbit of the Eye removed, by H. G.
Jameson, M. D. Baltimore.
Philadelphia Med. Recorder, vol. xii. p. 340, 1827.
64 BIBLIOGRAPHICAL INDEX.
Observations on Entropion, with a Case, by Samuel Jackson,
M. D. Northumberland, Pennsjdvania.
Am. Joiirn. Med. Sciences, vol. iv. p. 297, 1820.
Scirrhus of the Lachrymal Gland, successfully removed, by
George Bushe, M. D. New York.
Medico- Chirurgical Bulletin, vol. i. p. 38, 1832.
Dissertation on Fistula Lachrymalis, by Robert W. Haxall, M. D.
Richmond, Virginia. (Boylston Prize Essay.)
Medical Magazine, Boston, vol. i. p. 129, 1832.
On Anchylo-blepharon, by Isaac Hays, M. D. Philadelphia.
Am. Cyclopaedia of Practical Med. and Surg., vol. i. p. 464, 1834.
Blepharo-plastic Operations for Restoration of the Lower Eyelid,
by J. Mason Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxiv. p. 149, 1841.
Case of Congenital Hypertrophy of the Upper Eyelids and Mu-
cous Membrane of the Upper Lip, with an Inversion of the Eye-
lashes, by H. H. Toland, M. D. Columbia, South Carolina.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 244, 1841.
Blepharo-plastic Operation for Ectropion, by A. C. Post, M. D.
New York.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 258, 1842.
Plastic Operation for Ectropion, by Daniel Brainard, M. D.
Chicago.
Am. Journ. Med. Sciences, vol. x. N. S. p. 356, 1845.
Congenital Inability to raise the upper Eyelid, cured by Opera-
tion, by Charles A. Hall, M. D. Vermont.
Am. Journ. Med. Sciences, vol. xii. p. 143, 1846.
Symblepharon, successfully treated by a Plastic Operation, by
Isaac Hays, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xiv. p. 263, 1847.
Carcinoma of the Eyelid— Blepharoplasty after Dieffenbach's
Method, by C. Theodore Meier, M. D. New York.
New York Journ. Med., vol. ix. N.S. p. 205, 1852.
Case of Carcinoma Oculi and Extirpation of the Eyeball, by
Henry W. Williams, M. D. Boston.
Boston Med. and Surg. Journ., vol. xlvii. p. 202, 1852.
Case of Fungus Hsematodes of the Eye— Extirpation, by Ed-
ward Delafield, M. D. New York.
New York Journ. Med., vol. v. N. S. p. 199, 1850.
OPERATIONS ON THE HEAD AND FACE. 65
OPERATIONS ON THE EYEBALL.
Observations on Cataract and the various Modes of Operating for
its Cure, by G. Fricke, M. D. Baltimore.
Medical Recorder, vol. iv. p. 26, 1821.
Artificial Pupil and Modes of Operating, by G. Fricke, M. D.
Baltimore.
Medical Recorder, vol. vi. p. 36, 1822.
Artificial Pupil, by Edward Delafield, M. D. New York.
New York Med. Phys. Journ., vol. iv. p. 145, 1825.
An Account of a new Instrument for making Artificial Pupil
and cutting up the Lens, by John Hill, M. D. South Carolina.
New York Med. Phys. Journ., vol. iv. p. 490, 1825.
Case of "Wart on the Adnata, removed by Nitrate of Silver, by
P. S. Physick, M. D. Philadelphia.
Philadelphia Med. Journ., vol. v. N. S. p. 187, 1827.
Extirpation of a Cancerous Eye, by Harvey Lindsly, M. D.
Washington, District of Columbia.
Am. Journ. Med. Sciences, vol. vi. p. 349, 1830.
Operation for Formation of Artificial Pupil, by E. J. Davenport,
M. D. Boston.
Boston Med. and Surg. Journ., vol. xix. p. 165, 1839.
Extraction of Foreign Bodies from the Eye, by Isaac Hays, M. D.
Philadelphia.
Am. Journ. Med. Sciences, vol. xxiv. p. 514, 1839.
Case of Osseous Formation in the Eye, by J. Jeffries, M. D.
Boston.
Boston Med. and Surg. Journ., vol. xxiii. p. 302, 1841.
Cases of Strabismus (division of the internal Rectus), reported
by J. H. Dix, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxiii. p. 265, 1841.
Cases of Operations for Artificial Pupil, by John Jeffries, M. D.
Boston.
Boston Med. and Surg. Journ., vol. xxv. p. 249, 1841.
On the Operation for the Cure of Strabismus, by Joseph Pan-
coast, M. D. Philadelphia.
Medical Examiner, vol. iv. p. 390, 1841.
Sub-conjunctival Method of Operating for Strabismus, by E. J.
Davenport, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxv. p. 89, 1841.
5
66 BIBLIOGRAPHICAL INDEX.
Case of Congenital Tumor of the Eyeball, by W. T. Taliaferro,
M. D. Kentucky.
Am. Journ. Med. Sciences, vol. ii. N". S. p. 88, 1841.
Operation for Artificial Pupil and subsequent section of the Rec-
tns Superior, by J. Kearney Rogers, M. D. New York.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 248, 1842.
Operation for Artificial Pupil, by Isaac Hays, M. D. Philada.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 371, 1842.
Two Cases Malignant Ophthalmic Disease (Colloid Tumor of the
( >rbit and Melanosis of Globe), Geo. A. Bethune, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxxvi. p. 509, 1847.
Dislocation of the Crystalline Lens, from a Blow, by Francis
West, M. D. Philadelphia.
Philadelphia Med. Examiner, vol. vi. p. 241, 1850.
Dislocation of the Crystalline Lens, beneath the Conjunctiva,
extraction at the Inner Canthus, by Charles A. Pope, M. D. St.
Louis.
St. Lords Med. and Surg. Journ., vol. vii. p. 289, 1850.
Extraction of Cataract (the patient being under the influence of
ether), by H. "W". Williams, M. D. Massachusetts.
Boston Med. and Surg. Journ., vol. xlix. p. 338, 1853.
OPERATIONS ON THE FACE.
Tic Douloureux (cured by dividing the Infra and Supra-orbitar
Nerves), by Dr. Jeremy Stimpson, M. D. Boston.
New England Journ. Med. and Surg., vol. vi. p. 14, 1817.
Case of Anastomosing Aneurism of the Internal Maxillary Ar-
tery, by Granville Sharp Patteson, M. D. Baltimore.
Philadelphia Med. Recorder, vol. v. p. 108, 1822.
Facial Neuralgia, cured by Acupuncturation,by J. Hunter Ewin^,
M. D.
North American Med. and Surg. Journ., Philad., vol. vi. p. 77, 1826.
Cases illustrative of Remedial Effects of Acupuncturation, by
Franklin Bache, M. D. Philadelphia.
North American Med. and Surg. Journ., vol. i. p. 311, 1826.
Cases of Neuralgia, treated by division of the Nerves (Infra-
orbital Submaxillary, Portio Dura, and Supra-orbitar), by John C.
Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. i. p. 1, 1828.
OPERATIONS ON THE HEAD AND FACE. 67
Excision of the Submaxillary Nerve (for Tic Douloureux, cured),
by John C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. i. p. 2, 1828.
Case of Anastomosing Aneurism of the External Maxillary (Tem-
poral) Artery successfully treated by tying the Common Carotid,
by David L. Eogers, M. D. New York.
Am. Journ. Med Sciences, vol. xiii. p. 271, 1833.
On Acupuncturation, by Franklin Bache, M.D. Philada.
American Cyclopedia of Practical Medicine and Surgery, vol. i. p. 200, 1834.
Ehino-plasty, Blepharo-plasty, and Cheilo-plasty, in the same
patient, by F. H. Hamilton, M. D. Buffalo.
Buffalo Medical Journal, vol. iv. p. 549, 1S49.
A Horn (seven inches long and five broad at the base) excised
from the Face, by Frank H. Hamilton, M. D. Buffalo.
Buffalo Medical Journal, vol. vi. p. 13, 1850.
Tic Douloureux — Eelief by removing a portion of the Infra-
Maxillary Nerve by trepanning the Lower Jaw, by J. Mason War-
ren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxv. N. S. p. 85, 1853.
Excision of a portion of Inferior Maxillary Nerve for Neuralgia,
by S. Parkman, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxv. N. S. p. 95, 1853.
OPERATIONS ON THE EXTERNAL NOSE.
Rhino-plastic Operation (being the first successful Case in the
United States), by J. Mason Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xvi. p. 69, 1837.
Rhino-plastic Operation, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xx. p. 269, 1837.
Rhino-plastic Operation, by Thomas D. Mutter, M. D. Philada.
Am. Journ. Med. Sciences, vol. xxii. p. 61, 1838.
Rhino-plastic Operations, by J. Mason Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxii. p. 264, 1840.
Auto-plastic Operations, by J. Mason Warren, M. D. Boston.
Boston Med. Journ., vol. xxii. p. 268, 1840.
Taliacotian Operation, flap divided seventy-two hours after the
Operation (successful two years afterwards), by J. Mason Warren,
M. D. Boston.
Boston Med. and Surg. Journ., vol. xxviii. p. 69, 1843.
68 BIBLIOGRAPHICAL INDEX.
Rhino-plastic Operations, by J. Pancoast, M. D. Philada.
Operative Surgery, p. 345, 1844.
Rhino-plastic Operation (covering alas of one side), by B. J.
Raphael, M. D. Louisville, Kentucky.
Trans. Med. Joum., vol. i. N. S. p. 28, 1851.
Cases (Two) of Plastic Surgery (Rhinoplasty) successfully per-
formed, by David Gilbert, M. D. Philadelphia.
Philadelphia Med. Examiner, vol. vii. N. S. p. 238, 1851.
Rhinoplasty Operation (Indian method successfully performed),
by Joseph Pancoast, M. D. Philadelphia.
Medical Examiner, vol. viii. N. S. p. 341, 1852.
ON POLYPI.
Inquiry into the Pathology and Treatment of Polypous Tumors
of the Nasal Fossa?, with Observations on other Tumors in various
parts of the Body, by John Watson, M. D. New York.
Am. Joum. Med. Sciences, vol. iii. N. S. p. 325, 1842.
Case of Gelatinous Polypus, cured with Sanguinaria Canadensis,
after Extraction had twice failed, by Lewis Shanks, M. D. Ten-
nessee.
Am. Joum. Med. Sciences, vol. iv. N. S. p. 368, 1842.
A Nasal Operation for the removal of a large Tumor, filling up
the entire Nostril, and extending into the Pharynx, by Valentine
Mott, M. D. New York.
Am. Joum. Med. Sciences, vol. v. N. S. p. 87, 1842.
Removal of a large Polypus from the Nose, through the Pharynx
(by a tape), by Paul F. Eve, M. D. Georgia.
Southern Med. and Surg. Joum., vol. v. p. 466, 1849.
Malignant Polypus of the Nose ; Ligature of the Common Carotid
Artery; Death with Cerebral Symptoms, by William H. Van Buren,
M. D. New York.
New York Joum. Med., vol. ii. N. S. p. 297, 1849.
Exostosis of Nasal Bones — successfully removed, by William E.
Horner, M.D. Philadelphia.
Philadelphia Med. Examiner, vol. vii. N. S. p. 33, 1851.
OPERATIONS ON THE HEAD AND FACE. f)9
OPERATIONS ON THE LIPS.
Case of Double Harelip, operated on by Isaac Cathrall, M. D.
Philadelphia.
Med. Recorder, vol. ii. p. 372, 1819.
Double Hare-lip, with Fissure through the Hard and Soft Palate,
by J. C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. i. p. 140, 1828.
Remarks on the Operation of Hare-lip, by Zadoc Howe, M. D.,
Massachusetts.
Am. Journ. Med. Sciences, vol. vii. p. 414, 1831.
On the Operation of Hare-lip (within the week two cases success-
fully treated), by A. L. Peirson, M. D. Massachusetts.
Transylvania Journ. Med., vol. ix. p. 780, 1836.
Also, Boston Med. and Surg. Journ., vol. xv. p. 293, 1836.
Two Cases of Congenital Division of the Lip and Palate, occur-
ring in the same Family, in which Operations were performed, by
Isaac Parrish, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxii. p. 97, 1838.
Case of Congenital Double Hare-Lip, with both Fissures extending
through the Roof of the Mouth and Palate, by N. S. Davis, M. D.
New York.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 371, 1841.
Three Cases of Hare-lip, in one of which the Operation resulted
in Death. Reported by F. H. Hamilton, M. D. Buffalo.
Buffalo Med. Journ., vol. iv. p. 603, 1849.
Insect Pins in Cases of Hare-lip, by George Hay ward, M. D.
Boston.
Boston Med. and Surg. Journ., vol. xix. p. 153, 1838.
Hare-lip — Nursing during the process of Union (without any
strain on the Lip), by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 74, 1850.
On an early Operation in Hare-lip (within 24 hours), by A. L.
Peirson, M. D. Salem, Massachusetts.
Boston Med. and Swg. Journ., vol. xlvii. p. 134, 1852.
OPERATIONS ON THE UPPER JAW.
Osteo-sarcoma of the Upper Jaw, with a successful Operation for
its removal nearly entire, (that is, of both Superior Maxillae as far
70 BIBLIOGRAPHICAL INDEX.
back as the posterior external portion, adjacent to the Pterygoid
Processes,) by David L. Rogers, M. D. New York.
New York Med. Phrjs. Journ., vol. iii. p. 301; 1824.
Tumor in the Antrum Highmorianum extirpated, by Clarke
Wright, M. D. New York.
New York Med. Phys. Journ., vol. iv. 1825.
A Case of Fungus of the Antrum (carotid tied), by Michael A.
Finley, M.D. Maryland.
Maryland Med. Becorder, vol. i. p. 97, 1829.
Observations on Tumors of the Upper Jaw, by Horatio (x. Jame-
son, M. D.. Baltimore.
Maryland Med. Recorder, vol. i. p. 102, 1829.
Exostosis of the Upper Jaw, treated successfully by B. A. Rod-
rigues, M.D. Pennsylvania.
Am. Journ. Med. Sciences, vol. xxiv. p. 516, 1839.
Case of Osteo-sarcoma of Upper Jaw, successfully treated by
Extirpation of the whole of the Superior Maxillary and Malar Bones,
and portions of the Ethmoid and Sphenoid Bones, with Remarks,
by Alexander H. Stevens, M. D. New York.
New York Journ. of Med. and Surg., No. iv. p. 249, 1840.
Excision of the Upper Maxillary Bone, by R. D. Mussey, M. D.
Cincinnati.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 509, 1842.
Removal of Upper Maxillary Bone successfully performed, by J.
C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842.
Also, Am. Journ. Med. Sciences, vol. iii. N. S. p. 506, 1842.
Removal of the Upper Maxillary Bone for Cephalomatous Dis-
ease, by J. C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842.
On Muco-purulent Secretion of the Antrum Highmorianum, by
S. P. Hullihen, M. D. Wheeling, Virginia.
Boston Med. and Surg. Journ., vol. xxvi. p. 94, 1842.
Amputation of the Superior Maxillary, Malar, and Palate Bones,
for Disease of the Antrum— Recovery, by Daniel Brainard, M. D.
Chicago.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 250, 1847.
Removal of Superior Maxilla, and apparent Cure; Return of the
Disease. Second Operation (patient died), by J. Marion Sims,
M. D. Alabama.
Am. Journ. Med. Sciences, vol. xiii. p. 340, 1847.
OPERATIONS OX THE HEAD AND FACE. 71
Modified Operation for Excision of the Upper Jaw, cured (with-
out any incision through the cheek), by W. E. Horner, M. D. Phi-
ladelphia.
Medical Examiner, vol. vi. N. S. p. 1G, 1850.
Observation on Excision of the Superior Maxillary Bone — illus-
trated by seven cases, by S. D. Gross, M. D. Louisville.
Western Journ. Med. and Surg., vol. x. 3d series, p. 185, 1852.
Resection of Left Half of Upper Jaw (successful at time, but
disease returned in 19 months after operation), by Henry H. Smith,
M. D. Philadelphia.
Philadelphia Med. Examiner, vol. viii. N. S. p. 226. 1852.
Resection of Superior Maxillary Bone, by D. Gilbert, M. D.
Philadelphia. Eeported by W. H. Gobrecht, M. D. Philada.
Medical Examiner, vol. viii. N. S. p. 790, 1852.
Resection of Superior Maxillary and Malar Bones (not malignant,
cured), by Daniel Brainard, M. D. Chicago.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 131, 1852.
ON IMMOBILITY OF THE JAW.
Case of Immobility of the Jaw, successfully treated, by Valentine
Mott, M. D. Rutgers's College.
Am. Journ. Med. Sciences, vol. v. p. 102, 1829.
Case of Immobility of the Jaw and Taliacotian Operation, by
Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. ix. p. 47, 1831.
Case of Immobility of the Jaw, successfully treated, by Professor
Mott's complicated Lever, and a Modification of his Operation, by
Jesse W. Mighels, M.D. Maine.
Am. Journ. Med. Sciences, vol. ix. p. 50, 1831.
On Immobility or incomplete Muscular Anchylosis of the Jaw,
by William E. Horner, M.D. Philadelphia.
Am. Cyclopedia of Med. and Surg., vol. i. p. 470, 1834.
Subcutaneous Division of the Masseter Muscle (for Anchylosis of
the Jaw), by J. W. Schmidt, M. D. New York.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 516, 1842.
Two Cases of Immobility of the Lower Jaw, successfully treated
by Daniel Brainard, M.D. St. Louis.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 374, 1843.
72 BIBLIOGRAPHICAL INDEX.
Claims to Priority on the Division of the Masseter Muscle, &c,
in Immobility of the Inferior Maxilla, by John Murray Carnochan,
M.D. New York.
Mott's Velpeau by Townsend, vol. ii. p. 20, Appendix, 1847.
Immobility of the Jaw, relieved by Mott's Dilator, by Paul F.
Eve, M. D. Georgia.
South. Med. and Surg. Journ., vol. vi. p. 257, 1850.
Case of Immobility of the Lower Jaw from Adhesions, the Eesult
of Salivation, relieved by an Operation, by P. Calhoun, M. D.
Louisiana.
Charleston Med. Journ., vol. v. p. 43, 1850.
Case of Immobility of the Lower Jaw, cured by the Division of
the Masseter Muscles, by James K. Wood, M. D. New York.
New York Journ. Med., vol. v. N. S. p. 423, 1850.
Cases of Immobility of the Inferior Maxillary Bone produced by
the Abuse of Mercury, by H. H. Toland, M. D. California.
Charleston Med. and Surg. Journ., vol. viii. p. 145, 1853.
Operation for Immobility of the Lower Jaw, by J. F. Gaston,
M. D. South Carolina.
Charleston Med. Journ., vol. viii. p. 895, 1853.
OPERATIONS ON THE LOWER JAW.
Excision of nearly one-half of the Inferior Maxillary Bone, for
Osteo-sarcoma, in 1810, by W. H. Deaderick, M.D. Athens, Tenn.
(claiming justly to be the first operation of the kind ever performed,
being two years before that of Dupuytren).
Med. Recorder, vol. vi. p. 516, 1823.
Also, Am. Journ. Med. Sciences, vol. xiii. N. S. p. 521, 1847.
Case of Fracture of Inferior Maxilla, successfully treated by
Seton, by P. S. Physick, M. D. July, 1822.
Philada. Journ. Med. and Phys. Sciences, vol. v. p. 116, 1822.
Case of Osteo-sarcoma, in which the right side of the Lower Jaw
was removed successfully after tying the Carotid, by Val. Mott,
M.D. New York, 1821.
New York Med. and Phys. Journ., vol. i. p. 385, 1822.
2d Case of Osteo-sarcoma, in which the left Carotid was tied, and
a portion of the Lower Jaw removed successfully. March, 1823.
New York Med. Phys. Journ., vol. ii. p. 157, 1823.
3d Case of Osteo-sarcoma on the right side of the Lower Jaw,
OPERATIONS ON THE HEAD AND FACE. 73
removed at the Articulation, the Carotid tied — died fifth day, by
Val. Mott, M. D. 1823.
New York Med. Phys. Joum., vol. ii. p. 401, 1823.
Eemoval of nearly one-half the Lower Jaw, by Thos. Hunt, M. D.
Natchez, Miss.
Phila. Med. Recorder, vol. vii. p. 682, 1824.
Case of Amputation of part of the Lower Jaw, by Jno. Wagner,
M. D. Charleston, S. C.
New York Med. and Phys. Joum., vol. v. p. 533, 1826.
Also, Am. Joum. Med. Sciences, 1824.
Removal of half of the Lower Jaw Bone for Osteo-sarcoma, cured,
by J. C. Warren, M. D.
Boston Med. and Surg. Joum., vol. i. p. 90, 1828.
Amputation of the Lower Jaw for Osteo-sarcoma, cured by J.
Eandolph, M. D. Philadelphia, July, 1829.
Am. Joum. Med. Sciences, vol. v. p. 17, 1829.
Extract from a Eeport of a Committee upon the Subject of Osteo-
sarcoma of the Lower Jaw, to a Medical Society in New York,
April 1, 1830, by David L. Rogers, M. D., Chairman.
Am. Joum. Med. Sciences, vol. vi. p. 533, 1830.
Longitudinal Section of the Lower Jaw for the removal of a Tu-
mor, by J. Rhea Barton, M. D. Philadelphia.
Am. Joum. Med. Sciences, vol. vii. p. 331, 1831.
Case of Osteo-sarcoma of the Lower Jaw, successfully treated by
Amputation of the Bone, by W. W. Anderson, M. D. S. Carolina.
Am. Joum. Med. Sciences, vol. x. p. 315, 1832.
Case of Exsection of half of the Lower Jaw (disarticulated), by
George W. Campbell, M. D. Tenn.
Trans. Joum. Med., vol. vi. p. 400, 1833.
Amputation of nearly half of the Lower Jaw, by Paul F. Eve,
M. D. Georgia.
Am. Joum. Med. Sciences, vol. xxiii. p. 261, 1839.
Osteo-sarcoma and Excision of a large portion of the Lower Jaw,
by J. Wort, M. D. Indiana.
Am. Joum. Med. Sciences, vol. xxiv. p. 260, 1839.
Osteo-sarcoma of the Lower Jaw, removed by Dr. Batchelder,
June, 1825. Reported by S. W. Williams, M. D. Deerfield.
Boston Med. and Surg. Joum., vol. xxii. p. 39, 1840.
Case of Excision of a portion of the Inferior Maxillary Bone, by
H. H. Toland, M. D. S. Carolina.
Am. Joum. Med. Sciences, vol. i. N. S. p. 534, 1841.
74 BIBLIOGRAPHICAL INDEX.
Osteosarcoma of Lower Jaw, Amputation and Cure, by Charles
Bell Gibson, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 277, 1842.
Osteo-sarcoma of Lower Jaw, Excision and Cure, by James P.
Jervey, M. D. Charleston.
Am. Journ. Med. Sciences, vol. viii. N. S. p. Ill, 1844.
Exsection of Inferior Maxillary Bone, by Valentine Mott, M. D.
New York.
Am. Journ. Med. Sciences, vol. ix. N. S. p. 525, 1845.
Excision of a portion of the Lower Jaw, by N. Pinkney, M. D.,
U. S. Navy.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 335, 1846.
Osteo-sarcoma of the Lower Jaw, Eesection of Bone and Cure,
by J. Marion Sims, M. D. Alabama.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 128, 1846.
Osteo-sarcoma of Lower Jaw, removal of the Body of the Bone
anterior to its angle, without external incision, by J. Marion Sims,
M. D. Alabama.
Am. Journ. Med. Sciences, vol. xiv. N. S. p. 370, 1847.
Fibrous Tumor of the Lower Jaw, in which the left half of the
Bone was successfully removed (disarticulated), by S. D. Gross,
M. D. Louisville.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 344, 1848.
Exsection and Disarticulation of the Lower Jaw for Osteo-sar-
coma, by Geo. C. Blackman, M. D. New York.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 93, 1849.
Exsection of three inches Inferior Maxilla for Spina Yentosa,
cured by Paul F. Eve, M. D.
South. Med. and Surg. Journ., vol. vi. p. 261, 1850.
Case of Elongation of the Lower Jaw and Distortion of the Face
and Neck, caused by a Burn; successfully treated by Operations,
by S. P. Hullihen, M. D. Wheeling, Ya.
Med. Examiner, vol. vi. p. 188, 1850.
Eesection of a portion of the Lower Jaw (cured), by Drs. Gaines
and Henry. Hopkinsville, Ky.
West. Journ. Med. and Surg., vol. xi. 3d series, p. 217, 1853.
Observations on Excision of the Inferior Maxillary Bone, illus-
trated by five Cases, by S. D. Gross, M. D. Louisville.
West. Journ. Med. and Surg., vol. x. 3d series, p. 277, 1852.
Eesection of the Chin, with a portion of the Body of the Lower
Jaw, by Isaac Greene, M. D. N. Y.
N. Y. Med. Gazette, vol. iii. p. 266, 1852.
OPERATIONS ON" THE HEAD AND FACE. 75
Extirpation of more than half the Lower Jaw for a Cancerous
Degeneration (died), by F. H. Hamilton, M. D. Buffalo, N. Y.
K Y. Journ. Med., vol. viii. N. S. p. 289, from Buffalo Med. Journ.
Amputation of entire Lower Jaw, with Disarticulation of both
Condyles, by J. M. Carnochan, M. D. N. Y.
K Y. Journ. Med., vol. viii. N. S. p. 9, 1852.
Extirpation of the left half of the Lower Jaw, with the Submaxil-
lary Gland and Anterior Lobe of the Parotid, by Jno. G. F. Hols-
ton, M. D. Zanesville, Ohio.
West. Lancet, vol. xiii. p. 15, 1852.
Eesection of two-thirds of the Inferior Maxilla (successful), by
Carter P. Johnson, M. D. Eichmond.
Med. Examiner, vol. vii. N. S. p. 644, 1851.
Eesection of half the Lower Jaw (successful), by Wm. Gibson,
M. D. Philadelphia.
Med. Examiner, vpl. vii. N. S. p. 30, 1851.
Amputation of entire Lower Jaw for Osteo-sarcoma (patient lived
two years subsequently, and died of another disease), by Professor
Ackley, Cleveland, Ohio. (Details to be published hereafter.)
N. Y. Journ. Med., vol. x. N. S. p. 288, March, 1853.
Eesection and Disarticulation of half of Lower Jaw for Spina
Yentosa, by Chas. Bell Gibson, M. D. Eichmond, Ya.
Stethoscope, vol. i. p. 144, 1851.
On the Claims of Priority in the Exsection and Disarticulation
of the Lower Jaw, by George C. Blackman, M. D. N". Y.
N. Y. Journ. Med., vol. viii. p. 280, 1852.
Excision of a portion of the Inferior Maxillary Bone for Caries,
by W. G. Bullock, M. D. Savannah.
Am. Journ. Med. Sciences, vol. xxvi. N. S. p. 129, 1853.
Cartilaginous Exostosis of Condyle, Eamus, and Angle of Lower
Jaw, for which Eesection, with removal of Parotid gland and Zy-
gomatic arch was successfully performed, by Daniel Brainard, M. D.
Chicago.
Am. Journ. Med. Sciences, vol. xxvi. N. S. p. 397, 1853.
Extensive Enchondroma of the Inferior Maxilla removed by sec-
tion of the bone from the Symphysis to the angle on the right side,
by D. Gilbert, M. D. Philadelphia. Eeported by W. H. Gobrecht,
M.D.
Med. Examiner, vol. ix. p. 746, 1853.
76 BIBLIOGRAPHICAL INDEX.
OPERATIONS ON THE FACE.
Operation for the removal of a large Tumor on the Face, by Jas.
Webster, M. D. Philadelphia.
Phila. Med. Recorder, vol. viii. p. 275, 1825.
Case of Deformity of the Mouth from a Burn, successfully treated
by Dieffenbach's Method, by T. D. Mutter, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xx. p. 341, 1837.
Plastic Operations, by J. Pancoast, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 337, 1842.
Plastic Operations, by J. Pancoast, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. v. N. S. p. 99, 1843.
Genio-plasty, by George C. Blackman, M. D. New York.
Am. Journ. Med. Sciences, vol. x. N. S. p. 327, 1845.
A Case of Cheilo-plastic Operation, by Abraham Stout, M. D.
Easton, Pa.
Med. Examiner, vol. vi. p. 13, 1850.
Syncope from entrance of Air into the Facial Yein during re-
moval of Small Tumour below the Jaw, by Moses Gunn, M. D.
Michigan.
N. Y. Journ. Med., vol. viii. N. S. p. 356, 1852.
OPERATIONS ON THE TONGUE.
Amputation of the Tongue for Enlargement (the portion ampu-
tated measured — length 2| inches, circumference 1\ inches, thick-
ness 1 J inches), cured by H. S. Newman, M. D. Warren County,
Penn.
Med. Recorder, vol. vii. p. 541, 1824.
Case of Glossitis, attended with alarming Symptoms of Suffoca-
tion, removed by Deep Incisions made into the Substance of the
Tongue, by Abner Hopton, M. D. N. Carolina.
Am. Journ. Med. Sciences, vol. iv. p. 533, 1829.
Operation for Cancer of the Tongue (cured), by J. C. Warren,
M.D. Boston.
Boston Med. and Surg. Journ., vol. ii. p. 157, 1829.
Chronic Intumescence of the Tongue (very large), treated by
Amputation (cured), by Thos. Harris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. vii. p. 17, 1830.
OPERATIONS ON THE HEAD AND FACE. 77
Case of Hypertrophy of the Tongue (operated on), by Thomas
Wells, M. D. Columbia, S. Carolina.
Am. Journ. Med. Sciences, vol. x. p. 35, 1832.
Carcinoma of the Tongue, successfully treated with the ligature,
by M. Donnellan, M. D. Louisiana.
Am. Journ. Med. Sciences, vol. xvii. p. 540, 1835.
Case of Congenital Enlargement of the Tongue (Lingua Vitula),
by Thos. Harris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xx. p. 15, 1837.
Case of Enlarged Tongue, operated on by R. D. Mussey, M. D.
Fairfield, KY.
Am. Journ. Med. Sciences, vol. xxi. p. 394, 1837.
Removal of Cancer of the Tongue (believed to be rarely success-
ful), treated by Geo. Hayward, M. D. Boston.
Boston Med. and Surg. Journ., vol. xix. p. 158, 1838.
Case of Congenital Glossocele, amputated successfully by M. G.
Delaney, M. D., U. S. Navy.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 294, 1848.
Removal of a Foreign Body (Pin) from the Duct of Wharton, by
H. F. Campbell, M. D. Georgia.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 572, 1848.
Observations on Ranula, with Cases, Treatment, and Cure (iodine
injected into tumor), by Jas. M. Gordon, M. D. Ga.
Southern Med. and Surg. Journ., vol. v. p. 65, 1849.
OPERATIONS ON THE THROAT.
Obstinate Cough, caused by Elongation, of the Uvula, in which a
portion of that Organ was cut off, with a Description of the In-
strument employed for that purpose, and also for Excision of
Scirrhous Tonsils, by P. S. Physick, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. i. p. 262, 1827.
Case of Consumption (?) relieved by Truncating the Uvula, by
Augustus W. Mills, M. D. Kentucky.
Trans. Journ. Med., vol. ii. p. 530, 1829.
Extraction of a Thimble from the Pterygoid Fossa, by Isaac Par-
rish, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvii. p. 540, 1835.
Cancer of the Throat — Operation — Recovery — but the patient
78 BIBLIOGRAPHICAL INDEX.
subsequently died of Peritonitis (remarkable transposition of all
the organs), by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xix. p. 120, 1836.
OPERATIONS ON THE TONSILS.
The Double Canula and Wire Ligature, recommended in extir-
pating Tonsils and Hemorrhoidal Tumors, by P. S. Physick, M. D.
Philadelphia.
Phil. Journ. of Med. and Phys. Sciences, vol. i. p. 17, 1820.
Treatment of Enlarged and Indurated Tonsils, with a new Mode
(ligature) of removing these and Polypous Tumors, by Alexander
H. Stevens, M. D. N. York.
From N. Y. Med. and Phys. Journ., vol. vi. p. 523, 1827.
On an Improved Instrument for excising Tonsils and Uvula, by
C. B. Matthews, M. D. Philadelphia.
Phil. Med. Recorder, vol. xiii. p. 309, 1828.
Eemarks on the various Modes generally adopted for the removal
of the Tonsils, by Alex. E. Hosack, M. D. K York.
N. Y. Journ. Med. and Phys. Sciences, vol. i. p. 262, 1828.
Description of a Forceps used to facilitate the Extirpation of the
Tonsils, and invented by P. S. Physick, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. ii. p. 116, 1828.
Remarks on Enlarged Tonsils, with a new Instrument for Excision,
by Abrm. L. Cox, M. D. K York.
N. Y Med. and Phys. Journ., N. S. vol. ii. p. 52, 1830.
New Instrument for excising Tonsils, by David L. Rogers, M. D.
N. York.
N. Y. Med. and Phys. Journ., N. S. vol ii. p. 13, 1831.
A new Instrument for extirpating Tonsils, by J. K. Mitchell,
M. D. Philadelphia.
North Am. Med. and Surg. Journ., vol. xi. p. 239, 1831.
An Essay on Excision of the Tonsils with an Instrument, by
Geo. Bushe, M. D. N. York.
Med.-Chirurg. Bulletin, vol. ii. p. 161, 1832.
Description of an Instrument for the Excision of the Tonsils, by
Wm. B. Fahnestock, M. D. Pennsylvania.
Am. Journ. Med. Sciences, vol. xi. p. 249, 1832.
Instrument for the Excision of Tonsils, by N. R. Smith, M. D.
Baltimore.
North Am. Archives, Med. and Surg. Sciences, vol. i. p. 88, 1835.
OPERATIONS ON THE HEAD AND FACE. 79
On the Common Induration of the Tonsils, and a Description of
an Instrument for their Excision, by John C. Warren, M.D. Boston.
Surg. Obs. on Tumors, with Cases and Operations. Boston, 1839.
Remarks on the Enlargement of the Tonsils, attended by certain
Deformities of the Chest. By J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxiv. p. 523, 1839.
Tonsilotomy— Profuse Hemorrhage— by F. H. Hamilton, M. D.
Buffalo.
Buffalo Med. Journ., vol. iv. p. 217, 1849.
Case in which a large Thimble remained for two weeks in Pos-
terior Nares without detection (removed), by Eichard L. Howard,
M. D. Columbus, Ohio.
Ohio Med. and Surg. Journ., vol. v. p. 215, 1853.
ON STAPHYLORAPHY.
Suture of Palate in Infancy, believed to have been successfully
, performed by Nathan Smith, M. D. Yale College.
N. Y. Med. and Phys. Journ., vol. v. p. 525, 182G.
Staphyloraphy successfully performed, by A. H. Stevens, M. D.
N.Y.
North Am. Med. and Surg. Journ., vol. iii. p. 233, 1827.
Operation in May 1824, for the Cure of Natural Fissure of the
Soft Palate (the first in America, and performed without knowledge
of the operations of Roux), by J. C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. iii. p. 1, 1828.
Extensive Division of the Soft Palate (from a wound) sewed with
Physick's Needle, &c, by Thos. Wells, M. D. Columbia, S. C.
, Am. Journ. Med. Sciences, vol. x. p. 32, 1832.
Observations on Staphyloraphy with a new Instrument, by N. R.
Smith, M. D. Baltimore.
North Am. Archives, vol. i. p. 27, 1835.
Congenital Fissures of the Palate operated on, by James Deane,
M. D. Greenfield, 1837.
Boston Med. and Surg. Journ., vol. xvi. p. 333, 1837.
On Staphyloraphy, by Jno. P. Mettauer, M. D. Va.
Am. Journ. Med. Sciences, vol. xxi. p. 309, 1837.
On the Use of the Interrupted Suture in Cases of Cleft Palate
(with a description of a needle for it and hare-lip), by E. H. Dixon,
M. D. New York.
Boston Med. and Surg. Journ., vol. xxv. p. 329, 1841.
80 BIBLIOGRAPHICAL INDEX.
Cases of Cleft Palate (treated by Physick's Needle), by Tbos. D.
Mutter, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 74, 1841.
On Staphyloraphy, by Jos. Pancoast, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. vi. N. S. p. GO, 1843.
Operations for Fissures of the Soft and Hard Palate, by J. Mason
"Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 257, 1843.
Operation for Fissure of the Hard and Soft Palate, with the Re-
sult of 24 Cases, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 329, 1848.
On Fissure of the Palate, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxv. N. S. p. 95, 1853.
OPERATIONS ON THE EAR.
Extraction of Foreign Substances from the Ear, (by means of a
thread attached to the article by glueing with shell lac,) by Charles
Hooker, M. D. New Haven.
Boston Med. and Surg. Journ., vol. x. p. 317, 1834.
Polypi of the Meatus Auditorius Externus removed by Ligature,
by E. J. Davenport, M. D. Boston, 1837.
Boston Med. and Surg. Journ., vol. xvii. p. 235, 1837.
Congenital Absence of Meatus Auditorius Externus of both Ears
without much impairing the hearing, by R. D. Mussey, M. D. Fair-
field, n. y.
Am. Journ. Med. Sciences, vol. xxi. p. 377, 1838.
On the Extraction of Foreign Bodies from the Meatus Auditorius
Externus, by J. Marion Sims, M. D. Alabama.
Am. Journ. Med. Sciences, vol. ix. N. S. p. 336, 1845.
Fibrous Tumor removed from the Lobe of 'the Ear, by Geo. W-
Norris, M. D. Philadelphia,
Am. Journ. Med. Sciences, vol. xx. N. S. p. 557, 1850.
Maggots, probably 40, in the Ear (from previous entrance of a
fly), removed by Frank H. Hamilton, M. D. Buffalo.
Buffalo Med. Journ., vol. vi. p. 10, 1850.
Contributions to Aural Surgery — Analysis of 140 Cases of Dis-
eases of the Ear, by Edward H. Clark, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 31, 1852.
On Obstruction of the Pharyngeal Orifice of the Eustachian
Tube, by Jno. Neill, M. D. Philadelphia.
Med. Examiner, vol. ix. p. G26, 1853.
.
OPERATIONS ON THE NECK AND TRUNK. 81
PART III.
PAPERS RELATING TO OPERATIONS ON THE NECK
AND TRUNK.
ON EXTIRPATION OF THE PAROTID GLAND.
A Case of successful Extirpation of the whole of the Parotid
Gland for Scirrhus, by George McClellan, M.D. Philadelphia, 1826.
.The operation of Dr. Warren, of Boston, in 1798, was the first
case; that of Dr. McClellan, of Franklin County, Pa., in 1805, the
second ; that of Dr. White, of Hudson, in 1808, the third ; that of
Dr. Sweat, of Maine, in 1811, the fourth; and the operation of Dr.
George McClellan, referred to in his paper, was the fifth time it was
repeated in the United States, though the first published.
Neic York Med. and Phys. Joum., vol. v. p. 649, 182G; also Am. Med.
Review and Journal.
Case of Extirpation of the Right Parotid for Melanotic Enlarge-
ment, by George McClellan, M. D. Philadelphia, 1829, being his
second case.
New York Med. and Phys. Joum., vol. ii. N. S. p. 309, 1830.
Aii Account of the Extirpation of the Parotid Gland, by George
McClellan, M. D. Philadelphia.
West. Joum. of Med. and Phys. Sciences, vol. iv. p. 465, 1831.
A Case of Extirpation of the Parotid Gland, by Valentine Mott,
M. D. New York.
Am. Joum. Med. Sciences, vol. x. p. 17, 1831.
Three Cases in which the Parotid Gland was successfully removed
(December 14, 1827, September 16, 1830, and one not dated), by
George Bushe, M. D. New York.
Medico- Chirurgical Bulletin, vol. ii. p. 133, 1832.
Extirpation of the Parotid Gland, with other Cases, by Nathan
R. Smith, M. D. Baltimore.
Am. Joum. Med. Sciences, vol. xxiii. p. 59, 183U.
i.;
82 BIBLIOGRAPHICAL INDEX.
A Case of Extirpation of the Parotid Gland, by J. Randolph,
MID. Philadelphia.
Am. Journ. Med. Sciences, vol. xxiii. p. 517, 1839.
A Case of Extirpation of the Parotid Gland in 1805, by John
McClellan, M. D. Franklin County, Pennsylvania.
Am. Journ. Med. Sciences, vol. vii. N, S. p. 499, 1844.
Extirpation of a Scirrhous Parotid Gland, by H. H. Wheeler.
M. D. Pennsylvania.
Am. Jonrn. Med. Sciences, vol. ix. N.S. p. 5'20, 1845.
Extirpation of the Parotid Gland, by William E. Horner, M. D.
Philadelphia.
Phila. Med. Ex., vol. vii. N.S. p. 30, 1851.
Extirpation of the Parotid Gland (under chloroform), by A. B.
Shipman, M. D. N. Y.
Kelson's North. Lancet, vol. vi. p. 143, 1852.
Removal of the Parotid Gland (cured), by II. H. Toland, M. D.
San Francisco.
Charleston Med. and Surg. Joum., vol. viii. p. 78, 1853
Successful Removal of the Parotid Gland, by A. J. Wedderburn.
M. D. K Orleans.
N. Y. Journ. Med., vol. vii. N. S. p. 411, 1851, from If. Orleans Med. tfegistt i .
Cases (3) of Extirpation of Parotid Glands (one in 1811, one in
1814, and one in 1841, cured), by Moses Sweat, M. D. Maine.
If. Y. Joum. Med., vol. vii. N. S. p. 23.
Successful Extirpation of a Scirrhous Parotid Gland, by J. Mason
Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 332, 1852.
ON DEFORMITIES OF THE NECK.
A Case of Deformity from Burns (on the Face and Neck) relieved
by an Operation, by T. D. Mutter, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iv. N. S. p. GG, 1842.
A Case of Division of the Sterno-Cleido-Mastoid Muscle, for Wry
Neck, by J. Mason Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxv. p. 121, 1841.
A Case of Torticollis successfully treated by Myotomy and an
Apparatus, by John B. Brown, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxvi. p. 58, 1842.
Cases of Wry Neck cured without cutting (gradual extension
OPERATIONS ON THE NECK AND TRUNK. 83
by the hand applied to the head, the patient being in a state of
anaesthesia), by Gurdon Buck, Jr., M. D. New York.
N. Y. Med. Tunes, vol. ii. p. 131, 1852.
OPERATIONS ON THE (ESOPHAGUS.
Case in which a Copper Coin remained thirteen years in the (Eso-
phagus, by John Syng Dorsey, M. D. Philadelphia,
Neio York Med. and Fhilosoph. Journ., vol. iii. p. 173, 1811 ; also Philad.
Med. Museum., vol. i. N. S. p. 125, 1811.
Two Cases in which Poison was removed from the Stomach by
a new mode (the Stomach -Tube), by P. S. Physick, M. D- Philad.
Eclectic Repert. and Analytical Review, vol. iii. p. Ill, 1813.
A Case of Stricture of the GEsophagus, cured by Caustic, by
Charles T. Hildreth, M. D. Haverhill.
New England Journ. of Med. and Surg., vol. x. p. 235, 1821.
Extraction of a Fish-Hook and Line from the Stomach, by slip-
ping a Perforated Bullet over the Line and Point of the Hook, by
Dr. Brite. Communicated by S. Brown, M. D., of Lexington, Ken-
tucky.
Am. Med. Record, vol. vi. p. 581, 1823.
A new Instrument for extracting Coins, &c, from the Oesophagus,
by Nathan Smith, M. D. Yale College.
New York Med. and Phgs. Journ., vol. iv. p. 576, 1825.
Case of Stricture of the GEsophagus (with a new Instrument for
its Belief), by H. G. Jameson. Baltimore.
Med. Record., vol. viii. p. 1, 1825.
Description of an improved Instrument for extracting Poisons
from the Stomach, with Statements assigning the Credit of the
Invention of the Stomach-Tube to P. S. Physick, M. D., in 1800 (he
being then ignorant that Dr. Monroe, of Edinburgh, had done the
same thing), by C. B. Matthews, M. D. Philadelphia.
Am. Med. Record, vol. x. p. 322, 182G.
On the Kemoval of Foreign Bodies from the CEsophagus, by
means of Forceps, &c, by Henry Bond, M. D. Philadelphia.
North American Med. and Surg. Journ., vol. vi. p. 278, 1828.
Description of a new CEsophagus Forceps, by Constantiue Weever,
M. D. Michigan.
Am. Journ. Med. Sciences, vol. xiv. p. Ill, 1834.
84 BIBLIOGRAPHICAL INDEX.
Description of a new form of Stomach-Pump, by P. B. Goddard,
M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xv. p. 262, 1834.
Practical Observations on Organic Obstructions of the (Esopha-
gus, preceded by a Case which called for (Esophagectomy, and sub-
sequent Tracheotomy, with accompanying Illustrations, by John
Watson, M. D. New York.
Am. Journ. Med. Scienees, vol. viii. N. S. p. 309, 1844.
Case of Ulceration and Stricture of the (Esophagus, with Remarks
on Nutritive Enemata, as a means of sustaining life in such cases,
by D. J. C. Cain, M.D. Charleston.
Charleston Med. Journ., vol. iii. p. 393, 1848.
Death from a Foreign Body (a piece of Bone) cutting from the
Pharynx into the Larynx, by Paul F. Eve, M. D. Georgia.
Southern Med. and Surg. Journ., vol. v. p. 73, 1849.
Stricture of the (Esophagus (caused by swallowing Potash So-
lution, temporary Relief by Dilatation), died, by Robert H. Cum-
mins, M. D. "Wheeling.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 409, 1851.
Extirpation of Pharyngeal Tumours, by L. A. Dugas, M. D.
Georgia.
Southern Med. and Surg. Journ., vol. ix. p. 2G4, 1853.
Case of Stricture of the (Esophagus (cured by Dilatation), by
¥m. Johnson, M. D. New Jersey.
New Jersey Med. Reporter, vol. vi. p. 173, 1853.
ON TRACHEOTOMY AND EDEMATOUS LARYNGITIS.
Case of Hydrophobia, with the proposal of Tracheotomy, by P.
S. Physick, M. D. Philadelphia, 1801.
New York Med. Repository, vol. v. p. 1, 1802.
Case of Tracheotomy (cured) for removal of a Leaden Bullet in
the Trachea, by John Newman, M.D. Salisbury, North Carolina.
New York Med. Repository, vol. x. p. 250, 1807.
Tracheotomy for Croup (died), by Dr. Thompson.
New England Journ. Med. and Surg., vol. v. p. 318, 1810.
Case of successful Tracheotomy, for the Extraction of a Foreign
Substance (a Bean), by Amasa Trowbridge, M. D., of Jefferson
County. New York.
New York Med. Repository, vol. xx. p. 79, 1820.
OPERATIONS ON THE NECK AND TRUNK. 85
Bronchotomy successfully performed for the removal of a Water-
melon Seed, by H. G. Jameson, M. D. Baltimore.
Am. Med. Recorder, vol. v. p. G73, 1822.
Memoir on Bronchotomy, by II. G. Jameson, M.D. Baltimore.
Am. Med. Recorder, vol. vi. p. 151, 1823.
Case of a Pebble successfully extracted by Bronchotomy, by H.
G. Jameson, M. D. Baltimore.
Am. Med. Recorder, vol. vii. p. 36, 1824.
Three Cases of Bronchotomy, by S. Annan, M.D. Emmets-
burg.
Am. Med. Recorder, vol. vii. p. 42, 1824.
Case of Tracheotomy (successful) for the removal of a Water-
melon Seed, by Henry S. Waterhouse, M. D. Franklin County,
New York.
Philadelphia Journ. of Med. and Phys. Sciences, vol. viii. p. 391, 1824.
Case of a Bean extracted successfully by Bronchotomy, by
Joseph Palmer, M. D.
Am. Med. Recorder, vol. vii. p. 32, 1824.
Two Cases of Bronchotomy (in which one was cured, one died),
by Kichard Burgess, M. D.
Am. Med. Recorder, vol. vii. p. Ill, 1824.
Case of Tracheotomy for the removal of a Bean (cured), by Cal-
vin Jewett, M. D. Newberg, Vermont.
Neio England Journ. of Med. and Surg., vol. xiii. p. 237, 1824.
Case of Laryngotomy for a Watermelon Seed (cured), by Samuel
A. Cartwright, M. D. Natchez.
Neio England Journ. of Med. and Surg., vol. xiv. p. 135, 1825.
Case of Tracheotomy for the removal of a Bean (cured), by Peter
P. Woodbury, M. D. Bedford, New Hampshire.
New England Journ. of Med. and Surg., vol. xiv. p. 32, 1825.
Two Cases of Foreign Bodies lodged in the Trachea, one of which
was removed by Tracheotomy, and the other by introducing the
Forceps into the Trachea, by Enos Barnes, M. D., of Yates County,
New York.
New York Med. and Phys. Journ., vol. vi. p. 78, 1827.
Operation of Laryngotomy and Tracheotomy (successfully per-
formed at the same time, on the same Patient, for the removal of
an Extraneous Body (a Grain of Corn) from the Larynx, by Abner
Hopton, M. D. North Carolina.
Am. Journ. Med. Sciences, vol. iv. p. 534, 1829.
BIBLIOGRAPHICAL INDEX.
Case of Tracheotomy for the removal of a Bean (cured), by Zadok
I Lowe, M. D. Massachusetts.
Am. Journ. Med. Sciences, vol. iii. p. 347, 1829.
Case of Laryngotomy (for the removal of a Watermelon Seed,
cured), by Joseph F. E. Hardy, M. D. North Carolina.
Transylvania Journ. of Med., vol. iii. p. -67, 1830.
Operation of Tracheotomy (successfully) performed for the re-
moval of a Watermelon Seed, by Horatio G. Jameson, M. D. Bal-
timore.
Maryland Med. Recorder, vol. u. p. 594, lbol.
An unsuccessful Case of Cynanche Trachealis, in which Tracheo-
tomy was resorted to, by E. Atlee, M. D. Lancaster.
West. Journ. of Med. and Phrjs. Sciences, vol. iv. p. 23, 1831.
Remarkable Instance of a Brass Nail remaining in the Lungs for
more than a 3^ear,-by Amariah Brigham, M. D. Hartford, Conn.
Am. Journ. Med. Sciences, vol. xviii. p. 4G, 183G.
Case of Bronchotomy for the removal of an Iron Nail (1 inch
and gths long, and weighing 55 grains) from a child three years of
age, nine days after it was swallowed, by Calvin Jewett, M. D. St.
Johnsbury, Vermont.
Boston Med. and Surg. Journ., vol. xvi. p. 91, 1837.
Foreign Bodies (a Pipe-stem If inches long) in the Trachea re-
moved by Tracheotomy (cured), by Charles Hall, M. D. Vermont.
Am. Journ. Med. Sciences, vol. ix. N.S. p. 357, 1845.
Foreign Bodies in the Air-Passages (four Cases, viz., Pin in La-
rynx, Carpet-Tack, Horseshoe Nail, and Bean), Tracheotomy used
in one Case, by J. Mason Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. xxxvii. p. 389 : also
Am. Journ. Med. Sciences, vol. xv. N. S. p. 315, 1848.
Tracheotomy, successfully performed, for Membranous Croup (by
J. Pancoast, M.D.), reported by C. D. Meigs, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 529, 1848.
Case of Membranous Croup of a severe character, and attended
with all the symptoms of approaching death, cured without an ope-
ration for Tracheotomy, by Isaac Parrish, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 530, 1848.
A Foreign Body (Grain of Corn) in the Trachea, cured by Tra-
cheotomy, by William Davidson, M. D. Madison County, Indiana.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 2G3, 1848.
Also, Western Lancet, May, 1848.
OPERATIONS OX THE NECK AND TRUNK. 87
(Edematous Laryngitis successfully treated by Scarification of
the Glottis and Epiglottis, by Gurclon Buck, Jr., M.D. New York.
Transact. Amer. Med. Association, vol. i. p. 135, 1848; also Am. Jovrn. Mad.
Sciences, vol. xvii. N. S. p. 240, 1849.
History of five Cases of Pseudo-Membranous Croup, in which
Tracheotomy was performed (three cured, two died, Operation by
J. Pancoast, M. D.), with Remarks on the Treatment, and on the
Operation, by J. Forsyth Meigs, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 307, 1849.
Case of Tracheotomy for Laryngitis (died), by Dr. Townsend.
Boston. (Reported by Dr. J. B. S. Jackson.)
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 28, 1849.
Tracheotomy (successful), for Abscess at Root of Tongue, by
Daniel Brainard, M. D. Chicago.
Northwest Med. and Surg. Journ. vol. iii. p. 316, 1850.
Tracheotomy successfully performed in 3 Cases for the removal
of a Foreign Body, by D. Gilbert, M. D. Philadelphia.
(In the first, it was a grain of coffee ; operation 42 hours after its
entrance; child 3-£ years. In the second, a piece of raw sweet pota-
toe. In the third, aged six years, it was a grain of corn ; operation
a few days subsequently.)
Am. Journ. Med. Sciences, vol. xxi. N. S. p. 74, 1851.
Pseudo-membranous Croup — Tracheotomy (as last resort), portion
excised, no canula, death, by R. H. Mcllvaine, M.D. N. Carolina.
Am. Journ. Med. Sciences, vol. xxi. N. S. p. 387, 1851.
GlMematous Laryngitis successfully treated by Scarifications of
the Glottis and Epiglottis, by R. A. Kinlock, M. D. Charleston.
Charleston Med. Journ., vol. vi. p. 517, 1851.
Tracheotomy for Croup (fatal 17 hours after Operation), by Car-
ter P. Johnson, M. D. Richmond.
Stethoscope, vol. i. p. 670, 1851.
Tracheotomy for GEdema of Glottis (died of Pneumonia), by S.
Parkman, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxi. N. S. p. 40, 1851.
ffidema-glottidis successfully treated by Scarification, b}^ Dr.
Clarke. New York.
Western Lancet, vol. xii. p. 306, 1851.
From N. Y. Register of Med. and Pharmacy.
Tracheotomy successfully performed for Croup, by Gurdon Buck,
Jr., M. D. New York.
New York Journ. Med., vol. vii. N. S. p. 269, 1851.
88 BIBLIOGRAPHICAL INDEX.
Tracheotomy successfully performed for (Edematous Laryngitis,
by W. D. Stephenson, M. D. Mount Pleasant, Alabama.
Western Journ. of Med. and Surg., vol. viii. p. 91, 1851.
Tracheotomy for Croup (cured), by Joseph T. Pitney, M. D.
Morristown, New Jersey. (Reported by L. Condict, M. D., N. J.)
New Jersey Med. Reporter, vol. v. p. 332, 1852.
Laryogotomy, successfully performed in a Case of Foreign Body
in the Larynx (piece of Almond Shell lodged in Left Ventricle), by
G. R. Morehouse, M. D. Philadelphia.
Philadelphia Med. Examiner, vol. viii. X. S. p. 215, 1852.
Tracheotomy for the Relief of Croup (Tracheal Mucous Mem-
brane healthy when opened — died 42 hours), by Henry H. Smith,
M. D. Philadelphia.
Philadelphia Med. Examiner, vol. viii. N*. S. p. 222, 1852.
Two Cases of Tracheotomy for Foreign Bodies (Coffee and Corn
Grain), both cured, by John Fred. May, M. D. Washington.
Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 413, 1852.
Tracheotomy in CEdema of Glottis (cured); death six months
subsequently from soldering becoming softened, and permitting
the tube to fall into the Bronchia, by Dr. Wederstaul, of New
Orleans. (Reported to Society of Medical Improvement, Boston,
by Dr. Alley.)
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 87, 1852.
Laryngotomy, in consequence of Suffocation from Enlarged Ton-
sils (died), by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 9G, 1852.
Tracheotomy successfully performed (for Asphyxia from Acute
Laryngitis), by Joseph Pancoast, M. D. (Communicated by Joseph
Mauran, M. D. Providence.
Boston Med. and Surg. Journ., vol. xlvii. p. 17, 1852.
Membranous Croup successfully treated by Tracheotomy, by
Daniel Ayres, M. D. New York.
N. Y. Journ. Med., vol. ix. N. S. p. G9, 1852.
Tracheotomy performed for the Relief of Epilepsy (died subse-
quently in a fit; operation performed March 18; died with tube in
trachea, May 2), by John Neill, M. D. Philadelphia.
Trans, of Phil. College of Phijs. June, 1852.
Also Am. Journ. Med. Sciences, vol. xxv. N. S. p. 274, 1853.
Bean in Trachea— Tracheotomy— Cure, by Moses Hoyt, M. D.
Ohio.
Am. Journ. Med. Sciences, vol. xxv. N. S. p. 267, L^53.
OPERATIONS ON THE NECK AND TRUNK. 89
Membranous Croup — Tracheotomy — its Advantages — fatal ter-
mination twelfth day, by Henry J. Bigelow, M. D. Boston.
Am. Joum. Med. Sciences, vol. xxvi. N. S. p. 80, 1853.
Tracheotomy for a Foreign Substance (Grain of Corn) in the
Trachea, by B. F. Trabue, M. D. Kentucky.
Am. Joum. Med. Sciences, vol. xxv. N. S. p. 556, 1853.
Tracheotomy successfully performed (in extreme cases for acute
Laryngitis), by Dr. Foster, New Orleans.
Boston Med. and Surg. Joum., vol. xlviii. p. 168, 1853.
From New Orleans Med. and Surg. Joum.
Cockle Bur in Bima Glottidis removed, after several days, by
curved polypus forceps, by L. A. Dugas, M. D. Augusta, Ga.
Am. Joum. Med. Sciences, vol. xxvi. N. S. p. 556, 1853.
From Southern Med. and Surg. Joum., August, 1853.
Tracheotomy for a Foreign Body (chip of Bone in Soup), suc-
cessful, by W. H. Mussey, M. D. Cincinnati.
Western Lancet, vol. xiv. p. 660, 1853.
OPERATIONS FOR TUMORS ON THE NECK.
Case of Bronchocele relieved by taking up one of the Superior
Thyroid Arteries, by H. G. Jameson, M. D. Baltimore.
Am. Med. Record., vol. v. p. 116, 1822.
Case of Encysted Meliceris Tumor of the Neck (cured by Punc-
ture, and Injection of Wine), by Andrew Park, M. D. Eatonton,
Georgia.
Philada. Joum. of Med. and Phys. Sciences, vol. vi. p. 130, 1823.
Case of (Adipose Sarcomatous) Tumor (weighing eight pounds)
extirpated successfully (from the side of the neck), by David L.
Rogers, M. D. New York. Communicated by P. Cadwallader,
M.D.
Philadelphia Joum. of Med. and Phys. Sciences, vol. xiii. p. 161, 1826.
Case of a large Encysted Tumor, on the Side of the Neck, suc-
cessfully removed, by Alexander H. Stevens, M. D. New York.
New York Med. and Phys. Joum., vol. v. p. 311, 1826.
Case of an Operation for the Removal of a formidable Tumor
from the Neck (cured), by John C. Warren, M. D. Boston.
Boston Med. and Surg. Joum., vol. i. p. 26, 1828.
Case of the Bemoval of a Tumor of the Neck, in which the Pos-
terior Jugular Yein was cut off (cured), by John C. Warren, M. D.
Boston Med. and Surg. Joum., vol. i. p. 367, 1828.
'•"' BIBLIOGRAPHICAL IXDEX.
Case of a Tumor in the Neck, with an Account of the Operation
for its Removal, by G. Hay ward, M . D. Boston.
Am. Journ. Med. Sciences, vol. viii. p. 352, 1831.
Case of the Bemoval of a large Steatoinatous Tumor of the Keck,
by John C. Brent, M.D. Kentucky.
Western Journ. of Med. and Phys. Sciences, vol. iv. p. 487, 1831.
of Extirpation of a Tumor of the Neck, in which the Carotid
Artery and Internal Jugular Vein were tied (died), by William
Gibson, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xiii. p. 305, 1833.
e of Extirpation of a Tuberculated Sarcoma, from the Neck,
by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. xii. p. 121, 1833.
On Extirpation of Tumors on the Neck, by N. E. Smith, M. D.
Baltimore.
Am. Journ. Med. Sciences, vol. xiv. p. 526, 1834.
Extirpation of the Thyroid Gland (died 13th day), by Nathan
K. Smith, M.D. Baltimore.
North American Arc/tires Med. and Surg. Sciences, vol. ii. p. 309, 1835.
Case of Attempt at Suicide, in which the Internal Jugular Vein
was partially divided; successfully secured by Ligature, by John
G. Morgan, M. D. Geneva, New York.
Am. Journ. Med. Sciences, vol. xviii. p. 330, 1836.
Case of Excision of a large Tumor on the Neck, by R. D. Mussey,
M. D. Ohio.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 253, 1842; also Western Lancet,
May, 1842.
Case of Tumor of the Thyroid Gland successfully extirpated, by
Otis Hoyt, M. D. Boston.
Boston Mad. and Surg. Journ., vol. xxxv. p. 297, 1846.
On Hydrocele of the Neck, by Thos. D. Mutter, M. D. Philad.
Medical Examiner, vol. vi. N. S. p. 257, 1850.
Tumor of Neck of extraordinary size (weighed nearly 12 pounds,
and non-malignant), successfully removed by P. C. Spencer, M. D.
Petersburg, Virginia.
Stethoscope, vol. i. p. 258, 1851.
Statistical Table of Cases of Retro-Pharyngeal Abscess, with the
Means of Treatment, &c, by Charles M. Allin, M. D. New York.
New York Journ. Med., vol. vii. N. S. p. 307, 1851.
Eemarks on Tumors, with Cases, by James Bryan, M. D. Phila.
New York Journ. Med., vol. viii. N. S. p. 205, 1852.
OPERATIONS OX THE NECK AND TRUNK. 91
Cases of Polypus Laryngitis, by \Villard Parker, M. D. New
York. Reported by Stephen Smith, M.D., New York.
New York Journ. Med., vol. viii. N. S. p. 15, 1852.
Extirpation (successful) of Enlargement of Isthmus of Thyroid
Gland, by George A. Otis, M. D. Richmond.
Virginia Med. and Surg. Journ., vol. ii. p. 115, 1 853.
Cystic Goitre (treated by incision and tents, not cured at last
account), by Joseph Pancoast, M. D. Philadelphia.
Philadelphia Med. Examiner, vol. vii. X. S. p. 501, 1853.
Case of Hydrocele of the Neck, by D. Gilbert, M. D. Philad.
Med. Examiner, vol. ix. X. S. p. 220, 1853.
ON LIGATURE OF THE ARTERIA INNOMINATA AND
CAROTID ARTERIES.
Case of Ligature of the Innominata (the Ligature separated on
the fourteenth day, and on the twenty-sixth day the patient was
attacked with Hemorrhage, and died), by Valentine Mott, M.D.
New York, May 11, 1818.
Xeio York Med. and Surg. Register, p. 9, 1818 ; also Eclect. Repert. and
Analyt. Review, vol. ix. p. 1, 1819.
Case of Aneurism of the right Subclavian, in which a Ligature
was applied to the Innominata (patient died on the fifth day), by
Richard Wilmot Hall, M. D. Baltimore.
Baltimore Med. and Surg. Journ., vol; i. p. 125, 1833.
Case of Carotid Aneurism, cured by an Operation, by Wright
Post, M. D. (being the first operation successfully performed on this
artery in the United States.) Communicated by V. Mott, M. D.
New York.
Transact, of the New York Phys. Med. Soc., vol. i. p. 367, 1817.
Surgical Anatomy of the Arteries, with Rules for the Ligatures
of all of them, by George McClellan, M. D. Philadelphia.
Am. Med. Recorder, vol. iii. p. 25, 1820.
Case of Ligature of the Carotid Artery (cured), by R. D. Mussey,
M. D. Hanover, New Hampshire.
New England Journ. of Med. and Siu-g., vol. xi. p. 3G9, 1822.
Case of Ligature of the Carotid Artery, for Aneurism (success-
ful), by James Sykes, M. D. Dover, Delaware.
Philadelphia Journ. of Med. and Phys. Sciences, vol. vi. p. 139, 1823.
92 BIBLIOGRAPHICAL INDEX.
A new Instrument for tying Deep-seated Arteries, by Alexan-
der E. Hosack, M. D. New York.
New York Med. and Phys. Journ., vol. iii. p. 334, 1824.
Case of Fatal Hemorrhage occurring six weeks after the Liga-
ture of the Carotid Artery, by J. W. Cusack, M. D.
Med. Recorder, vol. vii. p. 104, 1824.
Account of a Case, in which both Carotids were tied successfully
at the interval of one month after the first Ligature, by Dr. McGill,
Maryland. Account furnished by J. Kearny Eodgers, M. D.
New York.
New York Med. and Phys. Journ., vol. iv. p. 570, 1825.
A Case of Ligature of the Carotid (died), by Mason F. Cogswell,
M. D. Hartford, Connecticut.
New England Journ. of Med. and Surg., vol. xiii. p. 357, 1824.
Three Cases of Ligature of the Carotid Artery, successfully per-
formed on Children of five, eleven, and sixteen years of age, by
George McClellan, M. D. Philadelphia.
New York Med. and Phys. Journ., vol. v. p. 523, 1826.
Case of an Operation for Carotid Aneurism (cured), by John C.
Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. i. p. 42, 1828.
Case of an Operation for Carotid Aneurism (cured), by Winslow
Lewis, M. D. Boston.
Boston Med. and Surg. Journ., vol. ii. p. 371, 1829.
Aneurism of the Arteria Innominata, involving the Subclavian
and the Eoot of the Carotid ; successfully treated by tying the Ca-
rotid, by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. v. p. 297, 1829 ;
also Maryland Med. Recorder, vol. i. p. 455, 1829.
Case of Ligature of the Carotid, in 1825, for Fungus of the An-
trum (died), by Michael A. Finley, M. D. Williamsport, Maryland.
Maryland Med. Record., vol. i. p. 97, 1829.
Case of Aneurism by Anastomosis, in which both Primitive
Carotids were tied (at 2 days interval, successfully, but did not
arrest the aneurism), by E. D. Mussey, M. D. New Hampshire.
Am. Journ. Med. Sciences, vol. v. p. 316, 1829 ;
also Maryland Med. Recorder, vol. i. p. 543, 1829.
Case of Ligature of the Carotid, for Anastomosing Aneurism, in
a Child three months old (cured), by Valentine Mott, M. D. New
York.
Am. Journ. Med. Sciences, vol. vii. p. 271, 1830; also vol. v. p. 255, 1830.
OPEKATIONS ON THE NECK AND TRUNK. 93
Description of the Circulation of the Head and Neck, in a Case
in which one Carotid had been tied, by Valentine Mott, M.D. New
York.
Am. Joum. Med. Sciences, vol. viii. p. 45, 1831.
Case of Telangiectasis of Cheek, cured by Ligature of the Com-
mon Carotid, by George Bushe, M. D. New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 53, 1832.
Case of Ligature of the Common Carotid (in a court-room), for
attempted Suicide, by "William E. Horner, M. D. Philadelphia.
Am. Joum. Med Sciences, vol. x. p. 403, 1832.
Case of Aneurism of the Carotid, treated by Puncture with a
Cataract-needle, heated to a white heat (in 1826), by George Bushe,
M. D. New York.
Medico- Chirurgical Bulletin, vol. ii. p. 209, 1832.
Ligature of both Carotid Arteries simultaneously (died in twenty-
four hours), by Valentine Mott, M. D. New York. Eeported by
Dr. Vache.
Am. Joum. Med. Sciences, vol. xiv. p. 530, 1834.
Case of Ligation of both Carotids (successful), by R. D. Mussey,
M. D. Fairfield, New York.
Am. Joum. Med. Sciences, vol. xxi. p. 397, 1837.
Case of Gunshot "Wound of the Face and Neck; Ligature of
Carotid (cured), by Dr. Twitchell, New Hampshire.
Am. Joum. Med. Sciences, vol. v. N. S. p. 510, 1843; also New England
Quarterly Journal Med. and Surg., Oct. 1842.
Case of Subcutaneous Erectile Tumor of the Cheek ; Ligature of
Common Carotid Artery (death from phlebitis and pus between
meninges of the brain), by A. C. Post, M. D. New York.
Am. Joum. Med. Sciences, vol. x. N. S. p. 539, 1845; also N. Y. Joum.
Med., Sept. 1845.
Case of Gunshot Wound, Secondary Hemorrhage, Ligature of
both Carotids at an interval of four and a half days (cured), by
John Ellis, M. D. Michigan.
Am. Joum. Med. Sciences, vol. x. N. S. p. 534, 1845; also New York Joum.
Med., Sept. 1845.
Case of Ligature of the Carotid Artery for Fungous Tumor of
the Neck (died), by George C. Blackman, M. D. New York.
Am. Joum. Med. Sciences, vol. x. N. S. p. 331, 1845.
Ligature (successful) of both Carotids (at an interval of near five
weeks), for a remarkable Erectile Tumor of the Mouth, Face, and .
Neck, by J. Mason Warren, M. D. Boston.
Am. Joum. Med. Sciences f vol. xi. N. S. p. 281, 1846.
94 BIBLIOGRAPHICAL INDEX.
Case of Ligature of Common Carotid for removal of the Parotid
Gland (successful), by A. B. Shipman, M. D. Illinois.
Am. Joum. Med. Sciences, vol. xiv. N. S. p. 2C4, 1847.
Case of Ligature of the Primitive Carotid Artery (cured), by H.
F. Campbell, M. D. Georgia.
Am. Joum. Med. Sciences, vol. xiv. N. S. p. 542, 1847 ; also Southern Med.
and Surg. Joum., August, 1847.
Case of Ligature of the Carotid Artery, followed by Hemorrhage,
and Eecovery, by G. Hayward, M. D. Boston.
Boston Med. and Surg. Joum., vol. xxxvi. p. 44 ( J, 1847.
Statistics of the Mortality following the Operation of tying the
Carotid Arteries and Arteria Innominata, by George W. Norri.-,
M. D. Philadelphia.
Am. Joum. 3fed. Sciences, vol. xiv. N. S. p. 13, 1847.
Ligature of both Primitive Carotids (successful), by George C.
Blackman, M. D. New York.
Am. Joum. Med. Sciences, vol. xv. X. S. p. 357, 184 v '.
Statistics of Large Surgical Operations (performed in private
practice), by Usher Parsons, M. D. Khode Island.
Am. Joum. Med. Sciences, vol. xv. X. S. p. 359, IE
Case of Ligature of the Common Carotid (in two cases, both died),
by John P. Mettauer, M. D. Virginia.
Am. Joum. Med. Sciences, vol. xviii. X. S. p. 348, 1849.
Case of Wound of the External Carotid — Ligature to Common
Carotid (result unknown), by E. Geddings, M. D. Charleston.
Am. Joum. Med. Sciences, vol. xviii. X. S. p. 550, 1849.
Case of Ligature of the Primitive Carotid Artery, below the
Omo-Hyoid Muscle (cured), by George Fox, M. D. Philadelphia.
Am. Joum. Med. Sciences, vol. xviii. X. S. p. 381, 1849.
Case of Wound of the External Carotid, in which a Ligature
was applied to the Common Carotid, by E. H. Deas, M. D. South
Carolina.
Charleston Med. Joum., vol. iv. p. 585, 1849.
Case of Ligature of the Principal Carotid (successful), by Paul F.
Eve, M. D. Georgia.
Southern Med. and Surg. Joum., vol. vi. p. 210, 1850.
Ligature of the Carotid Artery in Epilepsy (three years after
operation, patient as bad as ever), by C. Morrogh, M. D. New-
Brunswick, N.J.
X. V. Jvuin. Med., vol. viii. X. S. p. 419. 1852.
OPERATIONS OX THE NECK AND TRUNK. 95
Aneurismal Tumors upon the Ear successfully treated by Liga-
ture of both Carotids (at four weeks' interval, patient etherized), by
R. D. Mussey, M. D. Cincinnati.
Ohio Med. and Surg. Journ., vol. vi. p. 125, 1853.
ON LIGATURE OF THE SUBCLAVIAN AND AXILLARY
.ARTERIES.
Observations relative to the Ligature of the Subclavian Artery
(recommending a new Aneurismal Needle, since designated as the
Philadelphia Needle, with a drawing), by Joseph Parrish, M. I).
Philadelphia.
Eclectic Repert. and Analyt. Review, vol. iii. p. 229, 1813.
Ligature of the Axillary Artery (cured), by Thomas Hubbard,
M. D. Pomfret, Connecticut.
Xew England Journ. of Med. and Surg., vol. iv. p. 211, 1815.
Case of Brachial Aueurism cured by tying the Subclavian
Artery above the Clavicle, by Wright Post, M. D. New York.
Transact. Phys. Med. Society of New York, vol. i. p. 387, 1817.
Ligature of the Subclavian Artery for Axillary Aneurism (cured),
by Benjamin W. Dudley, M. D. Lexington, Ivy., 1825.
Transylv. Journ. Med., vol. ii. p. 363, 1829.
Remarkable Spontaneous Cure of Aneurism, with Observations on
Obliteration of Arteries, by William Darrach, M. D. Philadelphia.
Pliila. Med. and Phys. Journ. vol. xiii. p. 115, 1826.
Case of Axillary Aneurism (from the reduction of an old luxa-
tion), in which the Subclavian Artery was tied (died), by William
Gibson, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. ii. p. 136, 1828:
Case of Axillary Aneurism removed by the application of a
Ligature to the Subclavian Artery (cured), by Edward W. Wells,
M. D. Communicated by Felix Pascalis, M. D. New York.
Am. Journ. Med. Sciences, vol. iii. p. 28, 1828.
Case of Axillary Aneurism, in which the Subclavian was success-
fully secured by a Ligature, by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. vii. p. 309, 1830.
Case of Aneurism of the Right Subclavian Artery, in which that
vessel was tied within the Scaleni Muscles (died on the eighteenth
day), by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. xii. p. 354, 1833.
96 BIBLIOGRAPHICAL INDEX.
Case of Ligature of the Left Subclavian (successfully performed),
by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. xiv. p. 530, 1834.
Case of successful Ligature of the Subclavian, by G. II. White.
M.D. Hudson, N. Y.
Am. Journ. Med. Sciences, vol. xxiii. p. 351, 1839.
Case of Axillary Aneurism— Ligature of the Subclavian (above
the Clavicle), death on the thirty -first day, by S. D. Gross, M. D.
Louisville.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 517, 1841.
Case of Wound of the Axillary Artery and Plexus of Nerves,
Amputation below the Shoulder, Secondary Hemorrhage, Ligature
of the Subclavian (successful), by Alfred C. Post M. D. New York.
Am. Journ. Med. Sciences, vol. x. N. S. p. 263, 1845 ; also New York Journ.
Med. and Collat. Sciences, March, 1845.
A Table, showing the Mortality following the Operations of tying
the Subclavian Artery, by G. W. Norris, M. D. Philadelphia,
Am. Journ. Med. Sciences, vol. x. N. S. p. 13, 1845.
Case of Ligature of the Subclavian Artery, between the Scaleni
Muscles, attended with some Peculiar Circumstances (cured), by John
C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 539, 1846 ; also Med. Times.
Dec. 6, 1845.
Case of Ligature of the Left Subclavian within the Scaleni Mus-
cles (died), by J. Kearny Eodgers, M.D. New York.
Am. Journ. Med. Sciences, vol. xi. N.S. p. 541, 1846; also New York Journ.
of Med., March, 1846.
Case of Ligature of the Left Subclavian Artery, for Subclavian
Aneurism (cured), Ligature remaining ninety-six days, with a Ee-
markable Deviation of the Vessel and Consequent Change of its
Kelations, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 13, 184!'.
Notice of the Anatomical Phenomena, in a Case of Ligature of
the Subclavian Artery, four years subsequent to the Operation
(showing collateral circulation, &c), by P. S. Ainsworth, M. D.
Boston.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 83, 1850.
Ligature of Left Subclavian Artery, external to Scalenus Muscle-
(cured), by Valentine Mott, M. D. New York. Reported by John
O'Keilly, M.D.
N. Y. Journ. Med., vol. v. N. S. p. 16, 1851.
OPERATIONS ON THE NECK AND TRUNK. 97
Subclavian Aneurism successfully treated by Ligature of the Left
Subclavian Artery, with an Account of the Appearances on Dis-
section, a year subsequently (being the result of the case of ligature
of this artery reported in 1849), by J. Mason Warren, M.D. Boston.
Am. Joui~n. Med. Sciences, vol. xxi. N. S. p. 53, 1851.
Case of Ligature of the Subclavian Artery, with Statistical Data,
by Wm. H. Van Buren, M. D. New York.
Trans. Med. Soc. of New York, p. 27, 1853.
OX REMOVAL OF THE CLAVICLE.
Exsection of the entire Clavicle, in 1813, by Charles McCreary,
M. D. Hartford, Ky. (This was the first operation of the kind in
the United States, though it was not published till 1850.) The
patient lived 35 years subsequently, and had a useful limb.
History of Kentucky Surgery, p. 180, 1853.
An Account of a Case of Osteo-Sarcoma of the Left Clavicle, in
which Exsection of that Bone (entire) was successfully performed,
by Valentine Mott, M. D. New York.
This was the first case published, though the second performed.
Am. Journ. Med. Sciences, vol. iii. p. 100, 1828.
Case of Removal of the Clavicle in a State of Osteo-Sarcoma
(died on the fourth week), by John C. AVarren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xiii. p. 17, 1833.
Case of Complete Removal of the Clavicle (for Caries), by A. J.
"VVedderburn, M. D. New Orleans.
New Orleans Monthly Med. Register, vol. ii. p. 1, 1852.
OPERATIONS OX THE BREAST.
On Cancer of the Breast, by Joseph Parrish, M.D. Philadelphia.
North American Med. and Surg. Journ., vol. vi. p. 293, 1828.
History of a Case of Sarcomatous Tumor of the Mamma, extir-
pated by N. Hitt, M. D. Vincennes, Indiana.
Transylvania Journ. of Med., vol. iv. p. 508, 1831.
Case of Cancerous Breast, with partial Ossification of that Organ,
by John Maclellan, M. D. Greencastle.
Am. Journ. Med. Sciences,. voL xiii. p. 277, 1833.
7
98 BIBLIOGRAPHICAL INDEX.
Amputation of the Breast for Scirrhus (during etherization—
healed readily — disease returned in nine months), by Henry H.
Smith, M. D. Philadelphia.
Phila. Med. Examiner, vol. vii. p. 33, 1851. t
Amputation of Breast for Scirrhus (during etherization— healed
readily— disease returned in thirteen months), by Henry H. Smith,
M.D.* Philadelphia.
Phila. Med. Examiner, vol. vii. N. S. p. 236, 1851.
Removal of Breast (successful, but no subsequent history), by
Jos. Pancoast, M. D. Philadelphia.
Phila. Med. Examine)', vol. vii. N. S. p. 249, 1851.
Medullary Sarcoma of the Eight Breast (amputation — Tumor
weighed four and a half pounds — died fifty-seven days subse-
quently), by Carter P. Johnson, M. D. Eichmond, Va.
Stethoscope, vol. i. p. 139, 1851.
ON TUMORS OF THE CHEST.
Case of Enormous Steatoma, removed from the Side, by J. M.
Foltz, M.D., U.S.N.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 358, 1846.
A Case of Congenital Encysted Tumor of the Eight Side of the
Chest, successfully treated, Avith the Seton, by S. D. Gross, M. D.
Louisville.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 22, 1849.
Statistics of twelve Cases of Fungus Hagmatodes of the Trunk,
Mamma, Face, and Extremities, in which seven were operated
upon, and five benefited probably, by Paul F. Eve, M. D. Georgia.
Southern Med. and Sure/. Journ., vol. vi. p. 577, 1850.
OPERATIONS ON THE CHEST.
Case of Extensive Caries of the Fifth and Sixth Eibs, and Dis-
organization of the greater part (about two pounds) of the Right
Lung, with a Description of the Operation for the same (being its
removal, patient living several months subsequently), by Milton
Antony, M.D. Augusta, Georgia. (With a Certificate from John
Pugsley, M. D., of Jefferson County, Georgia.)
Phila. Journ. Med. and Phys. Sciences, vol. vi. p. 108, 1823.
OPERATIONS ON THE NECK AND TRUNK. 99
Escape of all the Intestines through a Hole in the Diaphragm
into the Eight Side of the Thorax, by Edward Cornell, M. D.
Coventry, Chenango County, New York.
Am. Med. Record, vol. viii. p. 236, 1825.
On the Pathology of Bones, with a Case of successful Removal
of Carious Ribs, by H. McDowall, M. D. Fincastle, Virginia.
Am. Med. Record, vol. xiii. p. 98, 1828.
Operation of the Trephine for the Removal of a Portion of Carious
Sternum, by Abner Hopton, M. D. North Carolina.
Am. Journ. Med. Sciences, vol. v. p. 545, 1829.
An Account of a successful Operation for the Excision of the
Ossified Cartilages, and Anterior Extremities of two Carious Ribs,
and the Lower Portion of the Sternum (the patient lived twenty
years subseqently), by George McClellan, M. D. Philadelphia.
Western Journ. of (he Med. and Phys. Sciences, vol. iv. p. 479, 1831 ; also
A Report, by J. H. B. McClellan, M. D., Med. Examiner, vol.
vi. N. S. p. 75, 1850.
Two Cases of Excision of the Ribs (successful), by John C. War-
ren, M. D. Boston.
Boston Med. Journ., vol. xvi. p. 201, 1837.
ON EMPYEMA.
Operation for Empyema— Excision of a Piece of the Lung, as
large as a Nutmeg (cured), by Isaac Rand, Esq., Vice-President of
the Massachusetts Medical Society. May, 1783.
Med. Communications and Dissertations of Mass. Med. Soc, vol. i. p. 69, 1790.
Case of Paracentesis Thoracis' (cured), by Charles Hall, M. D., of
Swanton, Vermont.
New York Med. Repository, vol. xx. p. 36, 1820.
Case of Paracentesis Thoracis, life prolonged, by Lemuel W.
Briggs, M. D. Bristol, Rhode Island.
New England Journ. of Med. and Surg., vol. ix. p. 223, 1820.
Case of Empyema successfully treated by Paracentesis Thoracis,
by Dr. Craven, of Harrisonburg, Virginia.
Am. Mel. Record, vol. vii. p. 363, 1824.
Case of Effusion into the Chest, in which Paracentesis Thoracis
was performed (died), by Samuel Jackson, M. D. Philadelphia.
Phila. Journ. Med. and Phys. Sciences, vol. x. p. 119, 1825.
100 BIBLIOGRAPHICAL INDEX.
Case of Empyema (cured by Paracentesis), by A. S. Sheldon,
M. D. Broome County, New York.
Am. Med. Record, vol. ix. p. 273, 182G.
History of a Case of Empyema, from protracted Measles and
Pleurisy, in which the Operation of Paracentesis gave immediate
Belief, by Samuel Merriwether, M. D. Indiana.
Western Joum. Med. and Plujs. Sciences, vol. iii. p. 65, 1830.
Paracentesis, successfully performed, for Empyema, by Dr. Wol-
fley. Lancaster, Ohio.
Maryland Med. Record, vol. ii. p. 56, 1832.
Case of Empyema cured by an Operation, by J. Pancoast, M. D.
Philadelphia.
Am. Jovrn. Med. Sciences, vol. xiii. p. 93, 1833.
Case of Empyema, successfully treated by an Operation (Para-
centesis Thoracis), by W. C. Sneed, M. D. Kentucky.
Am. Joum. Med. Sciences, vol. x. N. S. p. 538, 1845.
Case of Gunshot Wound of the Chest, the thick Linen Patch,
with which the Ball was enveloped, remaining in the Left Lung
twenty years, by M. H. Houston, M. D. Virginia.
Am. Joum. Med. Sciences, vol. ix. N. S. p. 342, 1845.
Case of Empyema, in which Paracentesis Thoracis failed from a
cause not generally noticed (a membrane, lining the Pleura Costalis,
being pushed before the instrument, and not opened), by John A.
Swett, M. D. New York.
Am. Joum. Med. Sciences, vol. xiii. p. 518, 1847 ; also New York Joum. of
Med., January, 1847.
Case of Paracentesis Thoracis for Abscess in the Lungs (Vomica),
Recovery, by S. Howard Dickson, M. D. Mecklenburg, Tenn.
Charleston Med. Joum., vol. vi. p. 667, 1851.
Case pf Empyema, with Remarks especially in reference to Para-
centesis (recommending it), by Wm. Pepper, M. D. Philadelphia.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 38, 1852.
Three Cases of Paracentesis Thoracis (performed by means of the
exploring trocar and suction apparatus), by Dr. Bowditch. Boston.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 103, 1852.
Paracentesis Thoracis (successful) in a Case of Acute Pleurisy, by
Dr. Williams. Boston.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 112, 1852.
On the Necessity of Paracentesis Thoracis in Pleuritic Effusion,
by Henry J. Bowditch, M. D. Boston.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 320, 1852.
OPERATIONS ON THE NECK AND TRUNK. 101
Cases (four) of Paracentesis Thoracis (by the trocar of Schuh), by
Jno. T. Metcalfe, M.D. New York.
New York Med. Times, vol. ii. p. 337, 1853.
Paracentesis Thoracis performed on a Child, seven years of age,
for Pleuritic Effusion— Rapid Recovery, by Wm. A. Tracy, M. D.
New Hampshire.
New York Journ. Med., vol. xi. p. 353, 1853.
ON OPERATIONS OF THE ABDOMEN.
Case of Incision of the Intestines, and Removal of a Silver Tea-
spoon which had been swallowed (cured), by Samuel White, M. D.
Hudson, New York.
New York Med. Repository, vol. x. p. 367, 1807.
Case of Evacuation of Water from the Abdomen by the Um-
bilicus (with a proposal to tap at that point), by Samuel Agnew,
M. D. Harrisburg.
Philadelphia Med. Museum, vol. i. N. S. p. 159, 1811.
A Remarkable Case of Encysted Dropsy and Paracentesis Ab-
dominis (635 pounds being drawn off' in eleven months), by Dr.
Amos Holbrook. Milton, Massachusetts.
Med. Communications and Dissertations of Mass. Med. Soc., vol. ii. p. 29,
Boston, 1813.
Experiments, to show that the Inflammation which supervenes
on the Surface of Wounded Cavities is the Consequence of the
Change and Diminution of Temperature caused by the Admission
of Air into them, by James Cocke, M. D. Maryland, 1804.
Amer. Med. Record., vol. ii. p. 489, 1819.
Case of a Scirrhous Tumor of the Caecum, mistaken for an Aneu-
rism of the Right External Iliac Artery, by Theophilus E. Beezley,
M. D. Salem, New Jersey.
Phila. Journ. Med. and Phys. Science, vol. vi. p. 350, 1823.
Wound of the Stomach (St. Martin), by Joseph Lovell, Surgeon-
General U. S. A.
Am. Med. Record., vol. viii. p. 14, 1825.
Experiments on Digestion (St. Martin), through a Wound in the
Stomach, by William Beaumont, M. D. Fort Niagara.
Am. Med. Record., vol. ix. p. 94, 1826.
Case of Excision of a Part of the Spleen (the patient recovered
after Peritonitis), by W. B. Powell, M.D. Kentucky.
Am. Journ. Med. Sciences, vol. i. p. 481, 1828.
102 BIBLIOGRAPHICAL INDEX.
Case of Penetrating Wound of the Abdomen and Section of the
Intestinal Canal, successfully treated on the Plan of Ramsdohr, with
Remarks, by Zina Pitcher, M.D., U.S.A.
Am. Journ. Med. Sciences, vol. x. p. 42, 1832.
Case of Hepatic Abscess, in which Tapping was performed before
Adhesion of the Liver to the Side had happened, and the Appear-
ances after Death, by Wm. E. Horner, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xiv. p. 83, 1834.
Notes of a Case of Fistulous Opening of the Stomach, success-
fully treated (by Pressure, &c), by J. H. Cook, M. D.
Am. Journ. Med. Sciences, vol. xiv. p. 271, 1834.
Case of Abscess of the Liver — Operation and Recovery, by Chas.
A. Savery, M.D. Hopkinton, N.Hampshire.
Boston Med. and Surg. Jotirn., vol. xvii. p. 56, 1837.
Case of Ascites, cured by the Injection of a Stimulating Fluid into
the Peritoneal Cavity, by John B. Sherrerd, M. D. New Jersey.
Am. Journ. Med. Sciences, vol. x. N. S. p. 525, 1845.
Case of Removal of seventeen inches of the Small Intestines —
Recovery of the Patient, by A. Brigham, M. D. Utica.
Am. Journ. Med. Sciences, vol. ix. N. S. p. 355, 1845.
Case of Gastrotomy (successful), by J. E. Manlove, M. D. Ten-
nessee.
Am. Journ. Med. Sciences, vol. x. N. S. p. 532 ; also Boston Med. and Surg.
Journ., July, 1845.
Sequel to the Case of Removal of seventeen inches of the Intes-
tines, and Recovery of the Patient, by A. Brigham, M.D. Utica.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 44, 1846.
Case of Ascites, in which the Patient was tapped 186 times in ten
years, and had 751f gallons of water drawn off, by John H. Griffin,
M. D. Virginia.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 401, 1850.
Perforation of Abdomen (four inches long) by fence-rail; intestines
protruded, covered with dirt; cleaned and replaced; recovery), by
Robert G. Jennings, M. D. Church Hill, Va.
Stethoscope, vol. i. p. 490, 1851.
Case of Ascites, tapped thirty-nine times — Removal of 140 gallons
of Fluid, by T. D. Lee, M. D. New York.
New York Journ. Med., vol. v. N. S. p. 50, 1851.
Case of Puncture of the Stomach, with Protrusion of this Organ
for six hours (aperture about three-fourths of an inch; nearly the
OPERATIONS ON THE NECK AND TRUNK. 103
whole stomach protruded; wound in the stomach closed by fine
suture, gently retained near the puncture of the abdomen ; water-
dressing; cure), by Chas. Wm. Ashby, M.D. Culpepper C. H., Va.
Stethoscope, vol. i. p. 6G0, 1851.
On Hydatids of the Liver — Operation — Cure, by J. Edward
Weber, M.D. New York.
New York Med. Times, May, 1852.
Three Cases of Ascites cured by Tapping, by Dr. Hayward, Sen.
Boston.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 348, 1852.
Wound of Small Intestines — Recovery (at one part nearly cut in
two by a bowie-knife; at another, cut an inch long; closed by glo-
ver's stitch with catgut; intestine returned; wound in abdomen
closed by silk sutures; water-dressing), by L. A. Dugas, M. D.
Augusta, Ga.
Southern Med. and Surg. Journ., vol. viii. p. 407, 1852.
Wounded Intestine (treated by suture), with Recovery, by J. J.
Chisholm, M.D. Charleston.
Charleston Med. Journ. and Review, vol. viii. p. 615, 1853.
Incised Wound of the Left Side (3 inches long), between the
Eighth and Ninth Ribs, followed by Protrusion of the Stomach and
Strangulation of the Organ — Reduction, and Recovery of the Pa-
tient, by W. W. Hart, M. D. Mississippi.
Western Journ. Med. and Surg., vol. xi. p. 496, 1853.
ON HERNIA.
Case of Strangulated Crural Hernia, operated on according to the
method of Don Antonio Gimbernat, with some Observations on the
Treatment of Hernia, by Jno. C. Warren, M. D. Boston.
Med. Communications Mass. Med. Society, No. 2, Part 2, p. 44, 1790.
Case of Strangulated Femoral Hernia, where the Operation suc-
ceeded after the Obstruction had continued ten days, by John Hahn.
M. D. Philadelphia.
Phila. Med. Museum, vol. iv. p. 26, 1808.
Case of Strangulated Hernia, with Observations on the Treatment
of Mortified Omentum, by Joseph Parrish, M. D. Philadelphia.
Eclectic Repertory and Analytical Review, vol. i. p. 98, 1811.
Practical Elucidation of the Nature of Hernia, &c, with an Ex-
104 BIBLIOGRAPHICAL INDEX.
planation of the Cures of certain Instruments, by G. A. Hull, M. D.,
late President of the Oneida Medical Society. New York.
New York Med. and rhys. Journ., vol. iv. p. 435, 1825.
Case of Strangulated Umbilical Hernia, cured by an Operation,
by T. S. Hewson, M. D. Philadelphia.
Am. Med. Record., vol. xi. p. 106, 1827.
Case of Hernia, in which the Stricture remained at the Mouth of
the Sac, after the Intestine was returned by Taxis, by N. Snead, M.D.
Virginia.
Transylvania Journ. of Med., vol. ii. p. 525, 1829.
Case of (Inguinal) Hernia (in a man eighty-four years of age), in
which there was no evacuation from the Bowels for seventeen days
before the Operation (treated successfully), by John J. Abernethy,
M.D. Hartford, Connecticut.
Am. Journ. Med. Sciences, vol. xi. p. 31, 1832.
Case of Strangulated Inguinal Hernia, attended with some Pecu-
liarities (Omentum strangulated and forced out by a Cancerous Tu-
mor of the Mesentery), by Horatio Gr. Jameson, M. D. Baltimore.
Maryland Med. Recorder, vol. iii. p. 54, 1832.
On Congenital Hernia (cured by an Operation), by Alexander H.
Stevens, M. D. New York. Eeported by Alfred C. Post, M. D.
New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 19, 1832.
A Case of Strangulated Inguinal Hernia, successfully treated, by
Hunting Sherrill, M. D. Duchess County, New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 20, 1832.
Case of Strangulated Umbilical Hernia, with Removal of the Cyst,
followed by a Radical Cure, by J. W. Heustis, M. D. Mobile.
Am. Journ. Med. Sciences, vol. xvi. p. 380, 1835.
Case of Strangulated Umbilical Hernia in a child seven years old
(died), by P. Fahnestock, M. D. Pennsylvania.
Am. Journ. Med. Sciences, vol. xvii. p. 368, 1835.
Cases of Hernia (with Remarks), by Frank H. Hamilton, M. D.
Rochester, New York.
Boston Med. and Surg. Journ., vol. xxv. p. 57, 1841.
Of a new Knife for dividing the Stricture in Cases of Stranjm-
latecl Hernia, by F. Campbell Stewart, M. D. New York.
Am. Journ. Med. Sciences, vol. v. N. S. p. 497, 1843.
Case of successful Operation for Strangulated Femoral Hernia
(with two Sacs), by J. Heaton, M. D. Boston.
Boston Mul. and Surg. Journ., vol. xxx. p. 35, 1844.
OPERATIONS ON THE NECK AND TRUNK. 105
Case of Radical Cure of Hernia, by including the Neck of the
Sac and External Ring in a Leaden Ligature, by J. C. Nott, M. D.
Mobile.
Am. Journ. Med. Sciences, vol. xiv. N. S. p. 402, 1847.
Case of Strangulated Inguinal Hernia, patient operated on while
uuder the influence of Chloroform (died seven days after the Opera-
tion), by James D. Trask, M. D. Whiteplains, New York.
^ Am. Journ. Med. Sciences, vol. xviii. N. S. p. 90, 1849.
Two Cases of Strangulated Hernia, having the Structure in the
Neck of the Sac (cured), by T. Wood, M. D. Cincinnati.
Western Lancet, vol. xi. p. 417, 1850.
Inguinal Hernia treated by Injection, by Henry J. Bigelow, M. D.
Boston.
Boston Med. and Surg. Jdurn., vol. xliii. p. 339, 1850.
Reduction of Strangulated Hernia in Mass, by Geo. C. Blackman,
M. D. New York.
New York Journ. Med., vol. v. N. S. p. 367, et supra, 1850.
Hernia (its radical cure not accomplished by Chase's Truss), by
T. Wood, M. D. Cincinnati.
Western Lancet, vol. xii. p. 273, 1851.
Strangulated Hernia — importance of operating early, with Cases
(eight), by Alfred Hitchcock, M. D. Fitchburg, Mass.
Boston Med. and Surg. Journ., vol. xlv. p. 89, 1851.
Remarks on Strangulated and Reducible Hernia (showing results
of attempts to cure radically), by Alden March, M. D. Albany.
Western Lancet, vol. xiii. p. 373, 1852.
Strangulated Crural Hernia, terminating in Artificial Anus, by
John C. Clark, M. D. Ohio.
Western Lancet, vol. xii. p. 613, 1852.
A singular Case of Strangulated Hernia (fold of the Intestine and
a portion of the Omentum badly strangulated; another large por-
tion of the Omentum not strangulated, but healthy), cured, by Wm.
II. Robert, M. D. Orion, Alabama.
Southern Med. and Surg. Journ., vol. viii. p. 533, 1852.
On the Radical Cure of Reducible Hernia by Injection (of Tinct.
Canth.), by Jno. Watson, M. D. New York.
New York Journ. Med., vol. ix. N. S. p. 290, 1852.
Case of Strangulated Hernia, presenting a peculiar Difficulty in
the Operation (old Hernia, composed of more than 12 inches of the
Large Intestine completely agglutinated, congested, and tumefied,
106 BIBLIOGRAPHICAL INDEX.
with a hypertrophied and indurated Mesocolon), Recovery, without
Fever, by S. N. Harris, M. D. Savannah, Ga.
Charleston Med. Journ., vol. vii. p. 19, 1852.
Strangulated Scrotal Hernia (cured), by Chas. Bell Gibson, M. D.
Richmond.
Stethoscope, vol. ii. p. 139, 1852.
Report on the Permanent Cure of Reducible Hernia, by Drs.
Hayward, Mason, Warren, and Parkman.
Boston Med. and Surg. Journ., vol. xlviii. p. 79, 1853.
Operations for the Radical Cure of Inguinal Hernia, by Jos. S.
Jones, M. D. Boston.
Boston Med. and Surg. Journ., vol. xlviii. p. 510, 1853.
Strangulated, Umbilical Hernia — Operation under Ether, by N.
L. Folsom, M. D. New Hampshire.
Boston Med. and Surg. Journ., vol. xlix. p. 317, 1853.
Case of Strangulated Scrotal Hernia (died), of unusual size, on
the Left Side — Presence of Ccecum in the Hernial Sac, by Wm. H.
Van Buren, M. D. New York.
New York Journ. Med., vol. x. N. S. p. 56, 1853, extracted from Rep. N. Y.
Path. Society.
Case of Strangulated Inguinal Hernia cured by Operation (under
Chloroform), by E. B. Moore, M. D. Boston.
Boston Med. and Surg. Journ., vol. xlvii. p. 525, 1853.
Remarks on an Operation (injection of Oil of Cloves or Tinct.
Canth. into the Canal, and immediate application of a Truss, failed
in numerous instances, hence prefers a small Seton at the External
Ring), by W. H. Robert, M. D. Orion, Alabama.
Southern Med. and Surg. Journ., vol. ix. p. 133, 1853.
ON ARTIFICIAL ANUS.
Two Cases illustrative of an Operation for the Cure of Artificial
Anus, by John Rhea Barton, M. D. Philadelphia.
Am. Med. Record., vol. vii. p. 356, 1824.
Case in which a new and peculiar Operation for Artificial Anus
was successfully performed in January, 1809, by P. S. Physick, M.D.
Drawn up for publication by B. H. Coates, M.D. Philadelphia.
North American Med. and Surg. Journ., vol. ii. p. 269, 1826.
OPERATIONS ON THE NECK AND TRUNK. 107
Singular Case of Artificial Anus, successfully treated by George
W. Campbell, M. D. Tennessee.
Transylvania Journ. of Med., vol. ii. p. 425, 1829 ; also Maryland Med.
Recorder, vol. i. p. 336, 1829.
Account of a successful Operation for Artificial Anus, accom-
plished by the Aid of a Novel Instrument, and performed by J. E.
Lotz, M. D. New Berlin, Pennsylvania. With Observations on
the Apparatus, &c, by Eeynell Coates, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xviii. p. 367, 1836.
Case of Artificial Anus (at the Umbilicus), by E. G. "Wharton,
M. D. Mississippi.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 256, 1843.
Case of Operation for Artificial Anus (cured), by J. Mason War-
ren, M.D. Boston.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 116, 1848.
Amussat's Operation for Artificial Anus, performed by J. M.
Bush, M. D. Lexington, Kentucky.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 275, 1850.
ON LIGATURE OF THE ILIAC ARTERIES.
LIGATURE OF THE COMMON ILIAC ARTERIES.
Case of Wound of the Common Iliac Artery, in which that ves-
sel was tied (being the first case known, the patient lived only fif-
teen days), by William Gibson, M. D. Philadelphia.
Am. Med. Record, vol. iii. p. 185, 1820.
Case of Ligature of the Common Iliac at its origin (cured), by
Valentine Mott, M. D.
Philadelphia Journ. of Med. and Phys. Sciences, vol. xiv. p. 176, 1827.
Case of Ligature of Eight Common Iliac Artery in a Child six
weeks old (died), by George Bushe, M. D. New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 55, 1832.
Ligature of the Primitive Iliac Artery, successfully performed,
by Edward Peace, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. v. N. S. p. 269, 1843.
Ligature of the Primitive Iliac Artery (died), by A. J. Wedder-
burn, M. D. New Orleans.
Neio Orleans Med. and Stirg. Journ., May, 1852.
108 BIBLIOGRAPHICAL INDEX.
LIGATURE OF THE INTERNAL ILIAC ARTERY.
Successful Case of Ligature of the Internal Iliac Artery, by S.
Pomeroy White, M. D. New York (formerly of Hudson).
Am. Juum. Med. Sciences, vol. i. p. 304, 1827.
Case of Ligature of the Internal Iliac Artery for a Traumatic
Aneurism of the Gluteal (died), by H. J. Bigelow, M. D. Boston.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 29, 1849.
Case of Ligature of the Internal Iliac Artery (died), by Gilman
Kimball, M. D. Lowell, Massachusetts.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 92, 1850.
LIGATURE OF THE EXTERNAL ILIAC ARTERY.
Ligature of the External Iliac Artery (cured by tying the artery
in the pelvis), by John Syng Dorsey, M. D. Philadelphia, August,
1811. (This was the first successful operation reported in the
United States, but the seventh ever performed — the six preceding
having been done in England, the first being that by Abernethy.)
Eclec. Bepert. and Anahjt. Review, vol. ii. p. Ill, 1811 ; also New England
Journ. of Med. and Surg., vol. i. p. 6G, 1812.
A Case of Inguinal Aneurism (successful ligature) of the External
Iliac (by means of Physick's needle), by Wright Post, M. D. New
York.
Am. Med. and Philosophical Register, vol. iv. p. 443, 1814.
Ligature of the External Iliac Artery, by J. B. Whitridge, M. D.
Sackett's Harbor.
New England Journ. of Med. and Surg., vol. iv. p. 318, 1815.
Case of Ligature of the External Iliac for Inguinal Aneurism
(cured), by Nathan Smith, M.D^of Yale College.
Philadelphia Journ. Med. and Phys. Sciences, vol. i. p. 415, 1820.
Ligature of the External Iliac, by II. G. Jameson, M. D. Balti-
more.
Am. Med. Recorder, vol. v. p. 118, 1822.
Case of Ligature of the External Iliac (cured), by Alexander H.
Stevens, M. D. New York.
N. T. Med. and Phys. Journ., vol. i. p. 112, 1822.
Case of Ligature of the External Iliac (cured), by John C. War-
ren, M. D. Boston.
New England Journ. of Med. and Surg., vol. xii. p. 225, 1823.
OPERATIONS ON THE NECK AND TRUNK. 109
Case of Inguinal Aneurism (in which an Empiric plunged a
lancet), reported by John Ehea Barton, M. D. Philadelphia.
Philadelphia Journ. of Med. and Phys. Sciences, vol. i. N. S. p. 127, 1825.
Ligature of the External Iliac (cured), by David L. Eogers, M. D.
New York. Communicated by P. Cadwallader, M. D.
Am. Medical Recorder, vol. ix. p. 2G9, 1826.
Case of Diffused Femoral Aneurism, for which the External Iliac
was tied (cured), by Valentine Mott, M. D. New York.
Am. Journ. Med. Sciences, vol. viii. p. 393, 1831.
Case of Aneurism of the External Iliac Artery, treated success-
fully by tying up the Vessel, by J. Kandolph, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. iii. p. 489, 1829 ; also North Amer. Med.
and Surg. Journ., vol. vii. p. 206, 1829.
Case in which the External Iliac Artery was successfully tied, by
James C. Hall, M. D. Washington.
Am. Journ. Med. Sciences, vol. x. p. 90, 1832.
Case of Aneurism of the External Iliac Artery, Ligature of this
Artery (died), by J. C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xix. p. 541, 1836.
Case of Inguinal Aneurism, in which the Eight External Iliac
Artery was successfully tied, by William H. Euan, M.D. St,
Croix, West Indies.
Am. Journ. Med. Sciences, vol. xviii. p. 43, 1836.
Case of Ligature of the External Iliac Artery (cured ; the Liga-
ture coming away on the thirtieth day), by Edward Peace, M. D.
Philadelphia.
Med. Examiner, vol. i. N. S. p. 645, 1842 ; also Am. Journ. Med. Sciences,
vol. iv. N. S. p. 250, 1842.
Femoral Aneurism, Ligature of the External Iliac, death on the
fifth day, by W. Power, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 511, 1842; also Maryland
Med. and Surg. Journ., Sept. 1842.
Ligature of the External Iliac Artery for Aneurism of the Femo-
ral Artery, cured, by J. M. Boling, M.D. Alabama.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 359, 1844.
Ligature of the External Iliac Artery (for Aneurism of the Fe-
moral, died), by A. J. Wedderburn, M. D. New Orleans.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 249, 1847 ; also New Orleans
Med. and Surg. Journ., Sept. 1846.
Ligature of the External Iliac of one side, and soon after of the
HO BIBLIOGRAPHICAL INDEX.
Femoral of opposite Limb (both successful), by C. Bell Gibson, M.D.
Baltimore.
Am. Journ. Med. Sciences, vol. xiv. N. S. p. 535, 1847.
Case of true Inguinal Aneurism ; attempt at Manual Compression
of the External Iliac; subsequent Ligature (cured), by William H.
Van Buren, M.D. New York.
New York Journ. Medicine, vol. ii. N. S. p. 168, 1849 ; also Am. Journ.
Med. Sciences, vol. xvii. N.S. p. 540, 1849.
Case of Inguinal Aneurism, Ligature of the External Iliac (cured),
by George Fox, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 377, 1849.
Case of Ligature of the External Iliac (patient died), by Dr. Sted-
man. Beported by S. Parkman, M. D. Boston.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 73, 1850.
Successful Ligature of External Iliac Artery to relieve Secondary
Hemorrhage, by Dr. Hastings. San Fraucisco.
Am. Journ. Med. Sciences, vol. xxiv. N. S. p. 564, 1852.
OPERATIONS ON THE BACK.
Gunshot Wound, Ball lodged in the posterior part of the Neck,
and subsequently discharged by Stool, by William Hening, M. D.,
late Surgeon U. S. A.
Eclect. Repert. and Analyt. Review, vol. vii. p. 240, 1817.
On the Use of Caustic Alkali in Tetanus, by Joseph Hartshorne,
M. D. Philadelphia.
[The caustic was rubbed firmly on an oval space 2| inches
wide by 1£ inches long, over the cervical vertebrae, and the patient
was relieved in less than two hours.]
Eclect. Repert. and Analyt. Review, vol. vii. p. 245, 1817.
Case of Steatomatous Tumor, weighing twenty-five pounds, re-
moved from the upper part of the Back, by J. S. Dorsey, M. D.
The circumference of the neck, or narrowest part of the tumor,
was two feet ten inches.
Thickest part vertically, three feet nine inches.
" horizontally, three feet one inch and a half.
of waist, after removal of tumor, two feet nine
inches.
Am. Med. Record., vol. i. p. 400, 1819.
OPERATIONS ON THE NECK AND TRUNK. Ill
Case of Lumbar Abscess, attended with Artificial Anus at the
Groin (opening the colon), by Wm. E. Horner, M. D. Philad.
Phila. Journ. Med. and Phys. Sciences, vol. i. p. 141, 1820.
Case of Gunshot Wound, in which Tetanus was controlled by a
Caustic Issue to the Spine, by David M. Eeese, M. D. Baltimore.
Am. Med. Record., vol. viii. p. 548, 1825.
Case of Fistula in the Lumbar Eegion, communicating with the
Bladder, by L. Proudfoot, M. D.
Am. Journ. Med. Sciences, vol. i. p. 241, 1827.
Cases in which portions of three Dorsal Vertebras were removed
with partial success for the relief of Paralysis from Fracture, by
Alban G. Smith, M. D. Danville, Kentucky.
North American Med. and Surg. Journ., vol. viii. p. 94, 1829.
Case of Fractured Spine, with the removal of depressed Spinous
Process, by an Operation (patient died), by David L. Sogers, M. D.
New York. (Communicated by S. E. Kirby, M. D.)
Am. Journ. Med. Sciences, vol. xvi. p. 91, 1835.
Case of Division of the Spinal Marrow (by a Chisel accidentally
driven in opposite the Spinous Process of the lower Dorsal Vertebra?,
causing Paralysis), the patient recovered, by Eli Hurd, M. D. Ni-
agara County, New York.
Am. Journ. Med. Sciences, vol. x. N. S. p. 531, i845; also New York
Journ. Med., Sept., 1845.
ON SPINA BIFIDA.
Three Cases of Spina Bifida successfully treated; two of them
by means of Wire Ligatures, and the other by the Knife, by Amasa
Trowbridge, M. D., of Watertown, New York.
Boston Med. and Surg. Journ., vol. i. p. 753, 1829.
Case of Spina Bifida, with Eemarks (punctured seventy times
without bad consequences, but died ultimately of diarrhoea), by
Charles Skinner, M. D. North Carolina.
Am. Journ. Med. Sciences, vol. xix. p. 109, 1836.
Case of Spina Bifida (cured, by Punctures and Pressure), by P.
H. Hurd, M. D. Oswego.
Boston Med. and Surg. Journ., vol. xviii. p. 109, 1838.
Case of Spina Bifida successfully treated by Eepeated Puncture,
by Alexander Stevens, M. D. New York.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 527, 1843 ; also New York Journ.
of Med. and Collateral Sciences, No. 2.
112 BIBLIOGRAPHICAL INDEX.
Case of Spina Bifida treated by Injection of Tincture of Iodine,
by Daniel Brainard, M. D. Chicago.
Am. Jour a. Med. Sciences, vol. xvi. N. S. p. 262, 1848; also III. and Lid.
Med. and Surg. Journ., Jan., 1848.
A Case of Spina Bifida of the Occiput (opened by bistoury),
Death, by Richard L. Howard, M. D. Columbus, Ohio.
Ohio Med. and Surg. Journ., vol. v. p. 214, 1853.
ON THE GENITOURINARY ORGANS AND RECTUM. 113
PART IV.
PAPERS ON THE GENITOURINARY ORGANS AND RECTUM.
OPERATIONS ON THE PENIS.
New Method of performing the Operation of Phymosis, by George
Bushe, M. D. New York.
JV. Y. Medico- Chirurgical Bulletin, vol. i. p. 224, 1832.
Induration and Enlargement of the Penis, with a new Mode of
Amputating that Organ, by Thomas L. Ogier, M. D. Charleston.
Am. Journ. Med. Sciences, vol. xviii. p. 382, 1830.
On Amputation of the Penis, by John P. Mettauer, M. D. Vir-
ginia.
Boston Med. and Surg. Journ., vol. xvii. p. 197, 1837.
A Case of Imperforate Prepuce, by D. J. C. Cain, M. D.
Charleston.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 521, 1847 ; also Southern
Journ. of Med. and Pharmacy, Jan. 1847.
Amputation of the Penis for Cancer (healed readily, but disease
reappeared at Pubis in seven months), by Wm. E. Horner, M. D.
Philadelphia.
Med. Examiner, vol. vii. N. S. p. 99, 1851.
Report of a Case of Phimosis (operated on by Ricord's Operation
and serres-fines instead of suture), by Josiah Harris, M. D. Augusta,
Georgia.
. Southern Med. and Surg. Journ., vol. viii. p. 21, 1852.
ON AFFECTIONS OF THE MALE URETHRA.
Fistula in Perineo, attended with considerable loss of substance,
cured by Lunar Caustic, by "Wm. E. Horner, M. D. Philadelphia.
Philadelphia Journ. of Med. and Phys. Sciences, vol. ix. p. 141, 1824.
114 BIBLIOGRAPHICAL INDEX.
On the Treatment of Strictures of the Urethra by a Perineal In-
cision, with Cases, by Horatio G. Jameson, M. D. Baltimore.
(First operation in 1820.)
Am. Med. Record., vol. vii. p. 251, 1824.
Description of an Instrument (with a Plate), for dividing Stric-
tures of the Urethra, by E. K. Chew, M. D. Louisiana.
North American Med. and Surg. Journ., vol. v. p. 341, 1828.
Practical Observations on Stricture of the Urethra, by H. G.
Jameson, M. D. Baltimore.
Amer. Med. Record., vol. xii. p. 329, 1828.
Case of Stricture of the Urethra (treated by a perineal section),
by Horatio (£. Jameson, M. D. Baltimore.
Maryland Med. Recorder, vol. i. p. 177, 1829.
Operations for Artificial Urethra (successful), by Jno. C. Warren,
M. D. Boston.
Boston Med. and Surg. Journ., vol. ii. p. 321, 1829.
Treatment of Stricture of the Urethra by rapid and free dilata-
tion, by Paul F. Eve, M. D. Georgia.
New York Med. Times, vol. iv. p. 301.
On Hypospadias (with Cases), by George Bushe, M. D. New
York.
New York Medico- Chirurgical Bulletin, vol. ii. p. 1, 1832.
Case of Stricture of Urethra strongly simulating Lithiasis, by
Nathan K. Smith, M. D. Baltimore.
North American Archives Med. and Surg. Sciences, vol. i. p. 185, 1835.
Complete Suppression of Urine from Obliteration of Membran-
ous portion of Urethra — Puncture of Bladder above the Pubis —
Perineum opened and new Urethra formed — cured, by E. Geddings,
M. D. Baltimore (now of Charleston).
American Archives Med. and Surg. Sciences, vol. i. p. 31, 1835.
A Case of Stricture of the Urethra cured by bougies of bark of
the slippery elm tree, by fm. Waters, M. D. Maryland.
Am. Journ. Med. Sciences, vol. xxv. p. 321, 1839.
Practical Observations on those Malformations of the Male
Urethra and Penis, termed Hypospadias and Epispadias, with an
anomalous Case, by John P. Mettauer, M. D. Virginia.
Am. Journ. Med. Sciences, vol. iv. N, S. p. 43, 1842.
Employment of Gutta Percha in the treatment of Strictures, by
Henry J. Bigelow, M. D. Boston.
Boston Med. and Surg. Journ., vol. xl. p. 9, 1849.
ON THE GENITOURINARY ORGANS AND RECTUM. 115
Case of Impermeable Stricture of the Urethra (operated on
through the Perineum — died 19th day, having suffered from he-
morrhage), with the suggestion of a new-shaped Catheter, by J. A.
Wragg, M. D. Savannah, Georgia.
Charleston Medical Journal, vol. viii. p. 799, 1852.
OPERATIONS ON THE TESTICLE AND CORD.
New Operation (Ligature of Arteries), for Circocele, cured by
H. G. Jameson, M. D. Baltimore.
Am. Med. Record., vol. viii. p. 271, 1825.
Operation for a Tumor of the Scrotum (Omental Hernia cured),
by Jno. C. Warren, M. D. Boston.
Boston Med. and Surg. Journ., vol. i. p. 237, 1828.
Case of Sarcocele successfully treated by tying the Spermatic
Artery, by Horatio G. Jameson, M. D. Baltimore.
Maryland Med. Recorder, vol. ii. p. 607, 1831.
Extirpation of the Testes and Penis affected with Cancerous Dis-
ease, by J. C. Hall, M. D. Washington.
Am. Journ. Med. Sciences, vol. x. p. 395, 1832.
Extirpation of the Testis ; death from Phlebitis, by Nathan R.
Smith, M. D. Baltimore.
North American Archives Med. and Surg. Sciences, vol. ii. p. 77, 1835.
On Tubercles of the Testis (Castration, &c), by Henry H. Smith,
M. D. Philadelphia.
Medical Examiner, vol. iii. p. 360, 1840.
Varicocele and Extirpation of the Testis, by F. H. Hamilton, M. D.
Rochester, New York.
Boston Med. and Surg. Journ., vol. xxv. p. 153, 1841.
Treatment of Diseases of the Testicle, by Compression, in No-
vember, 1803, by P. S. Physick, M. D. Reported by Edward
Hartshorne, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iii. N. S. p. 258, 1842.
Practical Observations on the Radical Treatment of Varicocele,
by John Watson, M. D. New York.
Am. Journ. Med. Sciences, vol. x. N. S. p. 316, 1845.
New Operation (Incision and Ligature), for the Radical Cure of
Varicocele, performed successfully eight times, by S. D. Gross,
M. D. Louisville.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 327, 1848.
116 BIBLIOGRAPHICAL INDEX.
Castration of Enlarged and Irritable Testis, by M. G. Delaney,
M.D., U.S.N.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 292, 1848.
Extirpation of Left Testicle (etherized, cured), by Wm. E. Hor-
ner, M. D. Philadelphia.
Medical Examiner, vol. vii. N. S. p. 33, 1851.
Extirpation of Testis (by Jobert's Operation, bi-valve flap, semi-
circular incision, convex downwards so as to insure subsequent
escape of pus), by Charles Bell Gibson, M. D. Eichmond, Va.
Stethoscope, vol. i. p. 145, 1851.
Ligature of Spermatic Artery for the Cure of Varicocele, by
Horace Nelson, M. D. Plattsburg, New York.
Boston Med. and Surg. Journ., vol. xliv. p. 334, 1851.
Eemoval of Diseased Testes (cured), by E. McSherry, M. D.,
U. S. N.
Am. Journ. Med. Sciences, vol. xxii. p. 119, 1851.
Case of Congenital Cystic Sarcoma of the left Testicle (extend-
ing from near left inguinal ring to near the knee), cured by exci-
sion, by D. Gilbert, M. D. Philadelphia.
Philadelphia Med. Examiner, vol. ix. N. S. p. 154, 1853.
ON HYDROCELE.
Hydrocele treated by Injection, by David Hosack, M. D. New
York.
New York Medical Repository, vol. i. p. 419, 1797.
Observations on Hydrocele, by B. Winslow Dudley, M. D. Lex-
ington.
Transylvania Journ. of Med., vol. i. p. 268, 1828.
Case of Congenital Hydrocele, tapped by Dr. McComb, with
Eemarks by George Bushe, M. D. New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 21, 1832.
On Hydrocele, by George Hayward, M. D. Boston.
Boston Med. and Surg. Journ., vol. xix. p. 154, 1839.
Case of Sudden Formation of Hydrocele, unconnected with in-
flammation of Tunica Vaginalis (operation— cure), by Henry H.
Smith, M.D. Philadelphia.
Am. Journ. of Med. Sciences, vol. xiii. N. S. p. 85, 1847.
Large Hydrocele (53 ounces), cured by injection and seton, by
Henry H. Smith, M. D. Philadelphia.
Medical Examiner, vol. vii. N. S. p. 175, 1851.
ON THE GENITO-URINARY ORGANS AND RECTUM. 117
OPERATIONS ON THE BLADDER.
Preternatural Retention of Urine in consequence of external in-
jury. Bladder tapped above the Pubis. Cured. By James Tha-
cher, M. D. Plymouth.
Med. Communications and Dissertations of Mass. Med. Society, vol. i.
p. 35, 1790.
Observations on Retention of Urine, by Samuel Anan, M. D.
Baltimore.
Maryland Med. Recorder, vol. i. p. 72, 1829.
Laceration of the Urethra from a fall on the perineum ; retention
of urine (Bladder punctured above the Pubis), died, by Thomas F.
Betton, M. D. Philadelphia. (With Observations by Isaac Hays,
M.D.)
Am. Journ. Med. Sciences, vol. xix. p. 389, 1836.
Paracentesis of the Bladder, through the Perineum, by N. R.
Smith, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. xxiii. p. 63, 1839.
Closure of the Urethra from an Injury of the Perineum; Urine
discharged by an Artificial Opening above the Pubes; the Natural
Passage restored by an Operation, by Gurdon Buck, Jr., M. D.
New York.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 544, 1844 ; also New York
Journ. of Med., Sept. 1844.
Puncture of the Bladder above the Pubis (cured), by Otis F.
Manson, M. D. North Carolina.
Stethoscope, vol. i. p. 324, 1851 ; and West. Lancet, vol. xii. p. 509, 1851.
ON LITHOTOMY.
Account of the Successful Application of Cold Water to the
Lumbar Region in cases of Calculus, by John Willday, in a Letter
to Benjamin Rush, M. D. 1788.
Transactions of the Philadelphia College of Physicians, vol. i. p. 76, 1793.
An Inaugural Dissertation on Stone in the Bladder (recommend-
ing the Use of the Bistoury and Staff, with a Drawing), by Henry
U. Onderdonk, M. D. New York.
Am. Med. and Philosoph. Register, vol. i. p. 394, 1811.
118 BIBLIOGRAPHICAL INDEX.
Extra-Uterine Foetus, iucrusted with Calculous Matter, extracted
by the Operation of Lithotomy, by Joseph Bossuet, M. D. Hing-
ham, Mass.
New England Joum. Med. and Surg., vol. vi. p. 135, 1817.
Lithotomy Forceps (made with a fenestrum so as to permit the
grasping of a large calculus without the extreme separation of the
handles of the instrument), by John Ehea Barton, M. D. Philad.
Philadelphia Joum. Med. and Phys. Sciences, vol. viii. p. 147, 1824.
Extraction of a Calculus from the Female Bladder, by Dilatation
of the Urethra, by Eobert Hamilton, M. D.
Am. Med. Record., vol. xi. p. 115, 1827.
Two Cases of Lithotomy (Lateral Operation, both cured), by
Lunsford Pitts Yandell, M. D. Lexington.
Transylvania Joum. of Med., vol. i. p. 431, 1828.
Description of a Eemarkable Urinary Calculus, by E. D. Mussey,
M. D. New Hampshire.
Am. Joum. Med. Sciences, vol. iv. p. 333, 1829.
Case of Lithotomy (Lateral Operation, cured), by Hugh H. To-
land, M.D. South Carolina.
Transylvania Joum. Med., vol. iii. p. 139, 1830.
Cases of Lithotomy (Lateral Operation; cured), in which the
Stones were dependent on the presence of a spicula of bone in the
bladder, by George W. Campbell, M. D. Tennessee.
Transylvania Joum. Med., vol. iii. p. 211, 1830.
Case of Chief- Justice Marshall; Operation of Lithotomy; more
than one thousand small Calculi extracted by Philip S. Physick,
M.D. Philadelphia.
Am. Joum. Med. Sciences, vol. ix. p. 537, 1831.
Case of Stone, in which the Fundus of the Bladder was coated
with Calculous Incrustations, successfully operated on by Lithotomy,
by Amasa Trowbridge, M. D. Watertown, New York.
Am. Joum. Med. Sciences, vol. xi. p. 27, 1832.
On the Bi-lateral Operation for Stone (with Drawings of Instru-
ments recommended for this Operation), by George Bushe, M. D.
New York.
New York Medico- Chirurgical Bulletin, vol. i. p. 1, 1832.
Lithotomy and Extraction of a Calculus, measuring nearly twelve
inches in circumference, and weighing upwards of seventeen ounces
avoirdupois (death, fifth day), by Valentine Mott, M.D. New York.
Am. Joum. Med. Sciences, vol. xiv. p. 530, 1834.
ON THE GENITOURINARY ORGANS AND RECTUM. 119
Supplementary Observations on Lithotomy, with a description of
the Instruments employed, &c., by N. E. Smith, M. D. Baltimore.
Bait. Med. and Surg. Journ., vol. ii. p, 13, 1834.
Case of Lithotomy in which the healing process was interrupted
by the supervention of an Eruptive Disease, by Jno. P. Mettauer,
M. D. Virginia.
Boston Med. and Surg. Journ., vol. xii. p. 283, 1835.
Statistical Account of the Cases of Urinary Calculi treated in the
Pennsylvania Hospital, from May, 1756, to May, 1835, by Eeynell
Coates, M.D. Philadelphia. (Sixty-one cases; fifty-two males; seven
died.)
Am. Journ. Med. Sciences, vol. xvii. p. 97, 1835.
Case of Lithotomy — Calculi of unusual size (about eight ounces,
cured), by Nathan E. Smith, M. D. Baltimore. (This case was the
twenty-third operated on, with complete success, by Dr. Smith.)
North Am. Archives Med. and Surg. Sci., vol. i. p. 177, 1835.
Lithotomy — Secondary Hemorrhage on the sixth and eighth days,
Pleuritis on the twelfth, cerebral irritation on the sixteenth, and
death on the twentieth day, by Nathan E. Smith, M. D. Baltimore.
North Am. Archives Med. and Surg. Sci., vol. i. p. 233, 1835.
Observations on the Operation of Lithotomy, illustrated by cases
from the practice of Professor B. W. Dudley, by James M. Bush,
M. D. Lexington.
Am. Journ. Med. Sciences, vol. xxi. p. 535, 1837 ; also Transylva. Journal
of Med., vol. x. p. 478, 1837.
Case of Urinary Calculus in a Girl, successfully removed by Li-
thotomy, by T. D. Mutter, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxi. p. 260, 1837.
Lectures on Lithotomy, with an Account of the Bi-lateral Opera-
tion, by Alexander H. Stevens, M. D. New York.
New York Journ. Med., vol. xi. p. 104, 1838.
Remarks on the Propriety and best manner of breaking and ex-
tracting large Calculi in the Lateral Operation, by J. C. Nott, M. D-
Mobile.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 328, 1842.
Lithotomy; Bi-lateral Operation, with cases, by Paul F. Eve, M.D.
Georgia.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 504, 1844.
On the Bi-lateral Operation for Lithotomy, and on Lithotrity in
the Female, by John C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 293, 1844.
120 BIBLIOGRAPHICAL INDEX.
On a new Form of Director and Gorget, by John P. Mettauer,
M. D. Virginia. (With a Drawing.)
Med. Examiner, vol. i. N.S. p. 648, 1845.
Lithotomy and Lithotrity (with an Account of Dr. Dudley's Ope-
rations), by J. M. Bush, M. D. Lexington, Kentucky.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 545, 1846; also Western
Lancet, January, 1846.
Bi-lateral Operation in Lithotomy, by K. D. Mussey, M. D. Cin-
cinnati.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 264, 1846.
Case of Lithotomy in the Female, with Remarks by A. Baker,
Jr., M. D. Chenango County, New York.
Transactions of Med. Society, State of New York, vol. vi. p. 133, 1846.
Extraordinary Case of Urinary Calculi, two hundred and twenty-
eight in number, by John Kelly, M. D. New York.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 246, 1847.
Lithotomy in a Child two years and eleven months old — Patient
•under influence of Chloroform (cured), by Frank H. Hamilton, M.D.
Buffalo.
Buffalo Med. Journ., vol. iv. p. 735, 1849.
Lithotomy in an Adult under the influence of Chloroform (death
in two weeks from Purulent Absorption), by Frank H. Hamilton,
M.D. Buffalo.
Buffalo Med. Journ., vol. iv. p. 736, 1849.
Lithotomy (Bi-lateral Operation), in a Boy ten years old, Calculus
weighing 3xxv — Attacked with Dysentery ninth day (died), by Paul
F. Eve, M. D. Georgia.
Southern Med. and Surg. Journ., vol. v. p. 596, 1849.
Case of Lithotomy in a Child (four years old, cut by the Bi-lateral
Section), Anesthesia (Ether), died forty -five hours after the Opera-
tion, by James R. Wood, M. D. New York.
New York Journ. Med., vol. ii. N. S. p. 326, 1849.
Lithotomy— One hundred and seventeen Calculi, weighing four
and a half ounces, successfully removed by Paul F. Eve, M. D.
Georgia,
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 539, 1849 ; also Southern Med.
and Surg. Journ., March, 1849.
Results of fifteen Operations for Lithotomy, by P. C. Spencer,
M. D. Petersburg.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 103, 1850.
Stone in the Bladder, weighing eight ounces— Unpleasant Anchy-
ON THE GENITO-URINAKY ORGANS AND RECTUM. 121
losis of the Hip — Successful Bi-lateral Operation, by Charles A.
Pope, M. D. St. Louis.
St. Louis Med. and Surg. Journ., vol. vii. N. S. p. 298, 1850.
Calculus in a Child seven years of age (weight of Calculus one
ounce, length one inch and seven-tenths, greatest circumference four
inches and seven-tenths) — Lithotomy — Eecovery, by F. M. -Eobert-
son, M. D. Charleston.
Charleston Med. Journ., vol. vi. p. 50, 1851.
Lithotomy — (Calculus, Phosphate of Ammonia and Magnesia ;
weight two ounces and seventeen grains) — Eecovery, by Henry H.
Smith, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 235, 1851.
A Case of Double Lithotomy (died in eighty -three hours ; first
lateral incision, then high operation, owing to the size of the Calcu-
lus ; weight nearly six ounces, length three inches, longitudinal cir-
cumference seven inches, width two inches, lateral circumference
five and three-fourth inches), by Wm. J. Johnson, M. D. Fort
Gaines, Georgia. '
Southern Med. and Surg. Journ., vol. vil. p. 727, 1851.
, Lithotomy (Bi-lateral Operation ; cured), by Henry F. Campbell,
M.D. Augusta, Georgia.
Southern Med. and Surg. Journ., vol. vii. p.*393, 1851.
Eemoval of an ounce and a half of Calculous Matter from the
Bladder by Lithotomy (Bi-lateral Section ; three Stones), by Henry
F. Campbell, M.D. Augusta, Georgia.
Southern Med. and Surg. Journ., vol. vii. p. 459, 1851.
Two Cases of Lithotomy (cured ; Chloroform ; Lateral Operation
by N. E. Smith's Beaked Knife), by Carter P. Johnson, M. D.
Eichmond.
Stethoscope, vol. i. p. 656, 1851.
Lithotomy successfully performed on a Boy aged seven (chloro-
formized and bi-lateral section), by Wm. Nephew King, M. D. Eos-
well, Georgia.
Southern Med. and Surg. Journ., vol. vii. p. 663, 1851.
Lithotomy — Bi-lateral Operation with the Double Lithotome of
Dupuytren (cured), by Jno. Fred. May, M.D. "Washington.
Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 407, 1852.
Lithotomy in a Female four years old (died), by Jno. Fred. May,
M. D. Washington.
Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 411, 1852.
Eeport of twenty-five Cases of Urinary Calculus, in twenty-three
122 BIBLIOGRAPHICAL INDEX.
of which the Bi-lateral Operation was performed, by Paul F. Eve,
M. D. Nashville.
Am. Jonrn. Med. Sciences, vol. xxiv. N. S. p. 41, 1852.
Operations for the removal of Calculi in the Urethra, by D. TV.
Hammond, M.D. Georgia.
Southern Med. and Surg. Journ., vol. viii. p. 654, 1852.
Summary of twenty-five Cases of Urinary Calculi, in twenty-
three of which the Bi-lateral Operation was performed (twenty- one
recovered), by Paul F. Eve, M. D. Nashville.
New York Journ. Med., vol. ix. N. S. p. 292, 1852, from Nashville Journ. Med.
Operation of Lithotomy (cured; Lateral Incision), by Alden March,
M. D. Albany.
Western Lancet, vol. xiii. p. 060, 1852.
Lithotomy in a Child eight years of age, successful under ether-
ization, by Henry H. Smith, M. D. Philadelphia.
Med. Examiner, vol. viii. N. S. p. 224, 1852.
Lithotomy (successful; Lateral Operation; Beaked Knife; two
Stones, each an ounce and a half), by Eichard L. Howard, M. D.
Columbus, Ohio.
Ohio Med. and Surg. Journ., vol. iv. p. 290, 1852.
Two Cases of Lithotomy (Lateral Operation ; cured), by Eichard
L. Howard, M. D. Columbus, Ohio.
Ohio Med. and Surg. Journ., vol. iv. p. 371, 1852.
Three Cases of Foreign Bodies introduced into the Bladder, which
were removed by the Operation of Lithotomy, reported by Amasa
Trowbridge, M. D. TVatertown, New York.
New York Med. Gazette, vol. iv. p. 289, 1853.
Case of Lithotomy (Chloroform ; Calculus five ounces ; died on
the nineteenth day), by M. L. Leider, M. D. Ohio.
Western Lancet, vol. xiv. p. 666, 1853.
Cases of Lithotomy (three, operated on by the bi-lateral method
and Chloroform ; two cured, one died), by L. A. Dugas, M. D. Au-
gusta, Georgia.
SoutJiern Med. and Swg. Journ., vol. ix. p. 82, 1853.
Stone in the Bladder, Lithotrity, Cystitis, &c. — Lithotomy, suc-
cessful, by TVm. H. Yan Buren, M. D. New York.
New York Med. Times, vol. ii. p. 369, 1853.
ON THE GENITOURINARY ORGANS AND RECTUM. 123
ON LITHOTRIPSY.
Lithotripsy successfully performed by L. Depeyre, M. D. New
York. (October, 1830. First successful Case in the United States.)
North American Med. and Surg. Journ., vol. xi. p. 492, 1831.
Successful Lithotrity, by Alban G. Smith, M. D. Danville, Ken-
tucky.
North American Med. and Surg. Journ., vol. xii. p. 256, 1831.
Lithotrity, successfully performed by P. S. Spencer, M. D. Vir-
ginia.
Am. Journ. Med. Sciences, vol. xii. p. 554, 1833.
Lithotripsy, successfully performed in six Cases, by J. Randolph,
M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xv. p. 13, 1834.
Removal of Calculi from the Urethra, by means of a "Wire Loop
attached to a Silver Bougie, by A. Leander Uttery, M. D. Provi-
dence.
Boston Med. and Surg. Journ., vol. xii. p. 237, 1835.
Case of Urinary Calculus, in which Dr. J. Randolph successfully
performed Lithotripsy, by Isaac Hays, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvii. p. 258, 1835.
Sketch of Lithotripsy, with Cases, by William Gibson, M. D.
Philadelphia.
Am. Journ. Med. Sciences, vol. xviii. p. 338, 1836.
Seven additional Cases of Stone in the Bladder, successfully
treated by Lithotripsy, by J. Randolph, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xix. p. 52, 1836.
Report of four additional Cases of Stone in the Bladder, success-
fully treated by Lithotripsy, by J. Randolph, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxi. p. 13, 1837.
Report of Cases of Lithotripsy, by K R. Smith, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. xxi. p. 25, 1837.
Cases of Lithotrity performed by J. Randolph, M.D. Reported
by A. E. Stocker, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 263, 1846.
Four Cases of Lithotripsy, performed by J. Randolph, M. D. (Two
on Children, aged four years.) Reported by J. M. Wallace, M. D.
Philadelphia.
Medical Examiner, vol. v. N. S. p. 288, 1849.
124 BIBLIOGRAPHICAL INDEX.
Lithotrity and Lithotomy, with the Use of Ether in those Ope-
rations, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 47, 1849.
Two Cases of Lithotripsy, by the late George McClellan, M. D.,
in one of which the male blade of Heurteloup's instrument broke
in the Bladder, and was subsequently passed by the Urethra. Re-
ported by J. H. B. McClellan, M. D. Philadelphia.
Med. Examiner, vol. v. N. S. p. 513, 1849.
Eemoval of three inches of a Gum Elastic Cathether by means of
Heurteloup's Instrument, by J. H. Dillson, M. D. Pittsburg.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 268, 1850.
Lithotripsy, successfully performed by *Wm. E. Horner, M. D.
Philadelphia.
Medical Examiner, vol. vii. N. S. p. 97, 1851.
Lithotripsy in the Female (cured), by J. Deane, M. D. Greenfield,
Massachusetts.
Boston Med. and Surg. Journ., vol. xlvi. p. 20, 1852.
OPERATIONS ON THE EXTERNAL ORGANS OF THE
FEMALE.
Case of Imperforate Hymen (patient married for two years before
the operation relieved her), by J. W. Horton, M. D. Maryland.
Maryland Med. Recorder, vol. i. p. 408, 1829.
Case of Fistulous Communication between the Vagina, Bladder,
and Rectum, by Charles Byrne, M. D., U. S. Army.
Am. Journ. Med. Sciences, vol. vi. p. 70, 1830.
Observations on Sanguineous Tumors of the Vagina, by Hugh
H. Toland, M. D. South Carolina.
Transylvania Journ. of Med., vol. vii. p. 204, 1834.
Fungus Hasmatodes (in Recto-Vaginal Septum; extirpation; cure),
by N. R. Smith, M.D. Baltimore.
Am. Archives Med. and Surg. Sci., vol. i. p. 37, 1835.
Case of Medullary Sarcoma of the Labia, &c, by A. B. Shipmaa,
M.D. New York.
Am. Journ. Med. Sciences, vol. v. N. S. p. 368, 1843.
A Case of Imperforate Hymen, by William Shultice, M. H. Vir-
ginia.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 243, 1844.
ON THE GENITO-URINARY ORGANS AND RECTUM. 125
Case of Imperforate Hymen, by John G. Metcalf, M. D. Massa-
chusetts.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 139, 1846.
Vaginal Hysterotomy and subsequent Delivery with the Forceps,
with safety to both Mother and Child, by G. S. Bedford, M. D. New
York.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 348, 1848.
A previous successful Case of the same.
New York Journal of Medicine, March, 1843.
Vaginal Hysterotomy (successful to Mother), by John H. Griffin,
M. D. Virginia.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 94, 1849.
On Occlusion of the Vagina (operation by incision and dilatation,
relieved), by H. J. Holmes, M. D. Mississippi.
Ohio Med. and Surg. Journ., vol. ii. p. 540, 1850.
OPERATIONS ON THE FEMALE PERINEUM.
Parturient Laceration of the Recto-Vaginal Septum, successfully
treated with Metallic Ligatures, by John P. Mettauer, M. D. Vir-
ginia.
Am. Journ. Med. Sciences, vol. xiii. p. 113, 1833.
Extirpation of the Os Coccygis for Neuralgia, by J. C. Nott, M.D.
Mobile.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 544, 1844.
Hints on the Treatment of Lacerated Perineum, by "Wm. E.
Horner, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 329, 1850.
OPERATIONS ON THE VAGINA.
Non-Existence of the Vagina remedied by an Operation, by John
C. "Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xiii. p. 79, 1833.
Case of Vesico -Vaginal Fistula, successfully treated by an Ope-
ration, by George Hay ward, M.D. Boston.
Am. Journ. Med. Sciences, vol. xxiv. p. 283, 1839.
Recto-Vaginal Fistula (cured), by J. Rhea Barton, M. D. Phila-
delphia.
Am. Journ. Med. Sciences, vol. i. N. S. p. 305, 1840.
126 BIBLIOGRAPHICAL INDEX.
On Vesico- Vaginal Fistula, by John P. Mettauer, U.J). Virginia.
Am. Journ. Med. Sciences, vol. xiv. N. S. p. 117, 1847.
Vesico- Vaginal Fistula, treated by the ordinary Hare-lip Opera-
tion (relieved), by Henry H. Smith, M. D. Philadelphia.
Med. Examiner, vol. v. N. S. p. 155, 1849.
Case of Imperforate Vagina and Malformation of the Superior
Portion. Operation (cure), by A. B. Shipman, M. D. Indiana.
Am. Journ. Med. Sciences, vol. xviii. p. 401, 1849.
Case of Procidentia Uteri — Successful Operation (diminishing the
orifice of the Vagina), by J. E. Wood, M. D. New York.
New York Med. Times, vol. i. p. 41, 1851.
Cases of Vesico- Vaginal Fistula, treated by Operation, by George
Hay ward, M.D. Boston.
Boston Med. and Surg. Journ., vol. xliv. p. 209, 1851.
Three Cases of Occlusion of the Vagina, accompanied by reten-
tion of the Catamenia, relieved by an Operation, by J. Mason War-
ren, M.D. Boston.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 13, 1851.
Occlusion of the Vagina — Operation — Death (in three days, from
Peritonitis, though the Peritoneum was not opened), by Jno. 0.
Stone. New York.
New York Journ. Med., vol. vi. N. S. p. 289, 1851.
Case of Vesico -Vaginal Fistula (cured by an Operation), by Prof.
Pancoast. Reported by C. D. Meigs, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 650, 1851.
Case of Constricted Vagina and Occlusion of the Os Uteri (punc-
tured; died), by Lawrence Turnbull, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 696, 1851.
Occlusion of the Vagina — Successful Operation (excision of Cica-
trix), followed by Conception and Delivery, by P. C. Spencer, M. D.
Petersburg, Va.
Stethoscope, vol. i. p. 209, 1851.
On the Treatment of Vesico- Vaginal Fistula, by J. Marion Sims,
M.D. Alabama.
Am. Journ. Med. Sciences, vol. xxiii. p. 59, 1852.
Almost complete Occlusion of the Vagina, cured by an Operation,
by Dr. Hayward, Sen. Boston.
Am. Journ. Med. Sciences, vol. xxiv. N.S. p. 350, 1852.
Cases of Complete Occlusion of the Vagina (one treated by inci-
sion, &c, but contracting, notwithstanding every effort to prevent
it), by Valentine Mott, M. D. New York.
New York Med. Times, vol. ii. p. 1, 1852.
ON THE GENITO-TJRINARY ORGANS AND RECTUM. 127
Three Cases of Occlusion of the Yagina, relieved by an Opera-
tion, by J. Mason Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxv. N. S. p. 86, 1853.
Eecto-Vaginal Fistula (cured ; clamp suture), by E. D. Mussey,
M. D. Cincinnati.
Ohio Med. and Surg. Journ., vol. vi. p. 127, 1853.
Case of Atresia Vagina, by 0. H. Taylor, M. D. Camden, N. J.
New Jersey Med. Reporter, vol. vi. p. 439, 1853.
Occlusion of the Yagina — Conception (Operation), by T. L. Ogier,
M. D. Charleston.
Charleston Med. Journ., vol. via. p. 811, 1853.
A Case of Atresia Yagina (Operation unsuccessful, the parts con-
tracting after incision, notwithstanding the employment of dilatation),
by D. E. Ewart, M. D. South Carolina.
Charleston Med. and Surg. Journ., vol. viii. p. 81, 1853.
A Case of Congenital Occlusion of the Yagina relieved by an
Operation (puncture and laceration), by Geo. L. Upshur, M. D.
Norfolk, Ya.
Med. Examiner, vol. ix. N. S. p. 523, 1853.
OPERATIONS ON THE UTERUS.
Amputation of the Cervix Uteri for Scirrhus (died), by H. G.
Jameson M. D. Baltimore.
Am. Med. Record., vol. vii. p. 543, 1824.
Case of successful Excision of the Cervix Uteri in a Scirrhous
State, by John B. Strachn. M. D. Yirginia.
Am. Journ. Med. Sciences, vol. v. p. 307, 1829.
Extirpation of a Cancer of the Uterus (died sixth day), by John
C. Warren, M. D. Boston.
Am. Journ. Med. Sciences, vol. iv. p. 536, 1829.
Uterine Tumor removed by an Operation (died), by Moses Hib-
bard, M. D. New Hampshire.
Boston Med. and Surg. Journ., vol. viii. p. 68, 1833.
Complete Extirpation of the Uterus by Ligature, after Chronic
Inversion of the Organ (successful), by John M. Esselman, M. D.
Nashville.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 254, 1844.
Case of Extirpation of a Fibrous Tumor by the large Peritoneal
Section, by Washington L. Atlee, M. D. Pennsylvania.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 539, 1844.
128 BIBLIOGRAPHICAL INDEX.
Case of successful Extirpation of a Fibrous Tumor from the
surface of the Uterus by the large Peritoneal Section, by Washing-
ton L. Atlee, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. ix. N. S. p. 309, 1845.
Amputation of the Neck of the Uterus, by N. J. McL. Moore,
M. D. New Hampshire.
Boston Med. and Surg. Journ., Dec. vol. xxxvii. p. 397, 1847.
Excision of the Cervix Uteri for Carcinomatous Disease (died),
by Washington L. Atlee, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 86, 1848.
A Sarcomatous Tumor, containing Hair and Stearine, removed
from the Womb, by Gunning S. Bedford, M. D. New York.
New York Journ. of Medicine, vol. ii. N. S. p. 30, 1849.
Case of Excision of the Uterus (died three months after the ope-
ration), by Paul F. Eve, M. D. Georgia.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 395, 1850.
An Eclectic Essay on the Non-Pediculated Fibro-Scirrhous
Tumors of the Uterus, by Wm. C. Eoberts, M. D. New York.
New York Journ. of Medicine, vol. iii. N. S. p. 330, 1849; also Ibid.,
vol. iv. N. S. p. 31, 1850.
Amputation of Uterus (successful) after Partial Inversion, by
Usher Parsons, M. D. Providence, Ehode Island.
Boston Med. and Surg. Journ., vol. xliv. p. 511, 1852.
Eemoval of a Fibrous Tumor from the Uterus, including a por-
tion of the Cervix Uteri (cured), by T. L. Ogier, M. D. Charleston.
Charleston Med. Journ., vol. vii. p. 154, 1852.
Occluded Os Tineas — Operation (puncture by Trocar), by A.
Barclay, M. D. Newburgh, New York.
American Lancet, vol. viii. p. 37, 1853.
ON POLYPUS UTERI.
Cases of Uterine Polypus treated by Ligatures, by Thomas Chad-
bourn, M. D. New York.
Boston Med. and Surg. Journ., vol. xxi. p. 289, 1839.
Polypus Uteri, removed by Excision, by C. R. Gilman, M. D.
New York.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 519, 1841.
Cases of Uterine Polypus (new Instrument for Ligature), by
John V. P. Quackenbush, M. D. Albany.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 241, 1844.
ON THE GENITO-URINARY ORGANS AND RECTUM. 129
Polypus and Inversion of Uterus ; Ligature, Excision of a large
portion of the Uterus (recovery), by A. L. Peirson, M. D. Salem,
Mass.
Am. Jour?i. Med. Sciences, vol. xvii. p. 339, 1849.
Case of Polypus Uteri, successfully removed by Ligature, by S.
B. Philips, M. D. New York.
New York Journ. Med. and Collateral Sciences, vol. iv. N. S. p. 199, 1850.
Case of Polypus of the Uterus, successfully removed, by S. B.
Phillips, M. D. New York.
New York Journ. Med., vol. iv. N. S. p. 348, 1850.
Polypus Uteri (cured, by double Canula), by Kobert G. Jennings,
M. D. Virginia.
Stethoscope, vol. i. p. 491, 1851.
Polypus of the Uterus (cured by Ligature, with Gooch's double
Canula), by A. Fattaway, M. D. Georgia.
Southern Med. and Surg. Journ., vol. viii. p. 532, 1852.
Case of Polypus Uteri (successfully removed with the double
Canula and Ligature, by Jno. P. Mettauer, M. D. Winchester, Ya.
Stethoscope, vol. ii. p. 8, 1852.
ON OVARIOTOMY AND GASTROTOMY.
Three Cases of Extirpation of the Ovaria, successfully per-
formed, by Ephraim McDowell, M. D. Kentucky, 1809. (This
operation was the first of the kind ever performed. The operation
of Dr. Houstoun, of Scotland, in 1701, and reported by Dr. Atlee
(Am. Journ. lied. Sciences, vol. xvii. N. S.) was merely the evacua-
tion of an ovarian dropsy, there being no proof of the removal
of the tumor, though his puncture was enlarged to five inches.
L'Aumonier's operation, generally thought to have been the first,
was also only the evacuation of an abscess of the ovary.) (See
Gross's History of Kentucky Surgery)
Eclectic Repert. and Analyt. Review, vol. vii. p. 242, 1817.
On Ovarian Disease and Abdominal Steatoma, by Thomas Hen-
derson, M. D. Georgetown, D. C.
Eclectic Repert., vol. viii. p. 545, 1818.
Observations and Cases (two), of removal of Ovaria, by Ephraim
McDowell, M. D. Danville, Kentucky.
Eclectic Repert., vol. ix. p. 546, 1819.
9
130 BIBLIOGRAPHICAL INDEX.
Case of Ovarian Tumor, successfully removed by an Incision
through the Abdomen, by Nathan Smith, M. D. July 5, 1820.
Yale College.
Am. Medical Recorder, vol. v. p. 124, 1822.
Case of Extirpation of Ovarian Sacs for the cure of Hydrops
Ovarii (died), by Joseph A. Gallup, M. D. Vermont.
New England Journ. of Med. and Surg., vol. xiv. p. 358, 1825.
Account of a Case of successful removal of a Diseased Ovarium,
by Alban G. Smith, M. D. Danville, Kentucky.
North American Med. and Surg. Journ., vol. i. p. 30, 1826.
Case of Ovarian Tumor, successfully extirpated, by David L.
Rogers, M. D. New York.
New York Med. and Phys. Journ., vol. ii. N. S. p. 285, 1830 ; also Am.
Journ. Med. Sciences, vol. v. p. 549, 1829.
Contributions to Ovarian Pathology, by E. Geddings, M. D.,
Baltimore.
North Amer. Archives Med. and Surg. Journ., vol. i. p. Ill, 1835.
Successful Operation for Ovarian Disease, Adhesion of Wall of
Vagina, &c, by R. D. Mussey, M. D. Fairfield, New York.
Am. Journ. Med. Sciences, vol. xxi. p. 377, 1837.
Case of successful Peritoneal Section for the removal of two Dis-
eased Ovaria, &c, by John L. Atlee, M. D. Lancaster.
Am. Journ. Med. Sciences, vol. vii. N.S. p. 44, 1844.
Case of Congenital Tumor (of the Abdomen) composed of numer-
ous Cysts, by Washington L. Atlee, M. D. Pennsylvania.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 84, 1844.
Extirpation of a Bi-locular Ovarian Cyst by the large Peritoneal
Section, by Washington L. Atlee, M. D. Lancaster.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 43, 1844.
Extra-Uterine Foetation, Gastrotomy, successfully performed ten
years after Conception, by Alexander H. Stevens, M. D. New
York.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 279, 1846 ; also New York
Journ. of Med., May, 1846.
Case of Extra-Uterine Pregnancy (cured by Gastrotomy), by
Edward Whinery, M. D. Iowa.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 351, 1846.
Removal of an Extra-Uterine Foetus, fifteen years in cavity of
Abdomen (through the Rectum), and complete recovery, by Thomas
Yardley, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 348, 1846.
ON THE GENITOURINARY ORGANS AND RECTUM. 131
Extirpation of a peculiar form of Uterine Tumor, simulating
Ovarian Disease, by the large Peritoneal Section (died), by Samuel
Parkman, M. D. Boston.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 371, 1848.
Extirpation of a Diseased Ovary, by Daniel Meeker, M. D. In-
diana.
Boston Med. and Surg. Journ., vol. xxxix. p. 116, 1848.
Ovarium, successfully removed, by H. Miller, M. D. Louisville.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 528, 1848.
Gastrotomy (for a Uterine Tumor which could not be removed),
recovery, by J. Deane, M. D. Greenfield.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 258, 1849 ; also Boston
Med. and Surg. Journ., vol. xxxix. p. 221, 1848.
Ovarian Dropsy cured by the long Abdominal Section in 1701,
by Eobert Houstoun. Glasgow, Scotland. Eeported by Washing-
ton L. Atlee, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 534, 1849.
Case of successful Extirpation of an Ovarian Tumor by the
large Peritoneal Section, by Washington L. Atlee, M. D. Phila-
delphia.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 336, 1849.
Solid Ovarian Tumor, extending from the Pubis to the Right
Hypochondrium, cured by Incision followed by Suppuration, by
David Prince, M. D. St. Louis.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 267, 1850.
Account of an Operation for the removal of an Ovarian Tumor,
by Alden March, M. D. Albany.
Transactions of New York Med. Society, vol. viii. p. 201, 1850 •
also New York Journ. Med., vol. v. N. S. p. 140, 1850.
Fibrous Tumor of the Left Ovarium successfully removed by the
large Abdominal Section, by Wm. H. Van Buren, M D New
York.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 272, 1850 ; also New York
Journ. Med., March, 1850.
Two Cases of Ovariotomy (with Statistics), by Washington L.
Atlee, M.D. Philadelphia.
Am. Journ. Med. Sciences, vol. xix. N. S. p. 318, 1850.
Ovariotomy, three Cases, by P. J. Buckner, M. D. Georgetown,
Ohio.
Am. Journ. Med. Sciences, vol. xx. N. S. p. 560, 1850 ; also Ohio Med.
and Surg. Journ., vol. iii. p. 1, 1850.
132 BIBLIOGRAPHICAL INDEX.
Ovarian Dropsy— removal of the Sac (large section) and fatal
termination, by A. H. Grimshaw, M. D. Delaware.
Med. Examiner, vol. vi. N. S. p. 630, 1850.
Gastrotomy successfully performed for Extra-Uterine Conception
(right tubal), by M. Franklin Brown, M. D. Hanibal, Missouri.
St. Louis Med. and Surg. Journ., vol. vii. p. 205, 1850.
A Table of all the known Operations of Ovariotomy, comprising
222 Cases, &c., by Washington L. Atlee, M. D. Philadelphia.
Transactions Am. Med. Association, vol. iv. 1851.
Double Ovarian Dropsy (both Ovaries successfully removed by
the large peritoneal section), by E. E. Peaslee, M. D. New York.
[This case, it is believed, is unique; both ovaries being success-
fully removed at the same operation. The catamenia appeared 72
hours after operation ; they had been seen 10 days before.]
Am. Journ. Med. Sciences, vol. xxi. p. 371, 1851.
Case of Ovarian Dropsy (Ovariotomy successfully performed), by
A. Dunlap, M. D. Ripley, Ohio.
Western Lancet, vol. xii. p. 355, 1851.
Gastrotomy successfully performed in a Case of Extra-Uterine
Pregnancy (patient under chloroform — foetus in right Fallopian
tube — size of 7 months — weight about 5 pounds), by Drs. Bradley
and Rogers, Pineville, Alabama.
Western Lancet, vol. xii. p. 520, 1851.
From New Orleans Med. and Surg. Journ.
Ovarian Tumor removed, per vias naturales, by Catheterism of
the Fallopian Tubes, by Samuel A. Cartwright, M. D. New Orleans.
Stethoscope, vol. i. p. 414, 1851.
From New Orleans Med. and Surg. Journ.
Attempted removal of an Ovarian Cyst by the small abdominal
section — unsuccessful from the absence of a pedicle (patient well,
two months subsequently), by S. Parkman, M. D. Boston.
Boston Med. and Surg. Journ., vol. xlv. p. 421, 1851.
Ovariotomy (large section, died), by James Deane, M. D. Mass.
Boston Med. and Surg. Journ., vol. xliv. p. 474, 1851.
Ovarian Dropsy cured by a simple operation (adhesion of the sac
to the abdominal parietes being produced by external irritation;
the incision was made near the linea semi-lunaris— the tumor tapped
and the canula kept in till a purulent discharge ensued — it was
then removed and the fluid left to discharge naturally), by Jno.
Douglass, M. D. Chester District, South Carolina.
Charleston Med. Journ., vol. vi. p. 669, 1851.
OF THE GENITOURINARY ORGANS AND RECTUM. 133
Ovariotomy successfully performed (for a multilocular cyst), by
Ezra P. Bennett, M. D. Connecticut.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 282, 1852.
A very large Mesenteric Tumor — simulating Ovarian disease —
successfully extirpated, by P. J. Buckner, M. D. Cincinnati.
Am. Joum. Med. Sciences, vol. xxiv. N. S. p. 358, 1852.
Eemoval of an Ovarian Tumor by the large Abdominal Section ;
death from Peritonitis, by Wm. H. Van Buren, M. D. New York.
New York Joum. Med., vol. viii. N. S. p. 212, 1852.
Ovariotomy (performed under chloroform — died), by Ezra P.
Bennett, M. D. Danbury, Connecticut.
New York Joum. Med., vol. viii. N. S. p. 288, 1852.
Ovariotomy (death on 14th day of general Dropsy), by D. D.
Franklin, M.D. Tiffin, Ohio.
Eclectic Med. Journal, vol. iv. p. 355, 1852.
Case of Ovariotomy (for first 18 days did well, then took cold,
and died one month afterwards of Peritonitis), by Samuel Gross,
M. D. Louisville.
Western Joum. of Med. and Surg., vol. xi. 3d series, p. 39, 1853.
Ovarian Tumor removed (successfully — large section), by D.
McEuer, M. D. Bangor, Maine.
Boston Med. and Surg. Joum., vol. xlviii. p. 74, 1853.
Eemoval of an Ovarian Tumor (died of hemorrhage 20J hours
after operation), by G. W. Bayless, M. D. Haslewood, Missouri.
St. L,ouis Med. and Surg. Joum., vol. xi. p. 204, 1853.
Ovariotomy by a new method (dividing the peritoneum around
the pedicle before applying the ligature), cured, by Eichard L.
Howard, M. D. Columbus, Ohio.
Ohio Med. and Surg. Joum., vol. v. p. 211, 1853.
Ovariotomy (adhesions), died 17th day after operation, by Ei-
chard L. Howard, M. D. Columbus, Ohio.
Ohio Med. and Surg. Joum., vol. v. p. 213, 1853.
ON THE CESAREAN OPERATION.
Caesarean Operation, successfully performed by John L. Rich-
mond, M. D. Ohio. (Done without assistance at 1 A. M. with In-
struments from a pocket-case.)
West. Joum. of Med. and Phys. Sciences, vol. iii. p. 485, 1830.
134 BIBLIOGRAPHICAL INDEX.
Observations on the Cesarean Operation (accompanied by an
Account of the Operation of Dr. Wm. Gibson), in which both
Mother and Child were preserved, by Joseph G. Nancrede, M. D.
Philadelphia.
Am. Journ. Med. Sciences, vol. xvi. p. 343, 1835.
Case where the Cesarean Section was performed with a fatal ter-
mination, by A. Brooke, M. D.
Am. Journ. Med. Sciences, toI. xviii. p. 258, 1836.
Account of a Case in which the Cesarean Section, performed by
Professor W. Gibson, was a second time successful in saving both
Mother and Child, by George Fox, M. D.
Am. Journ. Med. Sciences, vol. xxii. p. 13, 1838.
Csesarean Section on a Dwarf, by Cyrus Falconer, M. D.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 204, 1843; also Western
Journ. of Med. and Surg., May, 1843.
Case of Caesarean Section (successful), by Brodie S. Herndon,
M. D. Virginia.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 386, 1846.
Caesarean Operation (performed unsuccessfully), by A. B. Ship-
man, M. D. Indiana.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 122, 1849.
Caesarean Section successfully performed by Dr. Gorham, Lou-
isiana.
Am. Journ. Med. Sciences, vol. xxiii. N. S. p. 283 ; from New Orleans
Med. and Surg. Journ., Sept., 1851.
ON AFFECTIONS OF THE RECTUM.
Fistula in Ano in an Infant, eight months old, cured by Incision,
by Felix Pascalis, M. D. New York.
Philadelphia Med. Museum, vol. vi. p. 197, 1809.
Stricture of Rectum, successfully treated by an operation, by H.
G. Jameson, M. D. Baltimore.
Am. Med. Record, vol. v. p. 290, 1822.
Improved Mode of Operating for Hemorrhoids, by J. C. Rous-
seau, M. D. Philadelphia.
Am. Med. Record., vol. ix. p. 288, 1825.
Fissure of the Rectum, attended with Constriction of the Anus,
cured by division of the Sphincter Ani, by Alexander H. Stevens,
M.D.
New York Med. and Phys. Journ., vol. iv. p. 242, 1825.
OF THE GENITOURINARY ORGANS AND RECTUM. 135
Case of Prolapsus Ani, in which the entire Eectum was success-
fully extirpated, by J. W. Brite, M. D. New Castle, Kentucky.
Am. Med. Record, vol. x. p. 311, 1826.
Case of Blind Hemorrhoids, cured by Use of Setons, by Ransom
M. Collins, M. D. Louisiana.
Transylvania Med. Journ. vol. ii. p. 139, 1829.
Callous Stricture of Rectum (died), by Daniel King, M. D.
Charlestown, Rhode Island.
Boston Med. and Surg. Journ., vol. ill- p. 525, 1830.
Case of Prolapsus Recti, successfully treated by excision, by J.
W. Heustis, M. D. Alabama.
Am. Journ. Med. Sciences, vol. xi. p. 411, 1832.
New Instrument for Fistula in Ano, by T. D. Mutter, M. D.
Philadelphia.
Am. Journ. Med. Sciences, vol. xiv. p. 80, 1834.
Remarks on the Pathology and Treatment of Hemorrhoidal
Tumors, by N. R. Smith, M. D. Baltimore.
North American Archives, vol. ii. p. 10, 1835.
Prolapsus Ani (cured by Ligatures and Needles), by George
Hayward, M. D. Boston.
Boston Med. and Surg. Journ., vol. xix. p. 156, 1838.
Remarks on the Treatment of Hemorrhoids (suggesting a new
mode of operating), by Wm. E. Horner, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 358, 1842.
On Strictures of the Rectum, by Thomas D. Mutter, M. D. Phi-
ladelphia.
Med. Examiner, vol. i. N. S. p. 77, 1845.
Description of a new Operation for Hemorrhoids, by Amussat,
translated by Henry Selden, M. D. Virginia.
Am. Journ. Med. Sciences, vol. xi. N. S. p. 346, 1846.
Extraction of a Glass Goblet from the Rectum, by W. S. W.
Ruschenberger, M. D., U. S. N.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 409, 1849.
Imperforate Anus (operated on by trocar— child lived 18 months),
by J. H. York, M. D. Boston.
Boston Med. and Surg. Journ., vol. xlii. p. 273, 1850.
A Case of Imperforate Anus— operation— failure— remarks on
the causes of failure, by John S. Mitchell, M. D. Charleston.
Charleston Med. Journ., vol. v. p. 752, 1850.
136 BIBLIOGRAPHICAL INDEX.
Large Hemorrhoids operated on by Dr. Horner's plan (cured), by
Henry H. Smith, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 175, 1851.
Fatal Case of Tetanus following Ligature of Hemorrhoids (ether,
double ligature passed through tumor by needle), by James Bolton,
M. D. Virginia.
Stethoscope, vol. i. p. 662, 1851.
Imperforate Anus ; operation; death (rectum closed 1J inch up
by fleshy mass), by A. Bryant Clarke, M. D. Holyoke, Mass.
Boston Med. and Surg. Journ., vol. xlvi. p. 100, 1852.
Imperforate Anus, and other Malformation, relieved by an ope-
ration, by George Hay ward, M. D. Boston.
Am. Journ. Med. Sciences, vol. xxvi. N. S. p. 554, 1853.
From Virginia Med. and Surg. Journ., July, 1853.
Hemorrhoids of 17 years' standing; cured (by ligature and exci-
sion), by John McCall, M. D. Utica.
New York Journ. Med., vol. xi. p. 350, 1853.
GENEKAL OPEKATIONS ON THE EXTREMITIES. 137
PART V.
PAPERS RELATING TO OPERATIONS ON THE EXTREMITIES.
GENERAL OPERATIONS ON THE EXTREMITIES.
On the Arrest of the Progress of Whitlow, by means of Caustic,
by Dr. Perkins. Philadelphia.
Am. Medical Record, vol. ii. p. 490, 1819.
Surgical Account of the Naval Battle on Lake Erie (Gunshot
Wounds), by Usher Parsons, M. D., U. S. N. (now of Rhode Island.)
Eclectic Repertory, vol. ix. p. 28, 1819.
On the Best Method of Removing Contractions in the Limbs
from Burns, by Wm. G. Nice, M. D. Virginia.
Am. Med. Record, vol. iii. p. 341, 1820.
Hydrops Articuli in the Shoulder, by James Kent Piatt, M. D.
Plattsburg.
Am. Med. Record, vol. iv. p. 209, 1821.
Case in Proof of Efficacy of the Actual Cautery in Deep Sinuses,
by N. R. Smith, M. D. Burlington, Vermont.
Philadelphia Journ. of Med. and Phjs. Sciences, vol. vi. p. 128, 1823.
Removal of a large indolent Tumor on the Thigh, by the Appli-
cation of Caustic, by H. G. Jameson, M. D. Baltimore.
Am. Med. Record, vol. vi. p. 59, 1823.
Case of Wounded Nerve from Bleeding in the Forearm just be-
low the Elbow, cured by Division of the Nerve, by T. Nelson, M.D.
New York.
New York Med. and Phys. Journ., vol. iii. p. 62, 1824.
An Operation for Inverted Toe-Nail, by John D. Godman, M. D.
Philadelphia.
Philadelphia Journ. Med. and Phys. Sciences, vol. iii. p. 338, 1826.
138 BIBLIOGRAPHICAL INDEX.
Case of Kupture of the Tendo-Achillis, with an Account of the
Method of Treatment, by Wm. E. Horner, M. D. Philadelphia.
Phila. Joum. Med. and Phys. Sciences, vol. xii. p. 407, 1826.
Cases of Neuralgia or Painful Affections of the Nerves from In-
jury, &c, by Jno. C. Warren, M.D. Boston.
Boston Med. and Surg. Joum., vol. ii. p. 98, 1829.
Case of Diseased Sciatic Nerve, in which the Nerve was removed
by Excision (death), by Eobert Bayard, M. D. St. John's, New
Brunswick.
New York Med. and Phys. Joum., vol. ii. N. S. p. 37, 1830.
Abnormal Elongation of the Tibia consequent on extensive Ul-
ceration of the Leg, by Alexander Baron, M. D. South Carolina.
North American Archives, vol. ii. p. 290, 1834.
An Inquiry into the Pathology and Treatment of Secondary
Abscesses, &c, resulting from Injuries and Surgical Operations, by
Jno. Watson, M. D. New York.
Am. Joum. Med. Sciences, vol. xxi. p. 17, 1837.
Case of Varicose Veins cured by means of Needles passed through
the Veins after the Method proposed by Davat, by Henry H. Smith,
M. D. Philadelphia.
Am. Joum. Med. Sciences, vol. xxii. p. 525, 1838.
On the Treatment of Varicose Veins, by Henry H. Smith, M. D.
Philadelphia.
Med. Examiner, vol. ii. p. 821, 1839.
On Enlargement of Bursa over the Patella, by George Hayward,
M.D. Boston.
Am. Joum. Med. Sciences, vol. iv. N. S. p. 513, 1842; also New England
Quarterly Journal, July, 1842.
On the Pathology and Treatment of Varices, by John Watson,
M.D.. New York.
Am. Joum. Med. Sciences, vol. v. N. S. p. 36, 1843.
Adipose Sarcomatous Tumor (removed from lower border of
shoulder, over £ yard in circumference, 10 inches in diameter, and
8 inches in thickness), by M. Stephenson, M. D. New York.
N. Y. Joum. Med., vol. iv. N. S. p. 346, 1850.
Chronic Inflammation and Abscess of Head of Tibia, cured by
application of Trephine, by E. McSherry, M. D., U. S. Navy.
Am. Joum. Med. Sciences, vol. xxii. p. 118, 1851.
Cases (Four) of Tetanus cured by the Division of the Injured
Nerve, by Moses Sweat, M. D. North Parsonfield, Maine.
New York Med. Journ., vol. vi. N. S. p. 194, 1851.
GENERAL OPERATIONS ON THE EXTREMITIES. 139
Paronychia, an Epidemic, by James E. Morgan, M. D. Wash-
ington.
Am. Joum. Med. Sciences, vol. xxiii. p. 144, 1852.
Two Cases of Foreign Bodies (cartilages) successfully removed
from Knee-joint, by Jno. Fred. May, M. D. Washington.
Am. Joum. Med. Sciences, vol. xxiii. N. S. p. 415, 1852.
Enormous Development of a Steatomatous Tumor (upon the
shoulder — weight, 8 pounds), successfully removed, by J. S. Crane,
M. D. Columbia, South Carolina.
Charleston Med. Joum., vol. vii. p. 5G, 1852.
Successful Eemoval of a Foreign Body from the Knee-joint, by
J. Washington Smith, M. D. Croton, New York.
Med. Examiner, vol. viii. N. S. p. 578, 1852.
ON CLUB-FOOT.
Eeport of several Cases of Club-Foot successfully treated by
dividing the Tendo-Achillis, by W. Detmold, M. D. New York.
Am. Joum. Med. Sciences, vol. xxii. p. 105, 1838 ; also Med.
Examiner, vol. i. p. 198, 1838.
On Division of the Tendo-Achillis in Club-Foot, by James H.
Dickson, M. D. New York.
Am. Joum. Med. Sciences, vol. xxii. p. 512, 1838.
Congenital Club-Foot, and Division of the Tendo-Achillis, by
G. W. Norris, M. D. Philadelphia.
Am. Joum. Med. Sciences, vol. xxiii. p. 257, 1839.
Division of the Tendo-Achillis in Club-Foot, by N. E. Smith,
M. D. Baltimore.
Am. Joum. Med. Sciences, vol. xxiii. p. 61, 1839.
Case of Talipes Equinus, cured by Stromeyer's Operation, by
James H. Dickson, M. D. New York.
Am. Joum. Med. Sciences, vol. xxiii. p. 96, 1839.
Successful Club-Foot Operations (ten), by A. G. Walton, M. D.
Pennsylvania.
Am. Joum. Med. Sciences, vol. xxiii. p. 259, 1839.
Club-Foot Division of Tendo-Achillis, by Thomas J. Garden,
M. D. Virginia.
Am. Joum. Med. Sciences, vol. xxiv. p. 257, 1839.
Cases of Deformed Feet treated by Mechanical Means alone, with
140 BIBLIOGRAPHICAL INDEX.
a Description of the Apparatus, by Heber Chase, M.D. Philadel-
phia.
Am. Journ. Med. Sciences, vol. i. N. S. p. 88, 1841.
Club-Foot cured at an Advanced Age, by J. B. Brown, M. D.
Boston.
Am. Journ. Med. Sciences, vol. vii. N. S. p. 256, 1844.
Case of Varus (cured by Tenotomy and Apparatus), by John 0.
Reilly, M. D. New York.
New York Journ. Med., vol. v. N. S. p. 22, 1851.
Case of Double Club-Foot (Varus and Pes Equinus) treated by
Tenotomy and a Shoe (cure perfect five years afterwards), by Henry
H. Smith, M. D. Philadelphia.
Medical Examiner, vol. vii. N. S. p. 181, 1851.
ON ANEURISMS AND LIGATURE OF ARTERIES IN THE
EXTREMITIES.
Aneurism of the Thigh, cured by an Operation (two Ligatures),
and Use of the Limb preserved, by Thomas Kast, A. M. Boston.
Communications and Dissertations of Mass. Med. Soc, vol. i. p. 96, 1790.
Case of Varicose Aneurism at the Bend of the Arm, cured by
Ligature of the Brachial Artery, by P. S. Physick, M. D. Phila-
delphia.
Philadelphia Med. Museum, vol. i. p. 65, 1805.
Ligature of the Femoral Artery for a Wound, by John C. War-
ren, M.D. Boston.
Communications and Dissertations of Mass. Med. Soc, vol. i. p. 40, 1806.
Case of Aneurism of the Femoral Artery (successful), by David
Hosack, M. D. New York.
Amer. Med. and Philosophical Register, vol. ii. p. 49, 1811.
Ligature of the Femoral Artery (cured), by David Hosack, M.D.
New York.
New York Med. Repository, vol. xii. p. 103, 1809.
Account of a Case of Aneurism of the Femoral Artery, cured
(by rest and pressure), by Jos. Parrish, M. D. Philadelphia. (In
this paper there is the suggestion of Dr. Physick, to apply pressure
by means of a pad and screw, which could be tightened gradually
till a cure was effected.)
Eclectic Repertory, vol. i. p. 500, 1811.
GENERAL OPERATIONS ON THE EXTREMITIES. 141
Case of Popliteal Aneurism successfully treated by Ligating the
Femoral Artery, by Henry U. Onderdonk, M. D. New York.
Am. Med. and Philosoph. Register, vol. iv. p. 44, 1814.
Successful Ligature of the Femoral Artery for a Wound in the
Knee-Joint, by Henry U. Onderdonk, M. D. New York.
Am. Med. and Philosoph. Register, vol. iv. p. 176, 1814.
Case of Brachial Aneurism cured by tying the Subclavian Ar-
tery above the Clavicle, by Wright Post, M. D. New York. Com-
municated by J. C. Bliss, M. D.
Transactions of New York Physico-Med. Society, vol. i. p. 367, 1817.
Case of Popliteal Aneurism, &c, by Horatio Gates Jameson, M. D.
Baltimore.
Am. Med. Record, vol. iv. p. 94, 1821.
On the Utility of tying large Arteries in preventing Inflammation
in Wounds of the principal Joints, with Cases, by David L. Eogers,
M. D. New York.
New York Med. and Phys. Journ. vol. iii. p. 453, 1824.
Case of Aneurism of the Brachial Artery cured by Compression,
by W. B. Fahnestock, M. D. Pennsylvania.
Phila. Journ. Med. and Phys. Sciences, vol. ii. N. S. p. 363, 1825.
Spontaneous Cure of Aneurism, with Observations on the Obli-
teration of Arteries, by W. Darrach, M. D. Philadelphia.
Phila. Journ. Med. and Phys. Sciences, vol. iv. N. S. p. 115, 1826.
Case of Femoral Aneurism of the Left Thigh, and Popliteal
Aneurism of the Eight Leg, successfully treated by Valentine
Mott, M.D. (The Femoral was tied first for the Popliteal Aneurism,
and the External Iliac fourteen days subsequently, both successful.)
Am. Journ. Med. Sciences, vol. i. p. 483, 1828.
Diffused Aneurism at the Bend of the Arm, produced by punc-
ture with a Lancet in Bleeding, cured by an Operation (opening
the Sac and tying the Artery above and below), by Horatio G.
Jameson, M.D. Baltimore.
Maryland Med. Recorder, vol. i. p. 460, 1829.
Case of Aneurism of the Brachial Artery, cured by Compression,
by J. W. Heustis, M. D. Alabama.
Am. Journ. Med. Sciences, vol. ix. p. 261, 1831.
Pressure applied to the Femoral Artery as a means of curing
Popliteal Aneurism (Dec. 1826), by George Bushe, M. D. New York.
Medico- Chirurgical Bulletin, vol. ii. p. 213, 1832.
Wound of the Ulnar Artery at the Heel of the Hand, success-
142 BIBLIOGRAPHICAL INDEX.
fully treated by Compression after the Ligature had failed, by II.
G. Jameson, M. D. Baltimore.
Mart/land Med. Record., vol. ill- p. 40, 1832.
Ligature of the Femoral Artery for Popliteal Aneurism, Hemor-
rhage from the Femoral on the twelfth day— Second Application of
the Ligature above the Profunda, Hemorrhage on the eighth day,
arrested by Compression (cured), by N. R. Smith, M. D. Baltimore.
Baltimore Med. and Surg. Journ., vol. ii. p. 61, 1834.
Femoro-Popliteal Aneurism— Spontaneous Cure of the Popliteal
by the Occurrence of the Femoral Aneurism — Arteries Diseased-
Ligature of the Femoral — Hemorrhage on the eleventh day — Sepa-
ration of the Ligature on the nineteenth day — Recovery, by Nathan
R. Smith, M. D. Baltimore.
North American Archives, vol. ii. p. 75, 1835.
Ligature of the Brachial Artery for Veno- Arterial Aneurism
(cured), by Nathan R. Smith, M. D. Baltimore.
North Am. Arch. Med. and Surg. Sci., vol. i. p. 241, 1835.
Two Cases of Aneurism (Femoral and Brachial), exhibiting the
necessity of a Ligature both above and below the Tumor, by Win.
E. Horner, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. i. N. S. p. 74, 1841.
Ligature of the Femoral Artery for Popliteal Aneurism, by Jas.
Deane, M.D. Massachusetts.
Boston Med. and Surg. Journ., vol. xlix. p. 141, 1853.
Ligature of the Femoral Artery for Popliteal Aneurism (cured),
also of the Brachial (cured), by A. W. Shipman, M. D. New York.
Med. Examiner, vol. iv. p. 441, 1841.
Aneurism of the Femoral Artery, showing the importance of
applying a Ligature below as well as above the Sac, by Wm. E.
Horner, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 332, 1842.
Aneurism of the Femoral Artery from Fracture of the Femur,
Ligature of the External Iliac Artery (cured), by Daniel Brainard,
M. D. St. Louis.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 359, 1843.
Varicose Aneurism, successfully treated by Pressure, by William
Johnston, M. D. New Jersey.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 378, 1846.
Table, showing the Mortality following the Operation of Tying
the Iliac Arteries, by G. W. Norris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xiii. N. S. p. 13, 1847.
GENERAL OPERATIONS ON THE EXTREMITIES. 143
Popliteal Aneurism, successfully treated by Compression, by J.
Knight, M. D. New Haven.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 255, 1848 ; also Boston Med.
and Surg. Journ., vol. xxxviii. p. 293, 1848.
Statistics of the Mortality following the Operation of tying the
Femoral Artery, by G. W. Norris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 313, 1849.
Successful Ligature of the Femoral Artery for Wound of the
Anterior Tibial, by E. P. Bennett, M. D. Connecticut.
Am. Journ. Med. Sciences, vol. xix.N. S. p. 272, 1850 ; also New York
Journ. Med., vol. iv. N. S. p. 199, 1850.
Ligature of the Femoral Artery for Popliteal Aneurism (success-
ful), by Charles A. Pope, M. D. St. Louis.
St. lK>uis Med. and Surg. Journ., vol. vii. p. 292, 1850.
Femoral Aneurism cured (in 18 days) by Compression, by W.
H. Church, M. D. New York.
New York Journ. Med., vol. vi. N. S. p. 196, 1851.
Two Cases of Popliteal Aneurism successfully treated by Com-
pression, by James R. Wood, M. D. New York.
New York Journ. Med., vol. vi. N. S. p. 304, 1851.
Case of Popliteal Aneurism cured by Compression over the Tumor,
by H. N. Bennett, M. D. Bethel, Connecticut.
New York Journ. Med., vol. vii. p. 26, 1851.
Popliteal Aneurism successfully treated by Compression (of Fe-
moral Artery — Dupuytren's Instrument), by Wm. H. "Van Buren,
M. D. New York.
New York Med. Times, vol. i. p. 33, 1851.
Traumatic Aneurism of Posterior Tibial Artery (by shears punc-
turing six inches below knee); Ligature of Artery; Secondary Hemor-
rhage ; Amputation (cured), by J. H. Brown, M. D. Paris, Maine.
New York Journ. Med., vol. ix. N. S. p. 362, 1852.
Ligature of the Right Femoral Artery for the cure of Elephan-
tiasis Arabicum (cure perfect 16 months after the operation), by
J. M. Carnochan, M. D. New York.
N. Y. Journ. Med., vol. ix. N. S. p. 161, 1852.
Deligation (successful) of the Ulnar Artery for Aneurism, by
A. J. Crittenden, M. D. Heathsville, Virginia.
Stethoscope, vol. ii. p. 491, 1852.
Ligature of Femoral Artery for Popliteal Aneurism ; Recovery,
by Daniel Brainard, M. D. Chicago.
Northwest Med. and Surg. Journ., vol. iv. p. 414, 1852.
144 BIBLIOGRAPHICAL INDEX.
ON PSEUDARTHROSIS, &c.
Fracture of the Os Humeri, in which, from False Joint, the Cure
was effected by means of a Seton, by Philip S. Physick, M. D.
Philadelphia. (Operation 18th Dec. 1802.)
Medical Repository, vol. vii. p. 122, 1804.
Two Cases of Tardy Union (Pseudarthrosis) in Fractures, cured
by Caustic Issues in Integuments, by Joseph Hartshorne, M. D.
Philadelphia.
Eclectic Eepert., vol. iii. p. 114, 1813.
Ununited Fracture of the Humerus, cured by Seton, by Robert
Thaxter, M. D. Dorchester.
New England Journ. of Med. and Surg., vol. vii. p. 150, 1818.
Case of False Joint, treated by the Seton, by Nicholas Worthing-
ton, M. D. District of Columbia.
Philadelphia Journ. of Med. and Phys. Sciences, vol. ii. p. 337, 1821.
The Seton, successfully applied in Pseudarthrosis of the Forearm,
by John Baxter, M. D. New York.
Am. Med. Record, vol. vii. p. 30, 1824.
Application of Caustic, and Cure of Pseudarthrosis, by John
Rhea Barton, M.D. Philadelphia.
Am. Med. Record, vol. vii. p. 275, 1826.
Ununited Fracture of the Humerus, successfully treated by Resec-
tion after Failure of Seton, by J. Kearny Rodgers, M. D. New York.
New York Med. and Phys. Journ., vol. vi. p. 521, 1827.
Mechanism of Preternatural Joints, and Means of Cure, by Tho-
mas T. Hewson, M. D. Philadelphia.
North American Med. and Surg. Journ., vol. v. p. 1, 1828.
Ununited Fracture of the Os Humeri, successfully treated by the
Injection of a Stimulating Fluid (sol. cupri sulph.) into the Wound,
by Isaac Hulse, M. D., U. S. N.
Am. Journ. Med. Sciences, vol. xiii. p. 374, 1833.
Case of Ununited Fracture, successfully treated by Friction, by
Isaac Parrish, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xiv. p. 372, 1834.
Pseudarthrosis of both Bones of the Leg, treated by Excision
and Caustic, and again by Resection (failed in both instances from
Menorrhagia), by Henry H. Smith, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xv. N. S. p. 84, 1848.
GENEKAL OPERATIONS ON THE EXTREMITIES. 145
Ununited Fracture of the Femur (of one year's standing), suc-
cessfully treated by Resection, Denudation, and retaining Ends of
Bone by means of Wire, by D. Brainard, M. D. Illinois.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 256, 1849.
Pseudarthrosis of Fore-arm (successful operation of resection and
wiring ends of bone), by James M. Smith, M. D. Springfield, Mas-
sachusetts.
Boston Med. and Surg. Journ., vol. xlv. p. 123, 1851.
On the Treatment of Pseudartbrosis, by an apparatus (illustrated)
which permits the use of the limb and obviates the necessity of
amputation (or any operation), by Henry H. Smith, M. D. Phila-
delphia.
Am. Journ. Med. Sciences, vol. xxi. N. S. p. 106, 1851.
On Pseudarthrosis (with thirteen Cases), by John Watson, M. D.
New York.
New York Med. Times, vol. i. p. 1, 1851.
On Treatment of Pseudarthrosis by Subcutaneous Perforation of
the Bone (by brad-awls), with a Case, by Daniel Brainard, M. D.
Chicago.
Northwest Med. and Surg. Journ., vol. iv. p. 409, 1852.
Case of Ununited Fracture of Tibia of 4 years' standing ; cured
(by resection), by W. Gr. Williams, M. D. Chillicothe, Ohio.
Western Journ. Med. and Surg., vol. ix. 3d series, p. 16, 1852.
Resection of the Ununited Ends of a Fractured Femur (fresh
ends approximated by a silk ligature passed through them ; died
thirty hours after operation — chloroformed), by Carter P. Johnson,
M. D. Richmond.
Stethoscope, vol. ii. p. 267, 1852 ; also Med. Examiner,
vol. vii. N. S. p. 648, 1851.
ON RESECTION OF THE BONES OF THE EXTREMITIES.
Necrosis, two Cases operated on, by John H. Martin, M. D.
Maine.
New England Journ. of Med. and Surg., vol. i. p. 162, 1812.
Case of Wounded Shoulder-Joint, in which the Head of the
Humerus was removed successfully, by Henry Hunt, M. D.
Washington.
Medical Record, vol. i. p. 365, 1818.
10
146 BIBLIOGRAPHICAL INDEX.
Resection of nearly the whole of the Ulna, successfully, by Ro-
bert B. Butt, M. D. Virginia.
Philadelphia Journ. of Med. and Phys. Sciences, vol. i. N. S. p. 115, 1825.
Successful Extirpation of the Astragalus after Compound Luxa-
tion, by Alexander II. Stevens, M. D.
New York Med. and Phys. Journ., vol. v. p. 560, 1820.
Treatment of Anchylosis of the Hip-Joint by the Formation of
an Artificial Joint, a new Operation, devised and executed by John
Rhea Barton, M. D. Philadelphia.
North American Med. and Surg. Journ., vol. iii. pp. 279, 400, 1827.
Case of Necrosis, with some peculiarities (sequestrum remaining
too long), by Horatio G. Jameson, M.D. Baltimore.
Maryland Med. Recorder, vol. i. p. 463, 1829.
Successful Removal of the Astragalus in Compound Dislocation,
by Wm. A. Gillespie, M. D. Virginia.
Am. Journ. Med. Sciences, vol. xii. p. 552, 1833.
Resection of first three Metatarsal and the three Cuneiform
Bones — leaving the corresponding toes — cured (patient able to
walk well), by E. Geddings, M. D. Baltimore (now of Charleston).
Am. ArcJiives Med. and Surg. Science, vol. i. p. 36, 1835.
Resection of Shaft of Femur for Necrosis and Exostosis succeed-
ing a compound comminuted fracture — cured, by E. Geddings,
M. D. Baltimore.
Am. Archives Med. and Surg. Sciences, vol. i. p. 34, 1835.
Resection of the Astragalus (for Necrosis — Removal of the En-
tire Bone — cured), by N. R. Smith, M. D. Baltimore.
Am. Archives Med. and Surg. Sciences, vol. i. p. 83, 1835.
A Case of Excision of Elbow-Joint (being the first in the United
States), by Thomas Harris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xix. p. 341, 1836.
A new Treatment in a Case of Anchylosis of Knee (a V incision),
by J. Rhea Barton, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxi. p. 332, 1837.
Successful Operation to remedy a Deformed Fracture of the Leg,
by Charles Parry, M. D. Indiana.
Am. Journ. Med. Sciences, vol. xxiv. p. 334, 1839.
Operation for remedying an Anchylosis of the Hip-Joint, by J.
Kearny Rodgers, M. D. New York.
Am. Journ. Med. Sciences, vol. i. N. S. p. 507, 1840; also New York
Med. and Surg. Journ., Jan. 1840.
GENEEAL OPERATIONS ON THE EXTREMITIES. 147
Case of Excision of the Elbow-Joint, by Gurdon Buck, Jr., M. D.
New York.
Am. Journ. Med. Sciences, vol. ii. N. S. p. 249, 1841 ; also New York
Med. and Surg. Journ., April, 1841.
Case of Complete Anchylosis, in which the Knee-Joint was per-
manently Flexed, cured by an Operation, by Wm. Gibson, M.D.
Philadelphia.
Am. Journ. Med. Sciences, vol. iv. N. S. p. 39, 1842.
Deformity from unsuccessfully treated Fracture of Leg, treated
by Resection, by John Rhea Barton, M. D. Reported by W. S.
Ruschenberger, M.D. Philadelphia.
Med. Examiner, vol. i. N. S. p. 17, 1842.
Case of False Anchylosis of the Knee-Joint treated by mechani-
cal means alone, without the aid of Tenotomy, with a Description
of the Apparatus, by Heber Chase, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. iii. N. S. p. 101, 1842.
Excision of the Elbow-Joint (cured), by J. Pancoast, M. D.
Philadelphia.
Med. Examiner, vol. i. N. S. p. 609, 1842.
Excision of the Olecranon Process for Anchylosis of the Elbow-
Joint, by Gurdon Buck, Jr., M. D. New York.
Am. Journ. Med. Sciences, vol. v. N. S. p. 297, 1843.
Anchylosis of the Knee, successfully treated by Barton's Opera-
tion, by J. Piatt Burr, M. D. Louisiana.
Am. Journ. Med. Sciences, vol. viii. N. S. p. 270, 1844.
The Knee-Joint Anchylosed at a Right Angle. Restored nearly
to a straight position, after the Excision of a wedge-shaped portion
of Bone consisting of the Patella, Condyles, and Articulating Sur-
face of the Tibia, by Gurdon Buck, Jr., M. D. New York.
Am. Journ. Med. Sciences, vol. x. N. S. p. 277, 1845.
Removal of a Third of the Head of the Humerus, by N. Pinkney,
M.D., U.S.K
Am. Journ. Med. Sciences, vol. xii. N. S. p. 330, 1846.
Excision of the Elbow-Joint for Caries of the Articular Extremi-
ties of the Bones, by Gurdon Buck, Jr., M. D. New York.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 544, 1846.
Resection of Condyles of Humerus for Compound Fracture of
the Elbow-Joint — Recovery, with a new Joint, by John O. Stone,
M.D. New York.
New York Journ. Med., vol. vi. N. S. p. 300, 1851.
143 BIBLIOGRAPHICAL INDEX.
Resection of the middle Two-thirds of the Ulna (cured), by Carter
P. Johnson, M. D. Kichmond.
Med. Examiner, vol. vii. N. S. p. 644, 1851.
Eesection of Femur for Deformed Fracture (during etherization ;
died four days after operation), by Win. E. Horner, M.D. Phila-
delphia.
Med. Examiner, vol. vii. N. S. p. 32, 1851.
Resection of Femur above the Knee (Barton's operation), success-
fully performed by Thos. D. Mutter, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 37, 1851.
Successful Resection (by incision ; disarticulation and resection
of Condyles of the Femur and head of Tibia), by A. J. Wedder-
burn, M. D. New Orleans.
Southern Med. and Surg. Journ., vol. viii. p. 443, 1852, from New
Orleans Med. Register.
Excision of the Scapula for a large Tumor, by S. D. Gross, M. D.
Louisville.
Western Journ. of Med. and Surg., vol. xi. p. 419, 1853.
A Case of Femoral Exostosis — with Remarks, by L. A. Dugas,
M. D. Georgia.
Southern Med. and Suj-g. Journ., vol. ix. N. S. p. 718, 1853.
On Pulsating Tumor of Bone (Aneurism of Bone), with Remarks,
by Charles D. Smith, M. D. New York.
New York Journ. Med., vol. x. N. S. p. 153, 1853.
Pus within the Shaft of the Tibia — Trephined — Cured, by Dr.
Strong, of Boston.
Am. Journ. Med. Sci., vol. xxv. N. S. p. 81, 1853.
ON AMPUTATIONS.
Amputation at the Shoulder, by Jno. Warren, M.D. Boston,
1781. (First in the United States.)
Boston Med. and Surg. Journ., vol. xx. p. 210, 1839.
Amputation of the Arm at the Shoulder, together with the Acro-
mion Process of Scapula for Fungus Haematodes after the Ligation
of the Subclavian Artery (died), by Wm. C. Bowen, M.D. Providence.
New England Journ. of Med. and Surg., vol. iii. p. 314, 1814.
New Tourniquet, by Francis Moore, M. D. Connecticut.
New England Journ. of Med. and Surg., vol. iv. p. 209, 1815.
GENERAL OPERATIONS ON THE EXTREMITIES. 149
Amputation at the Shoulder- Joint (died), by J. B. Whitbridge,
M. D. South Carolina.
New England Journ. of Med. and Surg., vol. v. p. 21, 1816.
Amputation of part of the Foot (cured), by George Hayward,
M. D. Boston.
New England Journ. of Med. and Surg., vol. v. p. 338, 1816.
Eeport of extraordinary Cases of Amputation, by Amasa Trow-
bridge, M.D. Watertovvn.
New York Med. Repository, vol. xix. p. 20, 1819.
Case of Fungus Hcematodes, amputated by George McClellan,
M.D. Philadelphia.
Am. Med. Record., vol. v. p. 634, 1822.
Eemarks on Amputation (with the proposition of a new method
of performing the Flap Operation), by Nathan Smith, M. D., of
Yale College.
New York Med. and Phys. Journ., vol. iv. p. 303, 1825.
Successful Amputation at the Hip-Joint, by Valentine Mott, M. D.
New York.
Phila. Journ. Med. and Phys. Sciences, vol. v. N. S. p. 101, 1827.
Amputation at the Elbow- Joint (Flap, first in the United States,
cured), by J. Kearny Eodgers, M. D. New York.
New York Med. and Phys. Journ., vol. vii. p. 85, 1828.
Case of Encephaloid Degeneration (Fungus Hasmatodes) of the
Knee and Lower Part of the Thigh, in which Amputation was per-
formed, by E. Geddings, M. D. Baltimore.
Am. Journ. Med. Sciences, vol. xi. p. 17, 1832.
On the Circular and Flap Operations, by E. Tolefree, Jr., M. D.
New York.
Am. Journ. Med. Sciences, vol. xiii. p. 370, 1833.
On Amputation of the Leg (especially by the method of Nathan
Smith, M. D., Yale College, by Flaps), by Nathan E. Smith, M. D.
Baltimore.
North Am. Archives, vol. i. p. 377, 1835.
Dislocation and Fracture of the Astragalus, unsuccessful efforts
at Eeduction, Extirpation, Amputation (death), by G. W. Norris,
M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xx. p. 378, 1837.
Amputation of the Foot, by G. E. B. Horner, M. D., U. S. N.
Am. Journ. Med. Sciences, vol. xxi. p. 255, 1837.
Statistical Account of the Cases of Amputations performed at the
150 BIBLIOGRAPHICAL INDEX.
Pennsylvania Hospital from January, 1831, to January, 1838, by
George W. Norris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. xxii. p. 356, 1838.
Amputation at the Hip-Joint (died in forty-eight days), by Daniel
Brainard, M. D. Illinois.
Am. Journ. Med. Sciences, vol. xxii. p. 372, 1838.
Statistics of the Amputations of Large Limbs performed in the
Massachusetts General Hospital, with Eemarks by George Hayward,
M. D. Boston.
Am. Journ. Med. Sciences, vol. i. N. S. p. 64, 1840.
Statistical Account of the Amputations performed in the Penn-
sylvania Hospital from January, 1838, to January, 1840, by G. W.
Norris, M. D. Philadelphia.
Am. Journ. Med. Sciences, vol. i. N. S. p. 80, 1840.
Amputation at the Shoulder- Joint (died), with a Description of a
new Instrument for securing deeply-seated Arteries, by Wm. E.
Horner, M. D. Philadelphia.
Med. Examiner, vol. viii. p. 540, 1840 ; also Am. Journ. Med. Sci-
ences, vol. i. N. S. p. 266, 1841.
Case of Gunshot "Wound of the Hand, Forearm, and Arm, with
a Fracture of the Humerus, successfully treated (without Amputa-
tion), by E. W. Lindsay, M. D. District of Columbia.
Am. Journ. Med. Sciences, vol. i. N. S. p. 117, 1841.
Fungus Hsematodes of the Knee, Amputation (cured), by Henry
L. Levert, M. D. Mobile.
Am. Journ. Med. Sciences, vol. vi. N. S. p. 56, 1843.
Amputation at the Shoulder-Joint, by N. Pinkney, M. D., U. S. N.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 332, 1846.
Amputation of the Foot — Excessive Hemorrhage from the Stump
(over forty Ligatures applied), by J. C. Butler, M. D. Virginia.
Am. Journ. Med. Sciences, vol. xii. N. S. p. 541, 1846.
Amputation above the Shoulder- Joint, by David Gilbert, M. D.
Pennsylvania.
Am. Journ. Med. Sciences, vol. xiv. N. S. p. 360, 1847.
Statistics of Amputations in the New York Hospital, from January
1, 1839, to January 1, 1848 (ninety-one cases, twenty-six deaths), by
Henry W. Buel, M. D. New York.
Am. Journ. Med. Sciences, vol. xvi. N. S. p. 33, 1848.
Successful Amputation of the Shoulder- Joint, patient under Chlo-
roform, by Paul F. Eve, M. D. Georgia.
Am. Journ. Med. Sciences, vol. xvii. N. S. p. 257, 1849 ; also Buffalo Medi-
cal Journal, vol. v. p. 533, 1849.
GENERAL OPERATIONS ON THE EXTREMITIES. 151
Amputation of the Leg for Gangrene of the Foot, successfully
performed on a Negro at the age of 102 (died of Pleurisy), by
Richard Jarrott, M. D.
Charleston Med. Journ., vol. iv. p. 301, 1849.
Case of Secondary Hemorrhage after Amputation at the Shoulder-
Joint (cured by Pressure), by Charles S. Tripler, M. D., U. S. A.
New York Journ. Med., vol. iii. p. 40, 1849.
Amputations and Compound Fractures, with Statistics, by John
0. Stone, M. D. New York.
New York Journ. Med., vol. iii. N. S. p. 298, 1849.
Successful Amputation at the Shoulder-Joint, by Paul F. Eve,
M. D. Georgia.
Am. Journ. Med. Sciences, vol. xviii. N. S. p. 549, 1849.
Successful Amputation at the Shoulder- Joint in consequence of
an injury sustained fifteen years previously, by Wm. Byrd Page,
M. D. Philadelphia.
Med. Examiner, vol. v. N. S. p. 451, 1849.
Amputation of the Thigh, successful.
Leg,
" Thigh, cured in two weeks, by Paul F. Eve,
M. D., Georgia.
Southern Med. and Surg. Journ., vol. vi. pp. 261, 264, 1850.
Amputation of the Leg during etherization (cured), by Henry H.
Smith, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 29, 1851.
Amputation of the Thigh (for Disease of the Knee-Joint; cured),
by Henry H. Smith, M. D. Philadelphia.
Med. Examiner, vol. vii. N. S. p. 99, 1851.
Amputation of the Arm in a Case of Molluscum (successful, but
disease returned in a few weeks), by Henry H. Smith, M. D. Phila-
delphia.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 397, 1851.
Amputation at the Hip-Joint (cured), by John Fred. May, M. D.
Washington, D. C.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 313, 1851.
Amputation of the Thigh near the Trochanter (cured), by Jno.
Fred. May, M. D. Washington.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 321, 1851.
Amputation of the Thigh for Tetanus, &c. (died), by Jno. Fred.
May, M. D. Washington.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 323, 1851.
152 BIBLIOGRAPHICAL INDEX.
Amputation of both Legs (interval of seven days; cured), by Jno-
Fred. May, M. D. Washington.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 325, 1851.
Amputation at the Shoulder-Joint (for Traumatic Mortification ;
died), by Jno. Fred. May, M. D. Washington.
Am. Journ. Med. Sciences, vol. xxii. N. S. p. 327, 1851.
Amputation at the Shoulder-Joint (cured), by J. Mason Warren,
M. D. Boston.
Am. Journ. Med. Sciences, vol. xxi. N. S. p. 338, 1851.
Amputation of the Thigh, and subsequent Amputation at the
Hip-Joint, by Wm. H. Van Buren, M.D. New York.
New York Journ. Med., vol. vii. N. S. p. 50, 1851, from Trans. New York
Acad. Med.
Case of Amputation at the Shoulder-Joint (cured), by E. K. San-
born, M.D. Lowell, Massachusetts.
Boston Med. and Surg. Journ., vol. xlvii. p. 89, 1852.
Statistics of Amputation at the Hip-Joint, by Stephen Smitb,
M.D. New York.
New York Journ. Med., vol. ix. N. S. p. 184, 1852.
Amputation at the Knee-Joint (cured), by Willard Parker, M. D.
New York. (This paper contains statistics of this amputation.)
New York Journ. Med., vol. ix. N. S. p. 307, 1852.
Amputation at the Shoulder Joint — Cure, by Richard L. Howard,
M.D. Columbus, Ohio.
Ohio Med. and Surg. Journ.,. vol. iv. p. 288, 1852.
Amputation at the Hip- Joint (Boy, aged ten ; cured), by J. C.
Bradbury. Old Town, Maine.
Boston Med. and Surg. Journ., vol. xlvi. p. 349, 1852.
Amputation at the Hip- Joint (Adult; Fungus Haematodes; Lis-
franc's method ; three-fourths of the Flap healed by first intention,
but death followed on the forty-first day after the operation), by E.
M. Clark, M. D. Detroit.
Peninsidar Journ. of Med., vol. i. p. 59, 1853.
Amputation at the Shoulder- Joint (cured), by E. R. Peaslee, M.D.
New York.
New York Joufn. Med., vol. x. N. S. p. 297, 1853.
Amputation of the Leg during the Progress of Gangrene of the
Foot and Leg (cured), by Wm. Brodie, M. D. Detroit.
New York Journ. Med., vol. x. N. S. p. 325, 1853.
On the comparative merits of the Partial Amputations of the
GENERAL OPERATIONS ON THE EXTREMITIES. 153
Foot (Chopart's and Hey's, and in favor of Hey's), by J. M. Carno-
chan, M. D. New York.
New York Medical Gazette, vol. iv. N. S. p. 193, 1853.
Bemarks on Osteo- Aneurism, with a Case involving the Condyles
of the Left Femur (amputated ; cured), by J. M. Carnochan, M. D.
New York.
New York Med. Gazette, vol. iv. N. S. p. 2, 1853.
A Case Of Osteo Aneurism (?) occurring in the Os Calcis — Am-
putation and Recovery, by Willard Parker, M. D. New York.
New York Journ. Med., vol. x. N. S. p. 316, 1853.
Remarks on Double Capital Amputation, with two Cases, by J.
M. Carnochan, M.D. New York.
New York Med. Gazette, vol. iv. N. S. p. 145, 1853.
Amputation at the Shoulder-Joint (cured), by Chas. Freiott, M. D.
Troy.
New York Journ. Med., vol. xi. p. 331, 1853.
Amputation at the Large Joints — Statistics of Amputation at the
Shoulder and Elbow-Joints, by Stephen Smith, M. D. New York.
New York Journ. Med., vol. x. N. S. p. 9, 1853.
V
ALPHABETICAL LIST
AMERICAN SURGEONS,
FROM THE YEAR 1783 TO 1853, INCLUSIVE.
WITH THE
TITLES OF THEIR BOOKS AND PAPERS AS QUOTED IN THE PRECEDING
BIBLIOGRAPHICAL INDEX.
The dissimilarity that may be noted in the number and variety of the papers
assigned to the Surgeons quoted in the preceding Index, must not be regarded
as resulting solely from the difference in the number of their publications, but
rather from the fact that their articles were so issued as to be accessible to
the Author. Some of them have doubtless escaped his notice, either in con-
sequence of the limited circulation of the journals in which they were pub-
lished, or from the difficulty attendant on their preservation in our libraries ;
but as he has carefully examined most of those published in the last seventy
years, the greater portion of their writings will, it is thought, be found to be
referred to in the foregoing list.
PAGE
ABERNETHY, JOHN J. (Con-
necticut.)
Case of Inguinal Hernia
ACKLEY, Prof. (Cleveland.)
Amputation entire Lower Jaw
AGNEW, SAM'L. (Harrisburg.)
Evacuation of Water, by the
Umbilicus
AINSWORTH, F. S. (Boston.)
Anatomical Phenomena in Liga-
ture of Subclavian Artery
ALLEN, JONATHAN A. (Ver-
mont.)
Excision of Fungus Cerebri
ALLEN, R. N. (Maryland.)
Cephalhematoma
ALLIN, CHAS. M. (New York.)
Retro-Pharyngeal Abscess
104
75
101
90
61
59
90
ANDERSON, W. W. (Charles-
ton.)
Osteo-Sarcoma of Lower Jaw
ANDERSON, WM. (New York.)
System of Surgical Anatomy
ANNAN, S. (Emmetsburg.)
Three Cases of Bronchotomy
Retention of Urine
ANTONY MILTON. (Georgia.)
Removal of part of Right Lung,
&c.
ASHBY, CHAS. WM. (Alexan-
dria.)
Wound of Stomach
ATLEE, E. (Lancaster.)
Tracheotomy in Cynanche Tra-
chealis
ATLEE, JOHN L. (Lancaster.)
Operation for Diseased Ovaria
73
42
85
117
98
102
8G
130
156
ALPHABETICAL LIST OF
PAGE
ATLEE, WASH. L. (Lancaster.)
Excision of Cervix Uteri 128
Extirpation of Fibrous Tumor 127
Case of Congenital Tumor of
Abdomen 130
Bi-locular Ovarian Cyst 130
Removal of Tumor from Uterus 128
Extirpation of Ovarian Tumor 131
Two Cases of Ovariotomy 131
On Fibrous Tumors of Uterus 48
Statistics of Ovariotomy 132
AYRES, DANIEL. (New York.)
Tracheotomy in Croup 88
B
BACHE, FRANKLIN. (Phila-
delphia.)
On Acupuncturation 66
67
BATCHELDER. (Massachu-
setts.)
Resection of Lower Jaw 73
BAKER, Jr. A. (New York.)
Lithotomy in the Female 120
BARCLAY A. (New York.)
Occluded Os tincae 128
BARNES, ENOS. (New York.)
Foreign Bodies in the Trachea 85
BARNWELL, WM. (Philadel-
phia.)
Diseases of Warm and Vitiated
Atmosphere 41
BARON, ALEX. (South Caro-
lina.)
Elongation of Tibia 138
BARTON, BENJ. S. (Philadel-
phia.)
Memoir on Goitre 41
BARTON, JOHN RHEA. (Phil-
adelphia.)
Artificial Joint in Anchylosis 43
Operation for Tumor of Lower
Jaw 73
Operation for Artificial Anus 106
Lithotomy Forceps 118
Inguinal Aneurism 109
Recto-Vaginal Fistula 125
Caustic in Pseudarthrosis 144
Treatment of Anchylosis of Hip 146
Knee 146
Deformity from Fracture of Leg 147
BATCHELDER, Dr.
Resection of Lower Jaw 73
BAXTER, JOHN. (New York.)
Seton in Pseudarthrosis 144
BAYARD, ROBERT. (New
Brunswick.)
Diseased Sciatic Nerve 138
BAYLESS, G. W. (Missouri.)
Ovariotomy 133
BEAUMONT, WM. (Fort Nia-
gara.)
Experiments on Digestion,
through a Wound in Stomach 101
BEDFORD, G. S. (New York.)
Vaginal Hysterotomy 125
Sarcomatous Tumor of Uterus 128
BELL, JOHN. (Philadelphia.)
Averill's Operative Surgery 42
BENNETT, E. S. (Charleston.)
Tumor on Occiput 59
BENNETT, E. P. (Connecticut.)
Ligature of Femoral Artery 143
Ovariotomy 133
Multilocular Cyst 133
BENNETT, H. N. (Connecti-
cut.)
Popliteal Aneurism 143
BETIIUNE, S. R. (Boston.)
Malignant Ophthalmic Disease 66
BETTON, THOS. F. (Philadel-
phia.)
Lacerated Urethra from a Fall 117
BEEZLEY, THEOPHILUS E.
(New Jersey.)
Scirrhous Tumor of Caecum 101
BIGELOW, HENRY J. (Bos-
ton.)
Manual of Orthopedic Surgery 46
Gutta Percha in Strictures 114
Ligature of Internal Iliac 108
Anaesthetic Agents 56
Tracheotomy in Croup 89
Injection in Inguinal Hernia 105
BLACKMAN, GEO. C. (New
York.)
Genio-plasty 76
Ligature of Carotid 93
both Primitive Caro-
tids 94
Osteo-Sarcoma of Lower Jaw 74
Priority in Resecting Lower
Jaw 75
Strangulated Hernia 105
BOLING, WM. M. (Alabama.)
Ligature of External Iliac 109
AMERICAN SURGEONS.
157
BOLTON, JAS. (Richmond.)
Test for Safety Point in Anaes-
thesia 57
Report on Utility of Anaesthetics 57
Hemorrhoids 136
BOND, HENRY. (Philadel-
phia.)
Forceps for Bodies in GEsopha-
gus
BOSSUET, JOSEPH. (Massa-
chusetts.)
Lithotomy for Extra-Uterine
Foetus 118
BOWDITCH, HENRY J. (Bos-
ton.)
Maunoir on Cataract 45
Paracentesis Thoracis 100
Necessity of Operation 100
BOWEN, WM. C. (Providence.)
Amputation of Shoulder 148
BRADLEY, M. D. (Alabama.)
Gastrotomy 132
BRADBURY, J. C. (Maine.)
Amputation at Hip-Joint 152
BRAINARD, DANL. (Chicago.)
Plastic Operation for Ectropion 64
Amputation of Superior maxil-
lary bone 70
Collodion in Erectile Tumors 59
Resection of Upper Jaw 71
Immobility of Lower Jaw 71
Resection of Lower Jaw, &c. 75
Tracheotomy for Abscess 87
Iodine in Spina Bifida 112
Ununited Fracture of Femur 145
Amputation at Hip-Joint 150
Aneurism of Femoral Artery 142
Pseudarthrosis — wired 145
Spina Bifida 111
Ligature of Femoral 143
BRENT, JOHN C. (Kentucky.)
Removal of Tumor from Neck 90
BRIGGS, LEMUEL W. (Rhode
Island.)
Paracentesis Thoracis 99
BRIGHAM, AMARIAH. (Con-
necticut.)
Brass Nail in Lungs for a year 86
Removal of seventeen inches of
Intestine 102
Sequel to do. do. 102
BRITE, J. W, (Kentucky.)
Prolapsus Ani 135
Extraction of Fish-Hook from
Stomach 83
BRODIE, WM. (Detroit.)
Amputation during gangrene 152
BROOKE, A.
On Caesarian Section 134
BROWN, M. FRANKLIN.
(Missouri.)
Gastrotomy 132
BROWN, J. H. (Maine.)
Traumatic Aneurism 143
BROWN, J. B. (Boston.)
On Club-Foot 140
Myotomy in Torticollis 82
BRYAN, JAMES. (Philadel-
phia.)
Tumors 90
BYRNE, CHARLES. (U. S.
Army.)
Fistula between Vagina, Blad-
der, and Rectum 124
BUCK, GURDON, Jr. (New
York.)
Researches on Hernia Cerebri 62
Extension in Wry Neck 83
GMematous Laryngitis treated 87
Tracheotomy 87
Operation for Closure of Ure-
thra 117
Excision of Elbow-Joint 147
Olecranon Process 147
Anchylosis of Knee 147
Excision of Elbow-Joint 147
BUCKNER, P. J. (Ohio.)
Ovariotomy 131
Mesenteric Tumor 133
BUEL, HENRY W. (New York.)
Statistics of Amputations 150
BULLOCK, W. G. (Savannah.)
Resection of Lower Jaw 75
BURGESS, RICHARD.
Two Cases of Bronchotomy 85
BURR, J. PLATT. (Louisiana.)
Anchylosis of Knee 147
BUSH, J. M. (Lexington.)
Amussat's Operation for Arti-
ficial Anus 107
Dudley's Operations of Lithot-
omy 119
Lithotomy and Lithotrity 120
BUSHE, GEORGE. (New York.)
On Diseases of the Rectum 44
Torsion of Arteries 55
Telangiectasis 58
Scirrhus of Lachrymal Gland 64
Excision of Tonsils 78
158
ALPHABETICAL LIST OF
PAGE
Removal of Parotid Gland 81
Telangiectasis of Cheek 93
Aneurism of Carotid 93
Ligature of Right Common
Iliac 107
Operation for Phimosis 113
On Hypospadias 114
Congenital Hydrocele 116
Bi-lateral Operation for Stone 118
On Popliteal Aneurism 141
BUTLER, J. C. (Virginia.)
Amputation of Foot 150
BUTT, ROBT. B. (Virginia.)
Resection of Ulna 146
BYRD, H. L. (Savannah.)
Hydrocephalus 60
BYRNE, CHAS. (U. S. Army.)
Vaginal Fistula 124
C
CAIN, D. J. C. (Charleston.)
Nutritive Enemata to sustain
Life 84
Imperforate Prepuce 113
CALHOUN, P. (Louisiana.)
Immobility of Lower Jaw 72
CAMPBELL, GEO. W. (Ten-
nessee.)
Exsection of half Lower Jaw 73
Case of Artificial Anus 107
Operation of Lithotomy 118
CALDWELL, CHARLES. (Phi-
ladelphia.)
Translation of Bichat on the
Bones 41
CAMPBELL, H. F. (Georgia.)
Injuries of Cranium 63
Ligature of Primitive Carotid 94
Removal of Pin from Duct of
Wharton 77
Bi-lateral Lithotomy 121
CARNOCHAN, JNO. MURRAY.
(New York.)
Priority in Division of Masseter 72
Amputation of Lower Jaw 75
Ligature of Femoral Artery for
Elephantiasis 143
Best Amputation for Foot 153
Osteo-Aneurism 153
Double Amputations 153
CART WRIGHT, SAML. A.
(New Orleans.)
Laryngotomy for Watermelon
Seed 85
PAGE
Chloroform 57
Ovarian Tumor 132
CATHRALL, ISAAC. (Phila-
delphia.)
Case of double Harelip 69
CHADBOURNE, THOS. (New
York.)
Cases of Uterine Polypus 128
CHASE, HEBER. (Philadel-
phia.)
Report of Committee on Her-
nia 44
Cases of Deformed Feet 140
False Anchylosis of Knee-Joint 147
CHEW, E. R. (Louisiana.)
Instrument to divide Stricture
of Urethra 114
CHISHOLM, J. J. (Charleston.)
Suture of Intestine 103
CHURCH, W. H. (New York.)
Compression in Aneurism 143
CLARK, ED. II. (Boston.)
Aural Surgery 80
CLARKE. (New York.)
Oedema Glottidis 87
CLARK, JOHN C. (Ohio.)
Artificial Anus 105
CLARKE, A. BRYANT. (Mas-
sachusetts.)
Imperforate Anus 136
CLARK, E. M. (Detroit.)
Amputation at Hip-Joint 152
COATES, REYNELL. (Phila-
delphia.)
Cases of Urinary Calculi 119
COCKE, JOSEPH. (Maryland.)
Admission of Air into Wounds 101
COGSWELL, MASON F. (Con-
necticut.)
Ligature of Carotid 92
COLLINS, RANSOM M. (Louis-
iana.)
Case of Blind Hemorrhoids 135
COOK, J. H.
Fistulous Opening in Stomach 102
COOPER, SAMUEL. (Philadel-
phia.)
Properties and Effects of Stra-
monium 41
CORNELL, EDWARD. (New
York.)
Intestines through Diaphragm,
&c. • 99
AMERICAN SURGEONS.
159
COX, ABRAHAM L. (New-
York.)
Instrument to excise Tonsils 78
CRANE, J. S. (South Carolina.)
Steatomatous Tumor 139
CRAVEN, Dr. (Virginia.)
Paracentesis in Empyema 99
CRITTENDEN, A. J. (Virginia.)
Ligature of Ulnar Artery 143
CUMMINS, ROBT. II. (Virginia.)
Stricture of GEsophagus 84
CUSACK, J. W.
Ligature of Carotid 92
I)
DALE, TIIOS. F. (Pittsburg.)
Depressed Fracture of Cranium 61
DARRACH, WM. (Philadel-
phia.)
Spontaneous Cure of Aneurism 95
Drawings of Anatomy of Groin 43
Obliteration of Arteries 141
DAVENPORT, E. J. (Boston.)
Encysted Tumors of Eyelids 63
Operation for Artificial Pupil 65
" Strabismus 65
Polypi of Meat. Audit. Ext. 80
DAVIDSON, WM. (Indiana.)
Tracheotomy for Grain of Corn 86
DAVIS, EDWARD G. (Phila-
delphia.)
Beck on Ligature of Arteries 45
DAVIS, N. S. (New York.)
Congenital Double Harelip 69
DEADERICK, W. H. (Ten-
nessee.)
Excision of Lower Jaw 72
DEANE, JAMES. (Greenfield.)
Congenital Fissures of Palate 79
Case of Gastrotomy 131
Lithotripsy 124
Ovariotomy 132
Ligature of Femoral 142
DEAS, E. H.
Ligature of Common Carotid 94
DELAFIELD, EDW. (New York.)
Artificial Pupil 65
Extirpation of Eye 64
DELANEY, M. G. (U. S. Navy.)
Castration of Enlarged Testis 116
Amputation in Glossocele 77
DEPEYRE, L. (New York.)
Case of Lithotripsy 123
DETMOLD, WM. (New York.)
Abscess in Substance of Brain 62
Cases of Club-Foot 139
DICKSON, JAMES H. (New
York.)
Division of Tendo-Achillis 139
Case of Talipus Equinus 139
DICKSON, S. HOWARD. (Ten-
nessee.)
Paracentesis Thoracis 100
DILLSON, J. H. (Pittsburg.)
Gum-Elastic Catheter in Bladder 124
DIX, J. II. (Boston.)
On Strabismus 65
DIXON, E. II. (Boston.)
Interrupted Suture in Cleft Palate 79
DOANE, A. SIDNEY. (New York.)
Dupuytren's Surgical Clinic 44
Blandin's Topographical Ana-
tomy 44
Surgery illustrated from Cutler,
Hind, Velpeau, and Blazius 44
DONNE LL AN, M. (Louisiana.)
Ligature in Carcinoma of Tongue 77
DORSEY, JOHN SYNG. (Phila-
delphia.)
Elements of Surgery 42
Cooper's Surgical Dictionary 42
Trephining in Fractured Skull 60
Copper Coin in Oesophagus 83
Ligature of External Iliac 108
Steatomatous Tumor from Back 110
DOUGLASS, JNO. (South Caro-
lina.)
Ovarian Dropsy 132
DUDLEY, BENJ. WINSLOW.
(Lexington.)
Bandage in Gunshot Wounds, &c. 55
Injuries of the Head 61
Trephine in Epilepsy 61
Ligature of Subclavian 95
On Hydrocele 116
DUGAS, L. A. (Georgia.)
Tapping in Hydrocephalus 60
Pharyngeal Tumors 84
Tracheotomy 89
Wounded Intestine 103
Lithotomy 122
Femoral Exostosis 148
DUNLAP, A. (Ohio.)
Ovariotomy 132
160
ALPHABETICAL LIST OF
E
ELLIS, JOHN. (Michigan.)
Ligature of both Carotids 93
ESSELMAN, JOHN L. (Nash-
ville.)
Extirpation of Uterus 127
EWART, D. E. (South Carolina.)
Atresia Vagina 127
EWING, J. HUNTER.
Acupuncturation in Neuralgia 66
EVE, PAUL F. (Georgia.)
Anaesthesia in Operations 56
Compound Fracture of Cranium 61
Removal of large Polypus Na-
rium through Pharynx 68
Immobility of Lower Jaw 72
Amputation of half of Lower Jaw 73
Spina Ventosa in Lower Jaw 74
Foreign Body passing from Pha-
rynx to Larynx 84
Ligature of Primitive Carotid 94
Fungus Haematodes of Face, &c. 98
Dilating Strictures 114
Bi-lateral Operation for Stone 119
Case of Lithotomy 120
Bi-lateral Lithotomy 122
Excision of Uterus 128
Amputation at Shoulder-Joint 150
151
" Thigh 151
of Leg and Thigh 151
FAHNESTOCK, WM. B. (Penn-
sylvania.)
Instrument to Excise Tonsils 78
Aneurism of Brachial Artery 141
FAHNESTOCK P. (Pennsylva-
nia.)
Strangulated Umbilical Hernia 104
FALCONER, CYRUS.
Caesarean Section 134
FATTAWAY, A. (Georgia.)
Polypus Uteri 129
FINLEY, MICHAEL A. (Mary-
land.)
Ligature of Carotid for Fungus 92
FLINT, JOSHUA B. (Phila-
delphia.)
Druitt's Modern Surgery 46
FOLSOM, N. L. (New Hampshire.)
Umbilical Hernia 106
FOLTZ, J. M. (U. S. Navy.)
Enormous Steatoraa from Side 98
FOSTER, Dr. (New Orleans.)
Tracheotomy 89
FOX, GEORGE. (Philadelphia.)
Compressed Comminuted Frac-
ture of Skull 62
Ligature of Primitive Carotid 94
Inguinal Aneurism 110
FRANKLIN, D. D. (Ohio.)
Ovariotomy 133
FRICKE, G. (Baltimore.)
Operations for Cataract 65
Artificial Pupil 65
G
GAITHER, N. (Kentucky.)
Bandage in Wounded Arteries 55
GAINES & HENRY. (Kentucky.)
Resection of Lower Jaw 74
GALLUP, JOSEPH A. (Vermont.)
Extirpation of Ovaria 130
GARDEN, THOMAS J. (Vir-
ginia.)
Division of Tendo-Achillis 139
GASTON, J. F. (South Caro-
lina.)
Operation for Immobility of Jaw 72
GEDDINGS, E. (Charleston.)
Sanguineous Tumors on Head 59
Trephining 03
Ligature of Common Carotid 94
New Urethra 114
Ovarian Pathology 130
Encephaloid Degeneration 149
Resection of Femur 146
Resection of Tarsal Bones 146
GIBSON, CHAS. BELL. (Balti-
more.)
Osteo-Sarcoma of Lower Jaw 74
Ligature of External Iliac 110
Report on Anaesthetics 57
Resection of Lower Jaw 75
Strangulated Hernia 106
Castration 116
GIBSON, JOHN MASON. (Bal-
timore.)
Anatomy, &c. of the Eye 44
GIBSON, WM. (Philadelphia.)
Institutes of Surgery 43
Operation on Tumor in Neck 90
Axillary Aneurism 95
Wound of Common Iliac 107
AMERICAN SURGEONS.
161
P.\GE
Resection of Lower Jaw 7-5
Sketch of Lithotripsy 123
Operation for Anchyiosed Knee-
Joint 147
I laesarean Section 134
Second Cossarean Section 134
GILBERT, DAVID. (Pennsyl-
vania.)
Resection of Upper Jaw 71
Rhinoplasty 68
Resection of Lower Jaw 75
Tracheotomy 87
Hydrocele of Neck 91
Sarcoma of Testis 116
Amputation above Shoulder-
Joint 150
GILLESPIE, WM. A. (Virginia.)
Removal of Astragalus 14G
OILMAN, C. R. (New York.)
Polypus Uteri 128
GODDARD, P. B. (Philadel-
phia.)
Curling on Diseases of Testis 45
New Stomach-Pump 84
GODMAN, JOHN D. (Philadel-
phia.)
Coster on Surgical Operations 43
Inverted Toe-Nail 137
GODMAN, J. (Philadelphia.)
Pediculis Pubis on Tarsi Carti-
lages 63
GORDON, JAMES M. (Georgia.)
Cases of R-anula 77
GORHAM, Dr. (Louisiana.)
Caesarean Section 134
GREEN, HORACE. (New York.)
Polypi of Larynx 47
GREENE, ISAAC. (New York,)
Resection of Lower Jaw 74
GRIFFIN, JOHN H. (Virginia.)
. Tapping in Ascites 102
Vaginal Hysterotomy 125
GRIMSHAW.A.H. (Delaware.)
Ovarian Dropsy 132
GROSS, SAMUEL D. (Louis-
ville.)
Tavernier's Operative Surgery 43
Diseases of Bones and Joints 43
Liston's Elements of Surgery 45
Treatise on Diseases of Bladder,
&c. 47
History of Kentucky Surgery 48
Seven Cases of Excision of Up-
per Jaw 71
Fibrous Tumor of Lower Jaw 74
11
PAGE
Five Cases of Resection of Lower
Jaw 74
Ligature of Subclavian 90
Encysted Tumor of Side 98
Varicocele 115
Ovariotomy 133
Excision of Scapula 148
GUILD, JAMES. (Alabama.)
Trephining in Epilepsy 61
GUNN, MOSES. (Michigan.)
Air in Veins 76
II
HAIIN, JOHN. (Philadelphia.)
Strangulated Femoral Hernia
HALL, CHARLES A. (Ver-
mont.)
Tracheotomy for Foreign Bodies
Inability to raise Upper Eyelid
Paracentesis Thoracis
103
86
64
99
HALL, J. C. (Washington.)
Extirpation of Testes and Penis 115
Ligature of External Iliac 109
HALL, RICHARD WILMOT.
(Baltimore.)
Ligature of Innominata 91
Larrey's Military Surgery 42
HAMILTON, F. H. (Rochester.)
Rhino-plasty, Cheilo-plasty, &c. 67
Horn Excised from Face 67
Three Cases of Hare-lip 69
Resection of Lower Jaw 75
Hemorrhage in Tonsilotomy 79
Maggots removed from Ear 80
Cases of Hernia 104
Varicocele and Extirpation 115
Lithotomy in a Child 120
Lithotomy in an Adult 120
HAMILTON, ROBERT.
Stone in the Female 118
HAMMOND, D. W. (Georgia.)
Calculi in Urethra 122
HARDEN, JNO. (Louisville.)
Trephining in Fractures 63
HARDY, JOS. F. E. (North
Carolina.)
Laryngotomy for Watermelon
Seed 86
HARLAN, R. (Philadelphia.)
Medical and Physical Researches 44
HARRIS, JOSIAH. (Georgia.)
Phimosis 113
162
ALPHABETICAL LIST OF
HARRIS, S. M. (Savannau.)
Strangulated Hernia 106
HARRIS, THOMAS. [Philadel-
phia.)
Amputation of Enlarged Tongue 76
Congenital Enlargement of " 77
Excision of Elbow-Joint 146
HART, W. W. (Mississippi.)
Protrusion of Stomach, &c. 103
HARTSHORNE, JOS. (Phila-
delphia.)
Boyer on Diseases of the Bones 42
Caustic in Tetanus 110
Tardy Union in Fractures 144
HASTINGS, JOHN. (Philadel-
phia.)
Practice of Surgery 47
Ligature of External Iliac 110
IIAXALL, ROBERT W. (Vir-
ginia.)
On Fistula Lachrymalis 64
HAYS, ISAAC. (Philadelphia.)
American Cyclopaedia 44
Lawrence on Diseases of Eye 46
Parrish on Ruptures 42
Anchylo-blepharon 64
Plastic Operation in Symblepha-
ron 64
Extraction of Foreign Bodies
from Eyes 65
Operation for Artificial Pupil 66
HAYWARD, GEO. (Boston.)
Report on Hernia 48, 104
Comparative Value of different
Anaesthetics 57
Needles, &c. in Naevi Materni 58
Trephining in Epilepsy 62
Insect Pins in Harelip 69
Removal of Cancer from Tongue 77
Operation for Tumor in the Neck 90
Ligature of Carotid 94
Cases of Ascites 103
On Hydrocele 116
Vesico- Vaginal Fistula 125
Occlusion of Vagina 126
Prolapsus Ani 135
Enlarged Bursa over Patella 138
Amputation of part of Foot 149
Cases of Vaginal Fistula 126
Imperforate Anus 136
Statistics of Amputations 150
HEATON, J. (Boston.)
Strangulated Femoral Hernia 104
HENDERSON, THOS. (District
of Columbia.)
Ovarian Disease 129
IIENING, WM. (U. S. Armv.)
Gunshot Ball discharged by Stool 110
HERBERT, WILLIAM II. (New
York.)
Ducamp on Strictures 43
HERNDON.BRODIE S. (Bostox.
Caesarean Section 134
HEUSTIS, J. W. (Mobile.)
Compression in Wound of Bra-
chial Artery 55
Hernia Cerebri 61
Strangulated Umbilical Hernia 104
Prolapsus Recti 135
Aneurism of Brachial Artery 141
HEWSON, THOS. T. (Phila-
delphia.)
Coagulation of Blood 54
On Preternatural Joints 141
Strangulated Umbilical Hernia 104
HEWSON, ADDINELL. (Phil-
adelphia.)
Wilde on Aural Surgery 48
HIBBARD, MOSES. (New
Hampshire.)
Operation on Uterine Tumor 127
HILDRETII, CHAS. T. (Haver-
hill.)
Caustic in Strictured OEsopha-
gus 83
HILL, JOHN. (South Carolina.)
Artificial Pupil 65
HITCHCOCK, ALFRED. (Mas-
sachusetts.)
Early Operation in Hernia 105
IIITT, N. (Indiana.)
Extirpation of Tumor of Mam-
ma 97
HOLBROOK, AMOS. (Massa-
chusetts.)
Paracentesis Abd. in Dropsy 101
HOLMES, H. J. (Mississippi.)
Occlusion of Vagina 125
HOLSTON, J. G. F. (Ohio.)
Trephining in Epilepsy 62
Resection of Lower Jaw, &c. 75
HOOKER, CHAS. (New Haven.)
Extracting Foreign Bodies from
Ear 80
HOPTON, ABNER. (North
Carolina.)
Incisions in Glossitis 76
Laryngotomy and Tracheotomy
in same Case 85
Trephining in Carious Sternum 99
AMERICAN SURGEONS.
163
PAGE
HORNER, G. R. B. (U. S.Navy.)
Amputation of Foot 149
HORNER, WM. E. (Philadel-
phia.)
Hydrocephalus 60
Exostosis of Nasal Bones. 68
Excision of Upper Jaw 70
Immobility of Jaw 71
Ligature of Common Carotid 93
Extirpation of Parotid 82
Hepatic Abscess 102
Artificial Anus 111
Amputation of Penis 113
Fistula in Perineo 110
Extirpation of Testis 116
Lithotripsy 124
Treatment of Lacerated Peri-
neum 125
Treatment of Hemorrhoids 135
Rupture Tendo-Achillis 138
Femoral and Brachial Aneurism 142
Aneurism of Femoral Artery 142
Resection of Femur 148
Amputation at Shoulder-Joint 150
HORTON, J. W. (Maryland.)
Imperforate Hymen
(New
124
HOSACK, ALEX. E
York.)
On Removal of Tonsils 78
Instrument to tie Deep Arteries 92
HOSACK, DAVID. (New York.)
On Surgery of the Ancients 42
Aneurism of Femoral Artery 140
Injection in Hydrocele 116
Ligature of Femoral Artery 140
HOUSTON, ROBERT.
Case of Ovarian Dropsy 131
HOUSTON, M. H. (Virginia.)
Piece of Linen in Lungs twenty
years 100
HOWARD, ROBERT. (Louis-
ville.)
Paracentesis Capitis
HOWARD, RICHARD L. (Ohio.)
Thimble in Posterior Nares 79
Spina Bifida HI
Lithotomy 122
Lateral Operation 122
Ovariotomy — new plan 133
Amputation at Shoulder 152
HOWE, ZADOC. (Massachu-
setts.)
Operation of Hare-lip 69
Tracheotomy for a Bean 86
CO
HOYT, MOSES. (Ohio.)
Tracheotomy for Bean 88
HOYT, OTIS. (Massachusetts.)
Tumor of Thyroid Gland 90
HUBBARD, THOMAS. (Con-
necticut.)
Ligature of Axillary Artery 95
HULIHEN, S. P. (Wheeling.)
Muco-Purulent Secretion of An-
trum 70
Elongation of Lower Jaw, &c,
from Burn 74
HULL, G. A. (New York.)
Nature of Hernia, &c. 104
HULSE, ISAAC. (U. S. Navy.)
Ununited Fracture of Humerus 144
HUNT, THOMAS. (Natchez.)
Removal of half Lower Jaw 73
HUNT, HENRY. (Washington.)
Resection Head of Humerus 145
HURD, P. H. (Oswego.)
Case of Spina Bifida 111
Division of Spinal Marrow 111
ISAACS, C. E. (New York.)
Bernard and Huette, Op. Surg.
47
JACKSON, CHAS. (Boston.)
Anaesthetic Agents 57
JACKSON, SAMUEL. (Phila-
delphia.)
Paracentesis in Effusion into
Chest 99
JACKSON, SAMUEL. (North-
umberland.)
On Ectropion 64
JAMESON, HORACE G. (Bal-
timore.)
Naevus 58
Traumatic Hemorrhage 55
Tumor of Orbit of the Eye 63
Tumors of Upper Jaw * 70
Stricture of (Esophagus 83
Bronchotomy for Watermelon
Seed 85
Memoir on Bronchotomy 85
Bronchotomy for a Pebble 85
Tracheotomy 86
164
ALPHABETICAL LIST OF
PAGE
Taking up Thyroid Arteries for
Bronchocele 89
Strangulated Inguinal Hernia 104
Ligature of External Iliac 108
Perineal Incision in Stricture 113
Stricture of Urethra 114
New Operation for Circocele 115
Sarcocele 115
Amputation of Cervix Uteri 127
Stricture of Rectum 134
Caustic on Tumor of Thigh 137
Popliteal Aneurism 141
Diffused Aneurism 141
Wound of Ulnar Artery 142
Necrosis 14G
JARROTT, RICHARD.
Amputation in Gangrene 151
JEFFRIES, J. (Boston.)
Osseous Formation in Eye 65
Operation for Artificial Pupil 65
JENNINGS, ROBT. G. (Vir-
ginia.)
Wound of Abdomen 102
Polypus Uteri 121
JERVEY, J. P. (Charleston.)
Stricture of Urethra, &c. 45
Resection of Lower Jaw 74
JEWETT, CALVIN. (Newberg.)
Tracheotomy for a Bean 85
Bronchotomy for Iron Nail 86
JONES, JOSEPH S. (Boston.)
Radical Cure of Hernia 106
JOHNSON, CARTER P. (Rich-
mond.)
Resection of Inferior Maxilla 75
Tracheotomy 87
Amputation of Breast 98
Lithotomy 121
Pseudarthrosis 145
Resection of Ulna 148
JOHNSON, WM. (New Jersey.)
Stricture of CEsophagus 84
JOHNSON, WM. J. (Georgia.)
Double Lithotomy 121
JOHNSTON, WM. (New Jersey.)
Varicose Aneurism 1,42
JUDKINS, WM. (Ohio.)
Trephine in Injuries of Brain 61
KAST, THOMAS. (Boston.)
Aneurism of Thigh
140
KELLY, JOHN. (New York.)
Case of Urinary Calculus 120
KIMBALL, GILMAN.
Ligature of Internal Iliac 108
KING, DANIEL. (Rhode Island.)
Callous Stricture of Rectum 135
KING, WM. NEPHEW. (Geor-
gia.)
Lithotomy 121
KINLOCK, R. A. (Charleston.)
QMematous Laryngitis 87
KIRKBRIDE, T. S. (Philadel-
phia.)
Compression in Wounded Arte-
ries 55
KISSAM, J. B. (New York.)
Minor Surgery of Bourgery 44
KNIGHT, J. (New Haven.)
Popliteal Aneurism 143
LEBBY, ROBERT.
Water between Cranium and
Scalp 60
LEE, T. D. (New York.)
Ascites 102
LEIDER, M. S. (Ohio.)
Lithotomy 122
LEVERT, HENRY S. (Mobile.)
Metallic Ligatures on Arteries 55
Fungus Hematodes 150
LEWIS, WINSLOW. (Boston.)
Operation for Carotid Aneurism 92
LINDSAY, R. W. (District of
Columbia.)
Case of Gunshot Wound 150
LINDSLEY, HARVEY. (Wash-
ington.)
Extirpation of Cancerous Eye 65
LITTELL, S. (Philadelphia.)
Treatise on Diseases of the Eye 44
Walton on Ophthalmic Surgery 48
LOGAN, THOS. M. (South ( a-
ROLINA.)
Compendium of Operative Sur-
gery 44
LOTZ, J. R. (Pennsylvania.)
Operation for Artificial Anus 107
LOVELL, JOS. (U. S. Army.)
Wounds of Stomach 101
AMERICAN SURGEONS.
165
M
PAGE
McCALL, JNO. (Utica.)
Hemorrhoids 136
McCLELLAN, GEO. (Philadel-
phia.)
Principles and Practice of Sur-
gery 47
Operation for .Spina Ventosa 59
Extirpation of Parotid 81
Right Parotid 81
Parotid 81
Surgical Anatomy of Arteries 91
Ligature of Carotid in Children 92
Excision of Cartilages, Ribs,
and Sternum 99
Case of Lithotripsy 124
On Fungus nematodes 149
McCLELLAN, JOHN. (Green-
castle.)
Extirpation of Parotid 82
Cancerous Breast 97
McCLELLAN, JOHN II. B.
(Philadelphia.)
Principles of Surgery 47
McCREARY, CHARLES. (Ken-
tucky.)
Exsection of Clavicle 97
McDOWALL, II. (Virginia.)
Pathology of Bones, &c. 99
McDOWELL, EPHRAIM. (Dan-
ville.)
Extirpation of Ovaria 129
129
McGILL. (Maryland.)
Ligature of both Carotids 92
McILVAINE, R. H. (North
Carolina.)
Tracheotomy in Croup 87
McRUER, D. (Maine.)
Ovariotomy 133
McSHERRY, R. (U. S. Navy.)
Castration 116
Abscess in Tibia 138
MANLOVE, J. E. (Tennessee.)
G astro tomy 102
MANN, JAMES. (Massachu-
setts.)
Sketches of Campaigns of 1812,
'13, '14 42
MANSON, OTIS F. (North Ca-
rolina.)
Puncture of Bladder 117
MARCH, ALDEN. (Albany.)
Hernia 105
Lithotomy
Ovarian Tumor
MARTIN, JOHN II.
On Necrosis
(Maine.)
page
122
131
145
MATTHEWS, C. B. (Phila-
delphia.)
Instrument to Excise Tonsils 78
To Extract Poisons from Sto-
mach 83
MARKHAM, W. D. (Philadel-
phia.)
Surgical Practice in Paris 45
MARTIN, JOHN H. (Maine.)
Necrosis 145
MAY, JNO. FRED. (Washing-
ton.)
Tracheotomy 88
Lithotomy in Female 121
Bi-lateral Operation 121
Foreign Bodies in Joints 139
Amputation at Hip 151
Of Thigh 151
Of Thigh for Tetanus 151
Amputation of both Legs 152
" at Shoulder 152
MAYNARD, JOHN P. (Bos-
ton.)
On Collodion 55
MEASE, JAMES. (Philadel-
phia.)
Life and Surgical Works of
John Jones 41
MEEKER, DAN'L. (Indiana.)
Extirpation of Diseased Ovary 131
MEIER, C. THEODORE. (New
York.)
Carcinoma of Eyelid 64
MERRIWETIIER, SAMUEL.
(Indiana.)
Paracentesis in Empyema 100
METCALF, JOHN G. (Massa-
chusetts.)
Imperforate Hymen 125
METCALFE, JNO. T. (New
York.)
Paracentesis Thoracis 101
METTAUER, JOHN P. (Vir-
ginia.)
Staphyloraphy 79
Ligature of Common Carotid 94
Amputation of Penis
Hypospadias and Epispadias 114
Case of Lithotomy 119
New Director and Gorget 120
166
ALPHABETICAL LIST OF
PAGE
Rupture of Recto-Vaginal Sep-
tum 125
Vesico- Vaginal Fistula 12G
Polypus Uteri 129
MIGHELS, JESSE W. (Maine.)
Immobility of Jaw 71
MILLER, H. (Louisville.)
Ovariotomy 131
MILLS, AUGUSTUS W. (Ken-
tucky.)
Truncating Uvula in Consump-
tion 77
MITCHELL, J. K. (Philadel-
phia.)
Instrument to Excise Tonsils 78
MITCHELL, JNO. S. (Charles-
ton-.)
Imperforate Anus 135
MOREHOUSE, G. R. (Philadel-
phia.)
Laryngotomy 88
MOORE, E. B. (Boston.)
Inguinal Hernia 106
MOORE, FRANCIS. (Connecti-
cut.)
New Tourniquet 148
MOORE, N. J. McL. (New
Hampshire.)
Amputation Neck of Uterus 128
MORGAN, JOHN G. (Geneva.)
Ligature in Division of Jugular
Vein 90
MORGAN, JAS. E. (Washing-
ton.)
Epidemic Paronychia ' 139
MORTON, WM. T. G. (Boston.)
Effects of Sulphuric Ether 47
MORROGH, C. (New Jersey.)
Ligature of Carotid 94
MOTT, VALENTINE. (New
r Y0RK.)
Velpeau's Surgery 4G
Ligature of Carotid 58
Treatment of Injuries of Head Gl
Removal of Tumor from Nose 68
Immobility of Jaw 71
Taliacotian Operation 71
Osteo-sarcoma of Lower Jaw 72
72
72
Resection of Inferior Maxilla 74
Extirpation of Parotid 81
Tuberculated Sarcoma 90
Ligature of the Innominata 91
Ligature of Carotid
92
in Infant 92
Circulation of Head after Tying
Carotid 93
Ligature of both Carotids 93
Chloroform, importance of 57
Case of Axillary Aneurism 95
Aneurism of Right Subclavian 95
Ligature of Left " 96
(« ii ii
extornal to Scaleni 96
Osteo-sarcoma of Left Clavicle 97
Ligature of Common Iliac 107
External Iliac 108
Diffused Femoral Aneurism 109
Case of Lithotomy 118
Occlusion of Vagina 126
Femoral Aneurism 141
Amputation at Hip-Joint 149
MUSSEY, R. D. (Cincinnati.)
Entrance of Air into Veins 55
On Anaesthesia 56
Aneurism by Anastomosis 58
Exostosis of Frontal Bone 59
Excision of Upper Maxillary 70
Large Tumor of Neck 90
Operation on Enlarged Tongue 77
Congenital absence of External
Meatus 80
Excision of large Tumor on Neck 90
Ligature of Carotid 91
Ligation of both Carotids 92
Ligature of both Carotids 93
ii ii ii 95
On Urinary Calculus 118
Operation for Lithotomy 120
Recto- Vaginal Fistula 127
Operation of Ovariotomy 130
MUSSEY, WM. II. (Cincinnati.)
Anaesthetic Agents 57
Tracheotomy 89
MUTTER, THOMAS D. (Phila-
delphia.)
Liston's Operations of Surgery 47
Rhinoplastic Operation 67
Deformity of Mouth, and Dieffen-
bach's Method 7G
Physick's Needle in Cleft Palate 80
Operation for Deformity from
Burns 82
Hydrocele of the Neck 90
Urinary Calculus in a Girl 119
New Instrument for Fistula in
Ano 134
Stricture of Rectum 134
Resection of Femur 14b
AMERICAN SURGEONS.
167
N
NAXCREDE, JOS. G. (Phila-
delphia.)
On the Csesarean Operation 134
NEILL, JNO. (Philadelphia.)
Pirrie's Surgery 47
Obstruction of Eustachian Tube 80
Tracheotomy in Epilepsy 88
NELSON, HORACE. (New York.)
Ligature of Spermatic Artery 116
NELSON, T. (New York.)
Wounded Nerve from Bleeding 137
NEWMAN, II. S. (Philadelphia.)
Amputation of Enlarged Tongue 76
NEWMAN, JOHN. (North Caro-
lina.)
Tracheotomy for Lead Bullet 84
NICE, W. G. (Virginia.)
On Contractions in Burns 137
NORRIS, GEORGE W. (Phila-
delphia.)
Liston's Practical Surgery 45
Ferguson's " " 45
Chelius's System of " 47
Report of Cases of Injuries of
Head 61
Fibrous Tumor on Lobe of Ear 80
Statistics of Mortality following
the tying of Carotid and In-
nominata 94
Statistics of Ligature of Sub-
clavian 96
Congenital Club-Foot 139
Statistics of Ligature of Iliacs 142
Statistics of Ligature of Femoral 143
Fracture of Astragalus _ 149
Statistics of Amputations at
Pennsylvania Hospital 150
Second Statistics of Amputa-
tions 150
NOTT, J. C. (Mobile.)
Radical Cure of Hernia 105
Large Stones in Lateral Opera-
tion 119
Extirpation of Os Coccygis 125
O
OGIER, TIIOS. L. (Charleston.)
Compendium of Operative Sur-
gery 44
Amputation of Penis 113
Occlusion of Vagina 127
[Jterine Tumor 128
ONDERDONK, HENRY U. (New
York.)
On Stone in Bladder 117
Popliteal Aneurism 1-11
Ligature of Femoral Artery 141
O'REILLY, JNO. O. (New York.)
Varus 140
OTIS, GEORGE A. (Richmond.)
Extirpation of part of Thyroid 91
PAGE, WM. BYRD. (Philadel-
phia.)
Amputation at Shoulder- Joint 151
PALMER, JOSEPH.
Bronchotomy for a Bean 85
PANCOAST, JOSEPH. (Phila-
delphia.)
On Operative Surgery 46
Operation for Strabismus 65
Rhinoplastic Operations 67, 68
Plastic Operations 76
76
Staphyloraphy 80
Tracheotomy in Croup 86
" (Meigs) 87
" Laryngitis 88
Cystic Goitre 91
Cancerous Mammse 98
Empyema cured by Operation 100
Vaginal Fistula 126
Excision of Elbow-Joint 147
PARK, ANDREW. (Eatonton,
Georgia.)
Trephining in Fractured Skull 61
Encysted Tumor of Neck 89
PARKER, WILLARD. (New
York.)
Trephining, &c. in Epilepsy 63
Amputation at Knee-Joint 152
Osteo-Aneurism 153
PARKMAN, SAMUEL. (Boston.)
Velpeau on Diseases of the Breast 45
Excision of Inferior Maxillary
Nerve 67
Tracheotomy 87
Extirpation of Uterine Tumor 131
Ovarian Cyst 132
PARRISH, ISAAC. (Philadel-
phia.)
Anaesthetic Agents and Statis-
tics 56
Congenital Division of Lip and
Palate 69
168
ALPHABETICAL LIST OF
PAGE
Thimble in Pterygoid Fossa 77
Croup cured without Operation 86
Case of Ununited Fracture 144
PARRISH, JOSEPH. (Phila-
nELPIIIA.)
A Treatise on Ruptures 42
Surgical Observations 44
Ligature of Subclavian Artery 95
Cancer of Breast 97
Case of Strangulated Hernia 103
Aneurism of Femoral 140
PARRY, CHARLES. (Indiana.)
Deformed Fracture of Leg 146
PARSONS, USHER. (Rhode
Island.)
On Cancer of Mammae 45
Statistics of Surgical Operations 94
Amputation of Uterus 128
Battle on Lake Erie 137
PASCALIS, FELIX. (New York.)
Fistula in Ano 134
PATTESON, GRANVILLE
SHARPE. (Baltimore.)
Burns's Anatomy of Head and
Neck 42
Aneurism of Internal Maxillary 60
PEACE, EDWARD. (Philadel-
phia.)
Ligature of External Iliac 109
" Primitive 107
PEASLEE, E. R. (New York.)
Double Ovariotomy 132
Amputation at Shoulder-Joint 152
PEIRSON, A. L. (Massachu-
setts.)
Operation for Harelip 09
Early Operation for Harelip 69
Polypus and Inversion of Uterus 129
PEPPER, WM. (Philadelphia.)
Empyema 100
PERKINS. (Philadelphia.)
Arrest of Progress of Whitlow 137
PHILIPS, S. B. (New York.)
Case of Polypus Uteri 129
PHYSICK, PHILIP SYNC
Employment of Animal Liga-
tures 54
Tapping in Hydrocephalus 60
Nitrate of Silver in Wart on
Adnata 65
Seton for Fracture of Inferior
Maxilla 72
Cough, caused by Elongated
Uvula, &c. 77
PAGE
Double Canula and Wire Liga-
ture J8
Forceps for removing Tonsils 78
Stomach Tube in Poisoning^ 83
Tracheotomy in Hydrophobia 84
New Operation for Artificial
Anus 106
Diseases of Testicle 115
Operation of Lithotomy IIS
Ligature of Brachial Artery 140
Pseudarthrosis 144
PINCKNEY, N. ■ (U. S. Navy.)
Excision of Portion of Lower Jaw 71
Removal of one-third of Head
of Humerus 147
Amputation at Shoulder-Joint 150
PIPER, R. U. (Rhode Island.)
Operative Surgery 48
PITCHER, ZINA. (U. S. Army.)
Penetrating Wound of Abdomen 102
PITNEY, JOSEPH T. (New Jer-
sey.)
Tracheotomy 88
PLATT, JAMES KENT. (Pitts-
burg.)
Hydrops Articuli in Shoulder 137
POPE, CHAS. A. (St. Louis.)
Fracture of Cranium 62, 63
Dislocation of Crvstalline Lens 06
Stone in Bladder" 120
Ligature of Femoral Artery 143
POST, ALFRED C. (New York.)
Blepharoplastic Operation fur
Ectropion 64
Subcutaneous Erectile Tumor of
Cheek, &c. 93
Ligature of Subclavian, &c. 96
Congenital Hernia 104
POST, WRIGHT. (New York.)
Operation on Carotid Aneurism 91
Ligature of Subclavian for Bra-
chial Aneurism 95
Ligature of External Iliac 108
Case of Brachial Aneurism 141
POWELL, W. B. (Kentucky.)
Excision of Part of Spleen 101
POWER, W. (Baltimore.)
Femoral Aneurism 109
PRINCE, DAVID. (St. Louis.)
Ovarian Tumor 131
PROUDFOOT, L.
Fistula in Lumbar Region 111
PURPLE, SAMUEL S. (New
York.)
New Trephine 63
AMERICAN SURGEONS.
169
Q
QUACKENBTJSH, J. V. P. (Al-
bany.)
Uterine Polypus 128
R
KAMSAY, DAVID. (Charles-
ton.)
Improvements in Medicine in
Eighteenth Century
RAND, ISAAC. (Massachu-
setts.)
Operation for Empyema
RANDOLPH, J. (Philadelphia.)
Osteo-Sarcoma of Lower Jaw
Extirpation of the Parotid
Aneurism of External Iliac
Cases of Lithotripsy
Stone in Bladder
41
99
73
82
109
123
123
123
123
123
123
Cases of Lithotripsy
" Lithotrity
Case of Lithotripsy
RAPHAEL, B. J. (Louisville.)
Rhinoplastic Operation 68
REESE, DAVID M. (Baltimore.)
Cooper's Surg. Diet. 43
Tetanus controlled by Issues to
Spine 111
RICHMOND, JNO. L. (Ohio.)
Cesarean Section 133
RIVINUS, E.F. (Philadelphia.)
Larry on Wounds 44
ROBERT, WM. H. (Alabama.)
Singular Hernia 105
Injection for Cure of Hernia 106
ROBERTS, WM. C. (New York.)
Tumors of Uterus 128
Minor Surgery of Bourgery 44
ROBERTSON, F. M. (Charles-
ton.)
Lithotomy in Child 121
RODGERS, J. KEARNY. (New
York.)
Operation for Artificial Pupil 66
Ligature of Left Subclavian 96
Ununited Fracture of Humerus 144
Amputation at Elbow-Joint 149
Anchylosis of Hip 146
RODRIGUES, B. A. (Pennsyl-
vania.)
Exostosis of Upper Jaw 70
ROGERS, DAVID L. (New
York.)
Trephining in Epilepsy 61
Ligature of Common Carotid 67
Osteo-Sarcoma of Upper Jaw 70
" " Lower Jaw 73
Excising Tonsils 78
Excision of Tumor from Neck 89
Ligature of External Iliac 109
Operation for Fractured Spine 111
Ovariotomy 130
On tying large Arteries 141
ROUSSEAU, J. C. (Philadel-
phia.)
Operation on Hemorrhoids 134
RUAN, WM. II. (West Indies.)
Ligature of Right External Iliac 109
RUSCHENBERGER, W. S. W.
(Philadelphia.)
Marshal on Enlisting, &c. of
Soldiers 45
Glass Goblet in Rectum 135
RYLAND, KIRTLEY. (St.Louis.)
Chloroform in its Effects on
Hemorrhage 56
S
SANBORN, E. K. (Lowell.)
Amputation at Shoulder 152
SAVERY, CHARLES A. (New
Hampshire.)
Abscess of Liver 102
SARGENT, F. W. (Philadel-
phia.)
Druitt's Surgery 46
On Bandaging, &c. 47
Miller's Principles of Surgery 47
" Practice " " 48
SCHMIDT, J. W. (New York.)
Morbid Erectile Tissue 59
Division of Masseter Muscle 71
SELDEN, HENRY. (Virginia.)
On Hemorrhoids 135
SHANKS, LEWIS. (Tennessee.)
Treatment, &c. of Cephaleema-
toma 60
Bloodroot in Gelatinous Polypi 68
SHELDON, A. S. (New York.)
Paracentesis in Empyema 100
SHERRERD, JOHN B. (New
Jersey.)
Injection in Ascites 102
170
ALPHABETICAL LIST OF
SIIERPJLL, HUNTING. (New
York.)
Strangulated Inguinal Hernia
SHIPMAN, A. B. (Indiana.)
Injury of Head
Extirpation of Parotid
Ligature of Common Carotid
Medullary Sarcoma of Labia,&c.
Imperforate Vagina
Csesarean Operation
SHIPMAN, A. W. (New York.)
Ligature of Femoral Artery
SHULTICE, WM. (Virginia.)
Case of Imperforate Hymen
SIMS, J. MARION. (Alabama.)
Removal of Superior Maxilla
Osteo-Sarcoma of Lower Jaw
PAGE
104
62
62
62
82
94
124
126
134
142
124
70
74
74
Extraction of Foreign Bodies
from Ear 80
Vesico-Vaginal Fistula 126
SKINNER, CHARLES. (North
Carolina.)
Case of Spina Bifida 111
SMITH, ALBAN G. (Ken-
tucky.)
Operation on Vertebrae 111
Successful Lithotrity 123
Removal of Diseased Ovarium 130
SMITH, CHAS. (New York.)
Aneurism of Bone 148
SMITH, HENRY II. (Phila-
delphia.)
Civiale on Stone and Gravel 45
Minor Surgery 45
Resection of Upper Jaw Bone 71
Tracheotomy 88
Amputation of Breast 98
of Mammae 98
Tubercles of Testis 115
Very large Hydrocele 116
Sudden Formation of Hydrocele 116
Lithotomy, Lateral 121
Lithotomy in Child 122
Vesico-Vaginal Fistula 126
Case of Varicose Veins 128
Hemorrhoids 136
Treatment of Varicose Veins 138
Double Club-Foot 140
Excision and Caustic in Pseu-
darthrosis 144
Splint for Pscudarthrosis 145
Amputation of Thigh 151
Arm 151
" Leg 151
SMITH, J. AUGUSTINE. (New
York.)
Bell's Principles of Surgery 42
SMITH, J. WASHINGTON.
(New York.)
Foreign Body in Joint 139
SMITH, JAS. M. (Massachu-
setts.)
Pseudarthrosis 145
SMITH, NATHAN. (Yale Col-
lege.)
Suture of Palate in Infancy 79
To Extract Coins, &c. from
Oesophagus 83
Ligature of External Iliac 108
Operation for Ovarian Tumor 130
Remarks on Amputations 149
SMITH, NATHAN R. (Balti-
more.)
On Diseases of Internal Ear 43
Medical and Surgical Memoirs 43
Surgical Anatomy of Arteries 44
Caustic Threads in Vascular
Naevus 58
Extirpation of Tonsils 78
Observations on Staphyloraphy 79
Extirpation of Parotid 81
" Tumors on Neck 90
Stricture of Urethra 114
Extirpation of Testis 115
Paracentesis of Bladder through
Perineum 117
Instruments, &c. in Lithotomy 119
Cases of Lithotripsy 123
Fungus near Vagina 124
Hemorrhoidal Tumors 135
Actual Cautery in Deep Sinuses 137
Division of Tendo-Achillis 139
Case of Popliteal Aneurism 142
Ligature of Femoral 142
Brachial 142
Resection of Astragalus 146
Amputation of Leg 149
SMITH, STEPHEN. (New
York.)
Statistics of Trephining, by
American Surgeons 63
Polypus Laryngis 91
Statistics of Amputation at Hip-
Joint 152
Statistics of Amputation at
Shoulder and Elbow-Joints 153
SNEAD, N. (Virginia.)
Cases of Hernia 104
SNEED, W. C. (Kentucky.)
Paracentesis in Empyema 100
AMERICAN SURGEONS.
171
SPENCER, P. C. (Petersburg.)
Tumor of Neck 90
Results of Lithotomy 120
Case of Lithotrity 123
Occlusion of Vagina 126
SQUIBB, E. R. (U. S. Navy.)
Advantages of Simple Dressings
in Surgery 56
STEDMAN.
Ligature of External Iliac 110
STEPHENSON, W.D. (Alabama.)
Tracheotomy 88
STEPHENSON, M. (New York.)
Sarcomatous Tumor 138
STERLING, JOHN W. (New
York.)
Velpeau's Surgical Anatomy 43
STEVENS, ALEX. H. (New
York.)
Translation of Boyer on Surgi-
cal Diseases 42
Cooper's Practice of Surgery 42
On Encysted and other Tumors 59
Osteo-Sarcoma of Upper Jaw 70
Treatment of Enlarged and In-
durated Tonsils 78
Staphyloraphy 79
Encysted Tumor on Side of Neck 89
Congenital Hernia 104
Ligature of External Iliac 108
Puncture in Spina Bifida 111
Lectures on Lithotomy 119
Extra-Uterine Foetation 130
Case of Fissure of Rectum 134
Extirpation of Astragalus 146
STEWART, F. CAMPBELL.
(New York.)
Scoutetten on Club-Foot 45
Knife to divide Strictures in
Hernia 104
STIMPSON, JEREMY. (Boston.)
Tic Douleureux cured 66
STONE, JOHN O. _ (New York.)
Occlusion of Vagina 126
Resection of Elbow 147
Amputations and Compound
Fractures 151
STOUT, ABRAHAM. (Easton,
Pennsylvania.)
Cheiloplasty 76
STRACIIN, JOHN B. (Virginia.)
Excision of Cervix Uteri 127
STRONG, Dr. (Boston.)
Pus in Tibia 148
SWEAT, MOSES. (Maine.)
Three Parotids removed 82
Division of Nerves in Tetanus 138
SWETT, JOHN A. (New York.)
Paracentesis in Empyema 100
SYKES, JAMES. (Delaware.)
Ligature of Carotid 91
T
TALIAFERRO, W. T. (Ken-
tucky.)
Congenital Tumor of Eyeball 66
TAYLOR, O. H. (New Jersey.)
Atresia Vaginae 127
THACHER, JAS. (Plymouth.)
Bladder tapped above Pubis 117
THAXTER, ROB'T. (Dorches-
ter.)
Ununited Fracture of Humerus 144
THOMPSON, GEORGE. (Ten-
nessee.)
Compression on Wounded Ar-
teries 55
DR. THOMPSON. (Massachu-
setts.)
Tracheotomy for Croup 84
TOLAND, II. H. (South Caro-
lina.)
Congenital Hypertrophy Upper
Eyelid 64
Immobility of Jaw 72
Excision part Inferior Maxilla 73
Extirpation of Parotid 82
Case of Lithotomy 118
Sanguineous Tumors of Vagina 124
TOLEFREE, R. (New York.)
On Circular and Flap Opera-
tions 149
TOWNSEND. (Boston.)
Tracheotomy for Laryngitis 87
TRABUE, B. F. (Kentucky.)
Tracheotomy 89
TRACEY, WM. A. (New Hamp-
shire.)
Paracentesis Thoracis 101
TRASK, JAS. D. (New York.)
Ligature of Primitive Carotid,
&c. 59
Strangulated Inguinal Hernia 105
TRIPLER, CHARLES S. (U. S.
Army.)
Secondary Hemorrhage after
Amputation of Shoulder 151
172
ALPHABETICAL LIST OF
TROWBRIDGE, AMASA. (New
York.)
Tracheotomy for a Bean 84
Three Cases Spina Bifida 111
Operation of Lithotomy 118
Lithotomy 122
Extraordinary Cases of Ampu-
tation 149
TRUGIEN, J. W. II. (Virginia.)
Trephining in Compression 63
TURNBULL, LAWRENCE.
(Philadelphia.)
Occluded Os Uteri 12G
TWITCIIELL. (New Hamp-
shire.)
Ligature of Carotid in Gunshot
Wound 93
U
UPSHUR, GEO. L. (Virginia.)
Occlusion of Vagina 127
UTTERY, A. LEANDER.
(Providence.)
Calculus in Urethra 123
VAN BUREN, WM. H. (New
York.)
Bernard and Huette's Surgery 47
Malignant Polypus Nose, &c. 68
Ligature of Subclavian, with
Statistics 97
Rare Hernia 106
Ligature of External Iliac 110
Lithotomy 122
Tumor of Left Ovary 131
Ovariotomy 133
Popliteal Aneurism 143
Amputation at Hip 152
W
WAGNER, JNO. (Charleston.)
Amputation of part Lower Jaw 73
WALTON, A. G. (Pennsylva-
nia.)
Operations for Club-Foot 139
WARREN, JOHN. (Boston.)
Amputation at Shoulder 148
WARREN, JOHN C. (Boston.)
Observations on Tumors 45
page
Etherization, with Surgical Re-
marks 47
Effects of Chloroform 47
Air in Veins 55
Cold-Water Dressing 56
Etherization 56
Ether and Chloroform 56
A Death from Chloroform 56
Use of Anaesthetics 56
Division of Nerves in Neuralgia 66
Excision of Sub-maxillary Nerve 67
Double Harelip 69
Removal of Upper Maxilla 70
70
Removal of half Lower Maxilla 73
Operation for Cancer of Tongue 70
Induration of Tonsils 79
Natural Fissure of Soft Palate 79
Operation for Tumor of Neck 89
Excision of Jugular 89
Operation for Carotid Aneurism 92
Ligature of Subclavian Artery 96
Removal of Clavicle 97
Excision of Ribs 99
Strangulated Crural Hernia 103
Ligature of External Iliac 108
Aneurism of External Iliac 109
Artificial Urethra 114
Omental Hernia 115
Bi-lateral Operation for Stone 119
Non-Existence of Vagina 125
Cancer of Uterus 127
Cases of Neuralgia 138
Ligature of Femoral Artery 140
WARREN, JOHN MASON.
(Boston.)
Inhalation of Ether 56
Ligature of both Carotids 59
Trephining for Old Depression 62
Blepharoplastic Operations 64
Rhinoplastic " 67
67
67
Autoplastic " 67
Taliacotian " 67
Section of Infra-Orbitar Nerve 67
Nursing after operating for Hare-
lip 68
Cancer of Throat 78
Enlargement of Tonsils 79
Fissure of Palate 80
Fissures, Hard and Soft Palate 80
Hard and Soft Palate 80
Extirpation of Parotid 82
Division of Sterno-C.-Mastoid 82
Foreign Bodies in Air-Passages 86
Laryngotomy 88
Ligature of both Carotids
AMERICAN SURGEONS.
173
PAGE
Ligature of Left Subclavian 96
Ligature of Left Subclavian 97
Operation for Artificial Anus 107
Lithotomy and Lithotrity 124
Occlusion of Vagina 126
Three Cases of Occlusion of Va-
gina
Amputation at Shoulder
127
152
WATERHOUSE, HENRY S.
(New York..)
Tracheotomy for Watermelon
Seed 85
WATERS, NICHOLAS B. (Phi-
ladelphia.)
Bell's System of Surgery 41
WATERS, WM. (Maryland.)
Elm Bougies 114
WATSON, JOHN. (New York.)
Nature, &c. of Telangiectasis 58
Anaplastic Operation on Os
Frontis 60
Polypi in Nasal Fossas, &c. 68
Organic Obstructions of GEso-
phagus 84
Radical Cure of Hernia 105
Treatment of Varicocele 1 15
On Secondary Abscesses 138
On Varices 138
Cases of Pseudarthrosis 145
WEBER, J. M. (New York.)
Hydatids of Liver 47, 103
WEBSTER, JAMES. (Phila-
delphia.)
Removal of Tumor from Face 76
WEDERSTAUL. (New Orleans.)
Tracheotomy 88
WEDDERBURN. (New Orleans.)
Removal of Parotid 82
" " Clavicle 97
Ligature of Primitive Iliac 107
" External " 109
Resection of Femur 148
WEEVER, CONSTANTINE.
(Michigan.)
New CEsophagus Forceps
WELLS, EDWARD W.
Ligature of Subclavian 95
WELLS, THOMAS. (South Caro-
lina.)
Hypertrophy of Tongue 76
Extensive Division of Soft Palate 79
WEST, FRANCIS. (Philadel-
phia.)
Dislocation of Crystalline Lens 66
S3
WHARTON, R. G. (Mississippi.)
Artificial Anus 107
WHEELER, II. II. (Pennsyl-
vania.)
Extirpation of Parotid 82
WHINERY, EDWARD. (Iowa.)
Extra-Uterine Pregnancy 130
WHITE, G. H. (New York.)
Ligature of Subclavian 96
WHITE, S. POMEROY. (New
York.)
Ligature of Internal Iliac 108
WHITE, SAMUEL. (New York.)
Teaspoon removed from Intes-
tine 101
WHITRIDGE, J. B. (Charles-
ton.)
Tapping in Hydrocephalus ' 60
Ligature of External Iliac 108
Amputation at Shoulder-Joint 149
WILLDAY, JOHN.
Cold Water in Calculus 117
WILLIAMS, W. G. (Ohio.)
Pseudarthrosis 145
WILLIAMS, STEPHEN W. (Mas-
sachusetts.)
American Medical Biography 46
WILLIAMS, HENRY W. (Bos-
ton.)
Extirpation of Eyeball 64
Extraction of Cataract when
etherized 66
Empyema 100
WOLFLEY. (Ohio.)
Paracentesis in Empyema 100
WOOD, JAS. R. (New York.)
Division of Masseter in Immo-
bility of Jaw 72
Lithotomy in a Child 120
Procidentia Uteri 126
Two Cases of Popliteal Aneu-
rism 143
WOOD, T. (Cincinnati.)
Strangulated Hernia 105
Chase's Truss in Hernia 105
WOODBURY, PETER P. (New
Hampshire.)
Tracheotomy for Bean 85
WORT, J.
Osteo-Sarcoma of Lower Jaw 73
WORTHINGTON, NICHOLAS.
(District of Columbia.)
Case of False Joint 144
174
ALPHABETICAL LIST OF AMERICAN SURGEONS.
WRAGG, J. A. (Georgia.)
Impermeable Stricture
WRAGG, W. T.
Sutures in Surgery
WRIGHT, CLARKE.
York.)
Tumor in Antrum
(New
115
55
70
YANDELL, LUNSFORD PITTS.
(Kentucky.)
Two Cases of Lithotomy H8
YARDLEY, THOS. (Philadel-
phia.)
Removal of Extra-Uterine Foetus 130
YORK, J. II. (Boston.)
Imperforate Anus 135
OPERATIVE SURGERY.
PART I.
GENERAL DUTIES AND ELEMENTARY OPERATIONS.
INTRODUCTION.
Operative Surgery, in the usual acceptation of the term, has
been so long regarded as designating that department of medicine
in which diseases are treated by means of cutting instruments, that
the importance to an operator of other qualifications than those of
manual dexterity is liable to be overlooked. Although every medi-
cal man is presumed to know that a successful surgeon must neces-
sarily be also a good physician, yet as the absence of reference to
this fact may lead the inexperienced to place too much confidence
in mere mechanical measures, it seems right, in this portion of the
work, to call the attention of the reader to the value of constitu-
tional treatment, in connection with surgical operations of a hazard-
ous kind.
The human system, upon which a surgeon acts mechanically, is a
combination of organs, so mutually dependent on each other, that
the removal of any portion, or even the partial division of that tegu-
mentary membrane which encases and protects the whole, frequently
creates derangement which nothing but judicious medical treatment
can remedy. Appropriate constitutional measures are therefore
often as essential to the success of an operation, as anatomical
knowledge and manual dexterity is necessary to its performance ;
and the happiest results will usually be obtained by those who
closely attend not only to the local, but also to the general manage-
ment of the cases on which they operate. For this reason, it will
generally be found that a successful surgeon is not only a judicious
176 INTRODUCTION.
practitioner of medicine, but also a devoted nurse and careful ob-
server of the varying conditions of the system, under all circum-
stances. In every operation, lie justly feels that he is largely in-
debted to nature for the result ; without her aid he neither antici-
pates nor obtains success, whilst with it, especially as exhibited in
the process of adhesion, or reproduction of tissue, he possesses a
power that seems almost divine.
Admitting the necessity of thus combining medical skill with
operative dexterity, there yet remain to be noticed, two special
duties which are essential to a correct appreciation of the extended
qualifications requisite in an operator, to wit, tact in diagnosis aud
a correct knowledge of surgical pathology.
By diagnosis, the various mental and physical processes which
ennoble and augment the value of operative proceedings, are
brought into play. In the practice of medicine, the power of diag-
nosticating disease is universally esteemed a test of skill, but in
surgery it is occasionally apparent that its acquisition is deemed
more easy and of less value, than that assigned it in the kindred
branch of the profession. In surgery, a correct diagnosis is also
often deemed, a matter of little difficulty, because, as the duties of
the surgeon are limited to external complaints, many presume that
their characteristics are more tangible, and present peculiarities
which can be more readily recognized by the senses. Slight prac-
tice will, however, convince any one who entertains this opinion,
that the mere acquisition of that nice sense of touch, which is'
essential to the diagnosis of certain surgical diseases, is of itself
sufficiently difficult, to say nothing of the experience necessary to
regulate the mental impressions which touch creates, and without
which, every surgeon would be liable to err, and induced to ope-
rate in cases which a more practised touch would have taught him
to avoid. In operative surgery, diagnostic errors also take effect so
quickly, that heavy and prompt responsibility is connected with its
exercise by an operator, his means of treatment being liable to de-
stroy life, or produce irreparable mutilation before he can recognize
his mistake, whilst the action of medical means of treatment, even
when attended by as much danger, yet leaves more time to obviate
it. A correct diagnosis is, therefore, always presumed to precede
every attempt at the use of instruments.
Skill in surgical pathology, or a knowledge of the peculiarities of
diseased structure, together with the general phenomena of abnor-
GENERAL DUTIES. 177
mal action, is also a qualification which cannot be too highly esti-
mated in weighing the amount of knowledge essential to the for-
mation of a good surgeon. On the perfection of the knowledge
possessed by an operator in this department, rests the necessity of
submission by the patient, to any operative proceeding. If it is
requisite to remove a tumor, the surgeon is always supposed to
have fully recognized its characters and probable progress before
recommending its extirpation ; while his decision in regard to the
propriety of amputation (as shown in the serious question of loss
of limb or life), can alone be correctly based on such a perception
of those general actions of the economy, as surgical pathology alone
teaches. While, then, for the advantages of methodical arrange-
ment, the ensuing pages are mainly limited to mechanical details,
let it be especially remembered, that there is no intention of giving
them any other value than that of being one of the means of sur-
gical treatment occasionally demanded for the relief of disease, and
that the apparent prominence thus given to the more mechanical
portion of surgery, is permitted, only with the view of tempting the
student to repeat the operations upon the dead body until he has
acquired the manual skill necessary to fit him for operating on the
living; after which, the additional knowledge of the physician
must be brought to aid in the result, or the surgeon will degenerate
into a " cutter."
With this explanation, the subject of operative surgery may be
divided into two parts: 1st. Minor Operative Surgery, or simply
Minor Surgery, in which there is usually but little danger to
the life of the patient, from the means employed ; and 2d, Major
Surgery, or Operative Surgery proper, where, from the more
free use of instruments, risk to life may reasonably be anticipated.
To show the various modes of operating, and especially such as are
resorted to by surgeons in the United States, is the object of the
present volume.
For the exposition of the duties of Minor Surgery, the reader
is referred to the various treatises upon the subject, among which
may be found the third edition of that published by the author of
these pages. 1
In the systematic arrangement of the work, five divisions may be
1 Minor .Surgery, or Hints on the Every-day Duties of the Surgeon, 3d edition,
Philadelphia, 1850.
12
178 OPERATIVE SURGERY.
advantageously made : 1st. General Duties and Elementary Opera-
tions. 2d. Operations on the Head and Face. 3d. Operations on
the Neck and Trunk. 4th. Operations upon the Genito-Urinary
Organs; and, 5th. Operations on the Extremities.
In adopting this order, I have been guided by the opinion that
the natural relation of parts is that in which any one desiring in-
formation in respect to an operation, would almost intuitively seek
it. Thus, the treatment of Harelip would naturally be looked for
in connection with operations on the lips, and not among those per-
formed for malformations of the soft parts, or disorders of the skin
or muscles; while the process of Trephining would be sought under
injuries of the cranium, and not under that of affections of the
bones. With the same views, the details of each operation will be
presented in the order in which the operator should attend to them.
Thus, before operating, the surgeon naturally thinks of the anato-
mical relations of the region upon which he is to act ; then of the
methods of operating; then of the instruments that may be re-
quired ; then of the dressings ; and, lastly, of the adjuvants neces-
sary either to the local or general means of treatment.
CHAPTER I.
OF THE GENERAL DUTIES OF AN OPERATOR.
By the general duties of an operator, are understood all such
acts as may be required in connection with his mechanical proceed-
ings. These duties may be classed under three heads: 1st. Atten-
tion to the patient; 2d. Preparation of instruments; and 3d. Selec-
tion of assistants.
SECTION I.
ATTENTIONS TO THE PATIENT.
The attentions required by the patient, may be subdivided into
three periods: those which are demanded before the operation;
during its proceedings; and subsequent to its performance.
ATTENTIONS TO THE PATIENT. 179
As every operation in surgery is undertaken solely with the
view of benefiting the patient, the duties of an operator necessarily
commence with the establishment of a correct diagnosis. Certainty,
or a cautious examination of the nature of the disorder, should in
all instances be a sine qua non to any operation. Without it, every
application of the knife becomes barbarous and unjustifiable, and
he who entertains a just view of the responsibilities of a surgeon,
will ponder long and seriously upon the propriety of operating in
any case, where he is likely to expose his patient to greater risks
than those arising from the treatment of the affection by other
remedial measures.
The Prognosis of an operation, or the opinion that the result to
the patient will be preferable to his condition before it, should in
like manner be firmly settled ; but as all men are liable to error,
even when caution is largely exercised, it becomes the surgeon's
duty to demand a consultation with one or more of his professional
brethren, in every case where it is possible, not only in order to
render the necessity of the operation certain, but also to secure his
own reputation as to its correctness. The many cases of error of
judgment that have been published through the honorable candor of
surgeons possessed of the highest skill, renders such a course essen-
tial not only to the comfort of every young operator, but also ab-
solutely necessary to his personal safety and immunity from the
vexatious legal actions, so often exhibited, at the present time, in
many portions of the United States. The propriety of amputations
has more than once been subsequently doubted ; lithotomy has been
performed when a calculus did not exist; whilst the cure of fistula
in ano, or the performance of plastic operations, has sometimes
left the patient in a worse condition than he was previously. The
result, also, is by no means the same, even under apparently similar
circumstances. Death has occasionally ensued from an apparently
simple operation; a greater deformity has been created by operating
for strabismus than that which previously existed, and new noses
have not always proved as handsome as the old. The issue should,
therefore, be carefully weighed by each surgeon, before operating,
if only on account of his own reputation. But when, after due
deliberation, the affair has been decided, let him immediately, and
with perfect confidence, assume his part as the operator, and give
his attention to such general and local measures as will facilitate
the accomplishment of his object.
180 OPERATIVE SURGERY.
§ 1.— Duties of a Surgeon before Operating.
Among the first of the general measures required before operating,
may be placed the employment of such means as are occasionally .
necessary to induce the patient to consent to the performance of the
operation. Sometimes it happens that the individual is so timid
and fearful of pain, as to require strong inducements to lead him to
suffer that which is requisite for his cure. Under such circum-
stances, the surgeon may be obliged to promise largely, or present
a lively delineation of the benefits that will result from its perform-
ance; but if, on the other hand, his patient is over-bold, or has ob-
tained too exalted an idea- of the advantages that will accrue from
the operation, it may become necessary to diminish his anxiety to
submit, by pointing out the risks to which he will be exposed; lest,
anticipating too much, and being disappointed, he throw the blame
upon his surgical attendant.
Especially is this caution requisite in the case of females who
demand an operation for the improvement of their appearance.
A young girl is annoyed by a squint, and hopes to augment her
beauty ; or she has been disfigured by a burn, or deformed from a
fracture, and, full of the successful histories of friends and neighbors,
almost insists upon an operation. In these cases, it is imperatively
the surgeon's duty to display the darker tints of the picture, and limit
the anticipations that hope and vanity have so readily created.
In this, which has been termed the " moral preparation" of a pa-
tient, many of the measures necessary to be employed must be
decided by that indefinite quality of the mind known as "tact;" or
that nice perception which enables any one to anticipate the most
agreeable method of accomplishing an object. Some surgeons pos-
sess it naturally in a high degree, whilst others are less brilliant.
A proper study of character, together with a close observation of
the mental imbecility of those who exhibit such peculiarities, will,
however, do much towards enabling any surgeon to obtain such
an amount of it as will enable him to control if he cannot
change his patient's peculiarities. Nor is this study of a patient's
mental idiosyncrasies only of importance in respect to his comfort ;
it is also often found to be closely allied to the result of the case.
Fear depresses the vital powers, but hope enlivens and elevates
them; and their undue excitement in any case may, therefore, either
ANAESTHETICS.
181
prove a serious obstacle, or a powerful lever to the attainment of
the surgeon's object. 1
From the extensive sympathies of one organ with another, it also
becomes the operator's duty, at this stage of his proceedings, to
look not only at the mental, but also to the general condition of
his patient. Let him see that the digestive organs are as far as
possible free from disease, and active in the performance of their
functions ; that the secretions of the liver and kidneys are not ob-
structed ; that the lungs and heart are in a proper condition for the
circulation of the blood, and that the head is free both from mental
and physical disorders; in other words, let him always satisfy
himself before operating, that his patient is possessed of the mens
sana in corpore sano; or, in other words, that he is, as far as may be,
sound both in body and mind.
After thus attending to the general preparation of the patient, the
surgeon should next turn his attention to such means as will facili-
tate his own movements, and save his patient unnecessary suffering.
In some few instances, the development of the patient's sensibility,
as indicating the probable amount of the subsequent inflammatory
action, is an object at the time of the operation, as is seen in the
use of stimulants for the cure of hydrocele, where the complaints
of the patient are often taken as the index of the probable action of
the article that has been injected into the sac. But, in the majority
of cases, the creation of pain during an operation can only be re-
garded as both unnecessary and injurious. The surgeon should,
therefore, prevent it, and save his patient the excitement formerly-
caused by the use of the knife, by resorting to Anaesthetics, espe-
cially before severe operations. As the safety of such a course has
been most widely tested at the present day, philanthropy, and
that desire to ameliorate the sufferings of mankind which is the
true basis of sound practice, demand that neither prejudice nor igno-
rance of their effects, should longer prevent their employment by
every operator.
Eight years have now elapsed since the use of Ether as an Anaes-
thetic was suggested by Dr. Morton, of Boston, and applied in sur-
gery by Dr. John C. Warren, of the same city. The best surgeons
throughout the globe have employed it, and even those not so well
1 For many excellent details on the moral preparation of the patient, see Pathologie
Externe, par Vidal du Cassis, torn. 1. ; also Velpeau's Surgery, by Drs. Mott & Town-
send, vol. i., New York, 1847.
182 OPERATIVE SURGERY.
informed have not hesitated to resort to its influence. Yet, out of
the thousands thus indiscriminately exposed, few have suffered
from its effects, whilst numbers have passed through the most
severe operations without being conscious of anything more than
" a pleasant dream."
In my hands, pure Ether was at first very widely administered ;
but I have, for some time past, more frequently resorted to it mixed
with Chloroform, in the proportion of one part of the latter to five
of the Ether, by weight, and have yet to see the first patient in
whom evil has been caused by its use. Pure Chloroform, though
highly esteemed by some surgeons, and especially by those of Europe,
is certainly a more dangerous substance, as is frequently shown by
the reports of the deaths that have ensued upon its administration.
Having also been once an eye-witness to the risks attendant on its
use, and aware of many others in the hands of skilful surgeons, I
feel compelled to offer this caution against its administration.
Ether, or ether and chloroform, mixed in the proportion just
stated, is, in my judgment, an anaesthetic that may be safely admi-
nistered by any well-educated physician. That it is a powerful seda-
tive, and liable to abuse, cannot be doubted, yet is it by no means
so dangerous as aconite, morphia, or many other articles of the
materia medica in daily use. That any anaesthetic requires to be judi-
ciously or even cautiously administered, is also true ; but there is no
portion of our professional duties which does not require the same
caution; and the liability of anaesthetics to be abused, therefore,
loses its weight as an argument against their proper use.
In the administration of Anaesthetics, almost any article will
answer for the application of the vapor to the mouth of the patient,
such as a hollow sponge, towel, or handkerchief. But, as these
agents are exceedingly volatile, much will be wasted when they are
thus employed ; in addition to which, the operator will suffer, as I
nave often done, from the lassitude consequent on breathing the
atmosphere. around the patient whilst administering ether in this
manner during a prolonged etherization. I prefer, therefore, in all
cases, the use of a simple cone, open at both ends, to surround
the sponge, as it prevents the waste of the ether, and yet furnishes
quite enough fresh air to obviate any inconvenience to the patient.
The importance of recognizing the precise period when anaesthesia
is induced, and thus guarding against the administration of an un-
necessary amount of the anaesthetic agent, has induced surgeons to
DUTIES BEFORE OPERATING. 183
pay special attention to the signs which most correctly indicate
" when the patient has had enough," at least for the moment, and I
shall briefly state them in connection with the mode of administra-
tion pursued by myself in several hundred cases, without ever
having seen any ground for the apprehension of danger.
Administration of Ancesthetics. — The purest ether and chloroform
being ready mixed, in the proportions of one part of chloroform to
five of ether, by weight, and well shaken together in a bottle, a good
soft, porous, cup-shaped sponge,, which has been previously soaked
in warm water and then wrung dry in a towel, should be moistened
by pouring over its surface about half an ounce of the mixture.
The patient being then placed in the proper position for the opera-
tion, should have the neck entirely freed from the constriction of
any portion of the dress, the precaution having been also taken to
keep the stomach nearly empty, for three hours before the operation.
The attendant who is to administer the anaesthetic — and he should
also do nothing else — having then placed himself near the patient's
head, should hold the sponge or cone lightly between his thumb
and forefinger, so that his hand may not obstruct the passage of fresh
air through the cells of the sponge, and apply it within two inches
of the patient's mouth and nostrils. Then, whilst feeling the pulse
with the other hand, let him direct the patient to take a long inspi-
ration, and also to expire through the sponge. As the patient's
lungs become accustomed to the stimulus of the vapor, the assistant
should at once apply the sponge closer to the mouth and nostrils,
turning it round occasionally, and taking care not to compress it, lest
the ether escape from the sponge upon the patient's skin and irritate
it. When the cone is employed, this inconvenience is also obviated.
After a few inspirations, or in about two or three minutes from
the commencement of the inhalation, the pulse will be found to
quicken till it may count 100 or 120, and then, as the respiration
becomes slower, gradually diminish in frequency. At this period —
that is, when the pulse commences to change its frequency — close
attention should be paid to the perfection of the inspiration, and a
close examination made of the state of the patient's muscles. If these
continue to act, anaesthesia is not yet perfectly induced ; but if, whilst
the patient is quiet, his arm, on being raised, drops, as if lifeless, or if
the eyelid, when opened, remains so, or simply drops, and the eye-
ball continues turned upwards, the pulse remaining of good volume,
anaesthesia is perfect, and the operation may safely proceed, the
sponge being reapplied as often as signs of consciousness return.
184 OPERATIVE SURGERY.
The effects of anaesthetic inhalation have been well described by
Dr. Warren, as follows: —
"On inhaling Ether, the patient's respiration is at first short and
quick, and apt to be followed by a cough or gasp, which induces the
patient to refuse the inhalation. 1 The bronchia becoming accustomed
to the vapor, the respiration becomes fuller and slower, till at last
the inspiration is taken to the fullest extent, when, as etherization
is induced, it becomes slower and comparatively feeble.
"The pulse at first is quickened, but soon begins to diminish in
frequency, and ultimately becomes slow, till it counts even as low
as forty or fifty in the minute.
"As soon as the pulse begins to diminish in frequency, the inhala-
tion may be checked, and the soporific effect of the vapor carefully
noted. The face and neck will soon be seen to become flushed and
heated, and the action of the heart to be strong and vibrating. The
conjunctiva is also apt to become temporarily injected, the eye va-
cant and listless, and the patient soon loses all control over vision.
"The muscles are often excited at first, and their increased action
sometimes makes the patient troublesome until perfect etherization
is induced." 2 But, with the mixture of one part of chloroform and
five of ether, just referred to, this muscular excitement is less fre-
quent. In either case, however, a serious operation should not be
commenced until this stage has passed, and a slight continuation
of the inhalation will soon remove it.
"Dr. Simpson, of Scotland, has observed that, to produce the full
and perfect effects of etherization, the following conditions are neces-
sary. First, the patient ought to be left in a state of absolute quiet and
freedom from mental excitement, both during the induction of ether-
ization and during his recovery from it. All talking and question-
ing should be strictly prohibited. Secondly, the primary stage of
exhilaration should be entirely avoided, or at least reduced to the
slightest possible limit, by impregnating the respired air as fully
with the ether vapor as the patient can bear, and by allowing it to
pass into the lungs both by the mouth and nostrils, so as to super-
induce rapidly its anaesthetic effect." 3
The quantity of ether necessary to induce anaesthesia will depend
1 When the ether is combined with chloroform in the proportions above mentioned,
this temporary irritation is less frequently noticed.
2 Etherization, by John C. Warren, M. D., Boston.
3 Simpson on Anaesthesia, p. 27.
DUTIES BEFORE OPERATING. 185
in a great degree upon the peculiarities of individuals. Females, and
especially those of a nervous temperament, require a much smaller
quantity than males ; and, among the latter, those accustomed to the
free use of ardent spirits will require more than those who are
temperate. In fact, it has often seemed to me that the amount of
ether requisite to induce anaesthesia, might be taken as a good index
of the habits of the patient, some having "stronger heads" than
others. I usually give about half an ounce at first, and then, if this
is inhaled without inducing anaesthesia, pour on a half ounce more,
repeating this amount from time to time, as the sponge becomes dry.
A single half ounce is sufficient for females, though I have admi-
nistered over four ounces in different doses to males of intemperate
habits. Dr. Hay ward, of Boston, who was among the earliest of those
who administered ether, by itself, states 1 that, in operations which
require from five to ten minutes for their performance, he has found
from three to six ounces sufficient, if the ether is of the purest kind
(rectified); but that a much greater quantity may be used with per-
fect safety, and the patient kept under its influence a longer time
without danger, by removing the sponge occasionally, and reapply-
ing it when sensibility is about to return. The same surgeon also
states, as evidence of the safety with which Ether may be thus ad-
ministered, that he has given it to "infants of seven weeks old, and
to individuals of seventy-five years, with entire success. He has
also administered it to persons suffering under chronic pulmonary
disease, not only without injury, but, in some cases, with decided
benefit. In fact, he hardly knows a state of the system in which
he would be deterred from using it, if called on to operate." Though
a warm advocate of the safety of ether, Dr. Hayward objects to the
use of chloroform and of chloric ether, on account of the poisonous
effects which he thinks are peculiar to chloroform.
As the opinions of surgeons have differed widely in relation to the
safety and advantages of ether over chloroform as an anaesthetic, I
cite the following expressions of their sentiments : —
Dr. H. J. Bigelow 2 always uses ether, and never pure chloroform,
when it can be avoided, believing that "ether merits an unquestion-
able preference over chloroform."
1 Remarks on the Comparative Value of different Ansesthetics, Boston Med. and
Surg. Journ., 1850.
2 Morton, Physiological Effects of Sulphuric Ether.
186 OrERATIVE SURGERY.
Dr. J. C. Warren 1 thinks ether decidedly preferable to chloroform
as an anaesthetic.
Dr. Jno. Ware, of Boston; Jno. Watson, Gurdon Buck, Jr., and
A. C. Post, of New York; J. Knight, of New Haven; Wm. M.
Wood, of the Navy ; Mutter, and many others in Philadelphia, also
regard ether as a less dangerous article than chloroform. Some of
the latter surgeons have, however, in common with myself, em-
ployed the combination of ether and chloroform, in proportions
which have varied from one and three to one part of chloroform to
five of ether by weight ; and believe that, as thus combined, the
muscular excitement which is often marked on the administration
of ether alone is counteracted by the sedative influence of the chlo-
roform, whilst the dangerous sedation caused by the latter in its
pare condition is obviated by the stimulus of the ether.
Drs. R. D. Mussey and Wm. H. Mussey, of Cincinnati, having, in
1849, nearly lost a patient under the unskilful administration of
chloroform, have continued to employ the mixture of chloroform
and ether. "They now use no other anaesthetic agent, under the
opinion that the ether sustains the vital powers against the purely
sedative effect of the chloroform." 2 Dr. Mussey has, however, ex-
perienced accidents from even this.
Dr. Geo. Hayward, of Boston, has used both, but is doubtful of
the safety of chloroform alone.
Drs. Parker and Mott, of New York; Bolton, Gibson, Cunning-
ham, and Parker, 3 of Eichmond; Nathan R. Smith, 4 of Baltimore;
Eve, of Georgia, with others, formerly preferred chloroform, though
I do not know their present views in relation to it. Soon after
the introduction of chloroform, the opinion of surgeons seemed to
be much divided in regard to the safety of the two articles; but
subsequent experience, judging from reports of accidents following
the use of chloroform by itself, inclines me to think that, at present,
those who prefer chloroform to ether as an anaesthetic agent are in
the minority. In Boston, several surgeons have, in recent cases,
employed the pure chloric ether in preference to the sulphuric.
Dr. Jno. Fred. May advocates chloric ether, preferring it to all
other agents. During three years he has used it liberally in hospital
and private practice, and given it to all ages, from the infant to the
1 Address to Am. Med. Association. 2 Western Lancet 1853.
3 Transact. Am. Med. Association, vol. i. < ji ,7/.
TO WASH ETHER. 187
old and infirm man, from a few minutes to more than an hour at a
time, without being disappointed in its effects in a single instance. 1
As it is of great consequence that both ether and chloroform,
when employed, should be as pure as possible, the surgeon will do
well to try the following processes before resorting to any parcel
that may be obtained from a druggist : —
To test the purity of Chloroform, Dr. Fleming, of Dublin, recom-
mends that chloroform should first be tested by holding a piece of
litmus paper over the mouth of the bottle. If the vapor reddens
or bleaches it, the article is unfit-for inhalation. He next drops a
little chloroform into a glass containing water or a solution of
nitrate of silver. If the chloroform remains like a transparent
globule at the bottom of the glass, it is good; but if the globule
appears like a muddy lens, or becomes opalescent, it is adulterated,
and unfit for inhalation. 2
In order to enable a surgeon to resort to the common ether when
he is unable to obtain the purer article, the following process for
washing and testing it is given : —
To wash Ether. — Pour the ether (say six ounces) into a large
bottle, and add about half a pint of water ; then agitate them by
shaking the bottle, and pour all the contents into a filtering glass,
or decant the ether carefully. The ether, being slightly soluble in
water and lighter, will float, and may be readily poured off, whilst
any alcohol it may contain will unite rapidly with the water, and
sink with it when the agitation ceases. If any sulphuric acid is
present, litmus paper, dipped in the ether, will be reddened; but if
it is free from acid, the paper will remain unchanged. If the ether,
when poured on a cloth and allowed to evaporate, leaves much
odor, it is impure. 3
The following rules in relation to the use and administration of
anaesthetics, suggested in a valuable report "On the Utility and
Safety of Anaesthetic Agents," embrace so much that my own expe-
rience has confirmed, that I shall enumerate them, in a condensed
form from the report of a committee consisting of Drs. Bolton, C.
B. Gibson, Cunningham, and Parker, of Eichmond, to the Medical
Society of Virginia, with a few additions : —
1st. Test the purity of the article to be employed.
1 Am. Journ. Med. Sciences, vol. xxii. N. S. p. 329, 1851.
2 Etherization in Surgery, by Dr. Fleming. Dublin, 1851, p. 52.
3 Jackson on Anaesthetic Agents. (See Bibliography.)
188 OPERATIVE SURGERY.
2c7. Examine the general condition of the patient. Organic dis-
ease of the heart or lungs, and a tendency to apoplexy, generally
contra-indicate the use of anaesthetics.
3d Place the patient in such a position (recumbent or reclining,
if possible) that the vapor may gravitate towards the mouth. The
relaxation of the muscles consequent on anaesthesia also forbids the
upright position.
&th. Avoid administering anaesthetics on a full stomach, as it
delays anaesthesia, and nearly always causes subsequently, profuse
vomiting.
btli. See to the introduction of a full supply of fresh air with the
vapor of the anaesthetic.
6th. Secure complete anaesthesia before commencing a serious
operation, and maintain it during its performance.
7th. Pay more attention to the effect than to the quantity admi-
nistered, except in using chloroform, when more than half a drachm
at a time is often hazardous, as the effects are cumulative and very
sudden.
8th. Let it be the special business of an assistant, who has expe-
rience in the administration of anaesthetics, to attend to the etheri-
zation.
9th. Always have a bottle of strong aqua ammonia at hand, as
well as a basin of cold water, in case of accidents.
Means to be employed to resuscitate a patient when over-dosed by an
AnoestJietic. — Although I have never seen any cause for apprehen-
sion in the use either of pure ether or ether and chloroform when
combined in the proportion of five of ether to one of chloroform,
yet as the accident may happen, and as it has often happened where
chloroform alone has been employed, a brief reference to the best
means of resuscitating a patient may save life, by aiding the inex-
perienced in their efforts.
1st. Thrust the fore-finger into the top of the larynx, and remove
the epiglottis from it, if spasmodically closed.
2c?. Practise artificial respiration by pressing alternately on the
chest and belly, so as to excite the diaphragm, and then breathe
into the patient's mouth, whilst his larynx is gently pressed back to
the front of the vertebrae, so as to close the oesophagus and prevent
the air passing into the stomach.
3d. Apply strong aqua ammonia, on a sponge, to the nostrils, as
soon as the patient gasps, or before this, if the effort is not soon made.
EFFECTS OF THE USE OF ANAESTHETICS. 189
4th. Dash cold water suddenly on the face, top of the chest, and
head.
6th. Have ready, especially in hospitals where anaesthesia is fre-
quently resorted to, an electro-magnetic apparatus, by which mus-
cular action may be sustained in the heart and chest.
These rules embody the most useful means of resuscitation, and
are thus briefly stated in order to facilitate their remembrance when
needed.
Effects which sometimes ensue on the use of Anaesthetics. — Some pa-
tients, on recovering from the state of anfesthesia, resemble the maud-
lin condition of a man half drunk, and are either very merry or very
sad, jocose or sorrowful. Females also often present symptoms of
hysteria, and this condition may last twenty minutes, or more, though
it is not always seen. Eapid and even rough sponging of the face
and head, together with the admission of an abundance of fresh air
into the patient's lungs, will generally promptly remove it ; if not,
a little time will. If, however, the patient has been kept perfectly
quiet, and the etherization has been judiciously conducted, that is,
not pushed too rapidly, and to the exclusion of the proper amount
of fresh air, this state will be less frequently noted. If the stomach
has been kept empty prior to etherization, nausea or vomiting will
also be rare; otherwise, it will frequently supervene. When it does,
it may be most promptly relieved by giving free draughts of warm
water, to evacuate the contents of the stomach; after which, the
organ will generally remain quiet. In most instances, however, anaes-
thesia is not attended by inconvenience, and these effects will be
found to be due either to individual idiosyncrasy, or, more frequently,
to the surgeon's inattention to the administration of the anaesthetic,
especially in connection with the use of food. The stomach must
be kept empty, if headache or other inconvenience is to be avoided.
The local arrangements requisite for the performance of the ope-
ration should next claim attention — such as the preparation of the
parts to be operated on, and the employment of the measures likely
to facilitate its performance. These measures may be summed up
in two rules: 1st. To remove everything that can impede the ope-
rative proceedings. 2d. To employ such means as will especially
facilitate them.
In observing the first rule, the operator must necessarily be
directed by the peculiar circumstances of the operation : thus, a
contracted pupil will interfere with the operation for cataract; a
distended rectum increase the dangers of lithotomy; whilst the
190 OPERATIVE SURGERY.
presence of hair about the part may render the dressing difficult,
cause irritation from discharges, or possibly lead to erysipelas.
Under the second head, or the direct efforts likely to facilitate the
accomplishment of the operation, may be placed the removal of all
unnecessary clothing, and especially of any that is tight at the neck,
as close-fitting jackets or shirts; the cleansing of the part from
plasters and poultices; and the employment of such means as will
tend to secure the safety of adjoining organs, or render those ope-
rated on more prominent, as the injection of the bladder in lithotomy
and lithotripsy, or the retention of urine in similar cases. Attention
to such a position of the part as will tend to drain it of blood, will
also occasionally be required — as in large pendulous tumors or dis-
eases of the extremities, where the elevated position will often pre-
vent much unnecessary depletion.
§ 2. — Duties during the Operation.
The duties of a surgeon during an operation embrace two distinct
portions : first, those which are requisite for himself, and which, as
he acts solely for the benefit of the patient, may be j ustly placed in
the front rank ; and, second, those demanded for the comfort and
safety of the individual operated on.
Among the first of the surgeon's duties to himself, during an
operation, is certainly a perfect degree of preparation for that
which he is to execute.
In addition to such professional acquirements, as a knowledge of
structure, or of mechanical skill as an operator, he should also, in
capital operations, or those of great delicacy, give some attention
to the state of his own system. Without a sound condition of his
own body, no surgeon can be fully prepared to operate upon that
of another. Let him, therefore, at least for some hours previous to
an operation, abstain from every act, article of food or drink, that
can in any way tend to derange his nervous system. Let him secure
a proper amount of sleep on the previous night, and, if he desires
to have the most perfect control of his fingers, let him also abstain
from anything like violent muscular effort immediately before his
appointment. The mere exertion of lifting the patient, or of driving
a hard-mouthed horse, will in some persons be quite sufficient to
impair the entire command of their muscles, though others of a
coarser mould may possibly find such attention to personal details
perfectly unnecessary.
DUTIES DURING THE OPERATION. 191
It may also, perhaps, be thought useless to refer to the propriety
of abstinence by medical men from nervous stimulants, on all occa-
sions ; but, as steadiness of hand is peculiarly important to a sur-
geon, attention to such a point is especially necessary previous to
an important operation.
While operating, the surgeon should endeavor to have his eyes
and ears, as well as his hands and brain, fully ready for every event ;
and so intent will a good operator be upon that which he has to
perform, that it often happens he is perfectly unaware of the pa-
tient's cries, or of affairs passing around him, until he has accom-
plished his object. In the event of any unexpected change, either
in the tissues through which he is cutting, or variation in the
character of the complaint which he intended to treat, he should
always endeavor to remain perfectly self-possessed. If a large vessel
suddenly springs, let him remember that it is only necessary to
compress it with hi3 finger until it can be tied with a ligature. If
a tumor has deeper attachments than was anticipated, he has only
to free it from these parts, instead of those for which he commenced
his operation ; if it proves to be of a different character from what
it was supposed to be, let him think that he can accomplish this
new affair as readily as that which was at first proposed. If his
hydrocele, on being tapped, prove to be a sarcocele, let him, if
necessary, at once proceed to the extirpation of the testis ; but under
no circumstances let him for a moment suppose that anything has
occurred which his skill and coolness cannot remedy. If the patient
faints, he knows that it is a simple matter, and that lowering the
head, and stimulants, will soon revive him. If convulsions super-
vene, as in trephining, is it not an additional reason for the more
prompt application of the remedial measures? If, unfortunately,
air enters into a large vein, will not the prompt pressure of the
thumb arrest its progress to the heart, and subsequent manipulation
expel it from the vessel, or prevent serious injury; 'as in the case
reported by Dr. E. D. Mussey, of Cincinnati, in which the effects of
the entrance of air into the subclavian vein was relieved by the
application of stimulants to the nostrils? 1 In fact, let what will
occur, the surgeon who undertakes an operation, is totally unfit for
his duty if he cannot, by these or similar views of serious diffi-
culties, preserve sufficient equanimity to meet them. Although he
1 Am. Journ. Med. Sciences, vol. xxi. p. 392, Phila. 1837.
192 OPERATIVE SURGERY.
may not be able to acquire the entire philosophy of the Stoics, some
cultivation of it is certainly desirable, and such stoicism is not rash-
ness, nor yet total indifference, but only that state of mind which
the French have justly termed "sang froid," a phrase which presents
us with a most apt expression of the consummate coolness that
always characterizes a good operator. How to gain it, cannot be
told. In some men it is intuitive ; but it may also be most certainly
acquired by practice; and nothing within my experience is more
conducive to it than the fact of an operator duly weighing before-
hand, every accident that can possibly, not probably, happen. When
prepared for danger, it loses more than half its paralyzing power.
When a young surgeon — wanting in experience of the changing
scenes or excitement often noticed during an operation — is so situ-
ated that he can avail himself of the lessons furnished by observa-
tion of the habits and course of action of his seniors, he should
seize them promptly, for they possess a value which naught but
subsequent practice will enable him justly to estimate.
Another portion of the surgeon's duties, during an operation,
will be found in the various positions and manoeuvres he will be
required to execute, all of which should be duly settled before he
commences. Thus, in an amputation, he should settle in his own
mind which position will give him the most perfect control of the
patient's limb, or on which side he can most conveniently dissect
out a tumor ; in what manner he will remove a stone, or ligate an
artery ; what shall be the position of the patient, and what the posi-
tion of the assistant, so that each detail shall be fully weighed.
But as such arrangements vary* much under different circumstances,
the further consideration of them can be best given under their
proper head.
The credit which has been attached to certain operators, in refer-
ence to the rapidity of their operations, presents another point to
which, at this period, attention may well be directed. "If it were
done when 'tis done, then 'twere well it were done quickly," is the
rule apparently of some who enter the surgical arena, it being evi-
dent that the most thought is given to that portion of the sentence
in which reference is made to time. But though this may suit the
spirits of those who, in true Shakspearian style, look upon an ope-
ration as a dramatic exhibition, it is certainly not adapted to those
of others, who, with a more manly view of responsibility, regard the
interests of the patient as paramount to everything else. Safely
DUTIES AFTER THE OPERATION. 193
at all events, quickly if you can, should be the motto of every con-
siderate operator; and the slow and sure will very often prove to be
the quickest in the end.
During the operation, the surgeon's duties to the patient are very
much limited to those just enumerated in connection with himself.
The assistants must necessarily do much towards attending to the
patient's comfort and relieving his wants ; they should give him
drink, and revive or restrain his irritability according to circum-
stances; whilst the operator, by leaving such duties to them, may
confine himself strictly to his own acts, or simply encourage his
patient by voice and manner as he proceeds.
The duties of assistants will be detailed hereafter.
§ 3. — Duties after the Operation.
Notwithstanding the possession of all the qualifications and skill
which have been detailed as essential to an operator, the best ope-
rations will be likely to fail, unless the surgeon is also equal to the
performance of the duties which ensue upon its completion. The
proper application of the dressings; the judicious employment of
remedies to counteract the violence necessarily caused by the ope-
ration; the arrangement of the bed, the position of the patient, and
of the part operated on ; the resort to stimulants, the encouragement
of sanguine anticipations ; the calm of sleep, together with diet, &c,
are but a few of the points to which his attention must now be
given. To the well-educated surgeon, reference to such details may
seem to be a work of supererogation. But to the less accomplished
or experienced operator, or to practitioners whom circumstances
compel to act the part of a surgeon, the recapitulation may not be
without its value. As a general rule, most of these duties may be
summed up under one direction, to wit : the observance of such a
course of treatment as any good physician would naturally direct,
even if not possessed of surgical experience. A few of them, how-
ever, which embrace matters essentially surgical, seem to demand a
closer examination, especially the employment of stimulants, diet,
and exercise.
In respect to stimulants and diet, as all rules must be dependent
on the object to be attained by the operation, it becomes difficult or
impossible to establish any one law which will be applicable to every
13
194 OPERATIVE SURGERY.
case; and jet a mistake in relation to this most important part of
the after-treatment may cause the failure of all previous arrange-
ments. It may, however, be said that, generally, an operator will
not err in this part of his duty, if he bears in mind the great prin-
ciples of all sound practice, viz. the treatment of Inflammation. Is
the wound to heal by the first intention, or by granulation? Is the
object of the operation to be attained by exciting inflammation, or
will its development destroy the result ? Is the action to proceed
simply to effusion of lymph, or to suppuration ? Is the exercise of
the part operated on essential to its cure, as in strabismus, or is its
perfect rest necessary to success, as in false joint ? These and simi-
lar interrogatories will soon settle the doubts of any well-trained
medical mind in these details.
As respects the proper diet of a patient after an operation, much
will of course depend upon the replies made to the above questions;
but in many operations, such as amputations, removal of tumors,
and resections, where moderate vascular excitement is not likely
to result in hemorrhage, a surgeon will be very liable to error if
he invariably places his patient upon a restricted diet, either before
or after the operation. In some instances, and especially in advanced
life, the change from ordinary food to a strict diet is alone suffi-
cient to disorder the digestive organs, affect the circulation, and de-
range the nervous system, even where no other cause is liable to act
on the patient's general health. How likely, then, is it to do harm,
when, in addition to change of diet, the shock of an operation is
conjoined with the other perturbating causes. In most instances,
and especially where common prudence does not clearly demand
it, the operator should therefore make no other change in the pre-
vious diet of his patient than simply to restrict the quantity.
Indeed, in some instances even this will do harm, especially if it is
combined with purging. An increase both in the quality and
quantity of the nutriment, under certain circumstances, often proves
not only useful, but absolutely necessary, especially if strict atten-
tion is at the same time paid to the regular daily alvine and urinary
evacuations. In many instances I have known patients to become
feverish, irritable, and have a furred tongue whilst on a diet or
purged, who were promptly relieved by quinia, porter, and beef-
steak. A full diet will not auswer as a universal rule; but, with
attention to the state of the system before the operation, to the wast-
ing effects of the disease or of the wound, and especially to the
DUTIES AFTER THE OPERATION. 195
purely local disorder caused by a certain class of operations, good
diet will prove most useful, and the continuance of nutritious food
after an operation be more serviceable than the practice of deple-
tion before, and low diet for three or five days subsequently.
In recommending a fair or even full diet, that is, a moderate
allowance of meat and ordinary food after operations, I do not wish
to do more than suggest its value ; circumstances must restrict its
application, and in some instances do this very rigidly, as after
trephining, in cataract and in hernia. But in operating for the
removal of tumors in the breast or extremities, or in the case of
patients who whilst in full health are suddenly injured, and espe-
cially in operations consequent on chronic diseases, a moderate
amount of ordinary animal food for the first three days, and then a
tolerably full diet, will often prove most conducive to a successful
result, particularly when employed with judgment.
The propriety of employing a purgative at an early period after
the performance of a capital operation is also a question which
must be decided by the peculiarities of each case, and perhaps also
by the personal experience of the operator. Like diet, purging is
a point of treatment that cannot be regulated by any universal rule,
but it will generally be found to be good practice, to keep the bowels
free after an operation, but not to purge; these remedies having
usually been sufficiently employed prior to operating.
Dr. Jno. P. Mettauer, of Virginia, 1 whose skill and experience as
a surgeon are well known, advocates purging after an operation, as
one of the best means of preventing an undue degree of inflamma-
tion, and especially when swelling, tenderness, and throbbing of the
wound persist, the agents, by which the purging is accomplished,
being carefully adopted. In gastric disturbance after an operation,
or when the bowels have been, previously disposed to constipation
or diarrhoea, he prefers a decidedly cathartic enema (four heaping
tablespoonsful of salt, to a pint of warm water). If this fail to purge
sufficiently, he follows it by a purgative pill. In support of the
efficacy of early purging in preventing traumatic inflammation
after capital surgical operations, Dr. Mettauer states 2 that, out of
seventy-nine operations for stone in the bladder, seventy-five were
purged in from five to twelve hours after the operation, and in not
1 Virginia Med. and Surg. Journ., No. 1, p. 1, 1853.
2 Idem., p. 7.
196 OPERATIVE SURGERY.
a single instance did inflammation occur in any degree beyond what
was necessary for the healing of the wound. The only cases lost
were the four he did not purge. In fifty-eight operations for ascites,
every patient but one was purged within twelve hours without in-
flammation succeeding. In thirty cases of reduced strangulated
hernia, in fourteen cases of vesico-vaginal fistula, and in hundreds
of instances of other severe surgical operations, he has uniformly
prevented undue inflammation by purging, and perfect cures fol-
lowed; other means were only employed as auxiliaries.
SECTION II.
PREPARATION OF INSTRUMENTS.
Although a good operator can doubtless accomplish his object
with any instrument that he can obtain, yet few would desire
to neglect, or be justified in neglecting, the attentions referred to
under this head. A common instrument, with a skilful workman,
will do more than the best one that can be placed under the direc-
tion of an ignoramus; but even a skilful workman will obtain a
more perfect result by collecting and preserving such as are requi-
site for his daily wants.
In this division of his general duties, the surgeon's attention
should, therefore, be bestowed on the selection, preparation, mani-
pulation, and preservation of his " mechanical therapeia."
§ 1. — Action and Selection of Instruments.
In selecting his instruments, every operator must be mainly
guided by the wants of his own position. As a general rule, his
attention should be first bestowed upon the character of the steel,
its temper, finish, and shape. Very many of those who begin life
in expectation of devoting themselves to surgery, commit the mis-
take of purchasing a cheap article instead of a good one, and soon
have reason to repent of their bargains. Poor steel cannot be made
to keep an edge, and constant sharpening, independently of the dif-
ficulty arising from want of skill, soon renders it useless. Good
steel is a more costly article at first, but the cheapest in the end,
PREPARATION AND SHARPENING OF INSTRUMENTS. 197
and, like a true friend, never fails in the hour of need. Attention
to this fact is the more necessary in the United States, from the
great number of surgical instruments now hawked over the country,
and which, like Peter Pindar's razors, are only made to sell. Every
operator should, therefore, exercise some caution in the selection of
his cutler, and even with the best makers, will find some exer-
cise of judgment necessary in obtaining his instruments. Fashion
often perverts the utility of a knife as well as of other articles, and
a knowledge of the action requisite in the instrument will, there-
fore, materially aid in its choice. To assist the decision of those
who are inexperienced in this matter, special care has been bestowed
on the delineation of those hereafter represented; so that any one,
by consulting the plates, can see a specimen of such as are at least
capable of performing their duty; 1 but in selecting all instruments,
the observation of the quality of the steel, and not the brilliant
appearance of the work, will tend to prevent most errors of this
kind.
§ 2. — Preparation and Sharpening of Instruments.
Where an operator is so situated as to be able to avail himself
of the services of a cutler, this portion of his duty may be advan-
tageously placed in other hands; but, under different circumstances,
or where he desires to save expense, he will soon find it an easy
matter to accomplish perfectly the sharpening of the greater por-
tion of his own instruments, and especially those which are in most
constant use.
Preparatory to attempting the sharpening of any instrument, it
is necessary that the principle of its action should be thoroughly
understood, and that a good stone be obtained, as well as a strop or
piece of soft leather.
The action of every knife is beyond doubt the same as that of a
saw. No matter how fine the edge of a knife may be, a magnifying
glass will show points corresponding with the teeth of a saw; and a
1 To add to the value of these drawings, they have generally been made in accord-
ance with the patterns of Mr. Charles Schively, cutler, of South Eighth Street, Phila.,
a gentleman long identified with the operative surgery of the country, and to whom
many of our most distinguished surgeons are indebted for the means by which they
have accomplished their most important operations.
198 OPERATIVE SURGERY.
PLATE I.
A SIDE VIEW OF SOME OF THE INSTRUMENTS EMPLOYED IN MAKING
INCISIONS AND DISSECTIONS, IN THE EXTIRPATION OF TUMORS AND
THE LIGATURE OF ARTERIES.
These instruments are drawn about one-half the natural size.
Fig. 1. Small size Scalpel for delicate work.
Fig. 2. Operating Scalpel, medium size.
Fig. 3. Operating Scalpel, larger size.
Fig. 4. Operating Scalpel, of greater strength.
Fig. 5. The Silver-grooved Director. This instrument ought always
to be sufficiently soft to admit of its being bent when desired.
Fig. 6. Straight sharp-pointed Bistoury.
Fig. 7. Curved sharp-pointed Bistoury.
Fig. 8. Cooper's Hernia Bistoury.
Fig. 9. Probe-pointed curved Bistoury.
Fig. 10. Position of the Scalpel on the Hone in the first motion towards
Sharpening.
Fig. 11. The second Position of the Scalpel in Sharpening.
Fig. 12. Savigny's Tenaculum for Ligating deep-seated Arteries.
Fig. 13. Ordinary Tenaculum. This instrument is generally too much
curved, and the present one has, therefore, been carefully selected.
Fig. 14. Horner's Aneurism-Needle. A slip-knot is placed on the
shoulder at 1 and carried around the artery without creating any obstruc-
tion from the thickness of the ligature.
Fig. 15. Liston's "Bull-dog" Forceps.
Fig. 16. Torsion Forceps.
Fig. 17. Ordinary Dissecting Forceps.
Fig. 18. Polypus Forceps.
Fig. 19. Tumor Forceps.
PREPARATION AND SHARPENING OF INSTRUMENTS. 199
saw, to cut well, must be set so as to act chiefly in the reverse direc-
tion to that in which it is drawn, seldom cutting both up and down
with equal facility. The teeth in the scalpel being intended to cut
by being drawn over the tissue, in a manner similar to the upward
motion of the saw, their edge should be set forwards in sharpening,
or from the heel to the point. In the application of the blade to
the stone, such motion must, therefore, be given to it as will draw
its cutting surface in this direction, the blade being kept at an angle
of from 5° to 15° with the surface of the stone, so as to create the
proper edge, and yet preserve the polish of the instrument. Every
knife being also more or less wedge-shaped, that is, thick upon its
back and tapering to its edge, the sharpness of the wedge will con-
stitute the keenness of the blade. The flatter, therefore, the blade
is placed, provided it is not below 5° with the surface of the stone,
the more delicate will be the angle produced in the friction of
sharpening, whilst the more elevated the back, the greater the
pressure on the edge ; so that, after this elevation passes an angle
of 20°, it will be apt to result in a blunt, rounded or dull surface.
When, then, with a good stone (and in the United States there is
nothing superior to those of Arkansas or Missouri), the operator
wishes to give his scalpel a keen edge, let him proceed as fol-
lows : —
Place the blade very nearly flat upon the surface of a stone,
which has a smooth and well-ground face, after it is lubricated with
oil, and, holding the handle with the hand in a state of semi-prona-
tion, push the blade, with its edge forwards, across the stone (Plate
I, Fig. 10); then turning the hand into semi-supination, draw it
from heel to point with its edge towards the operator, over to the
point of departure, bearing on lightly or heavily, according to the
amount of grinding to be accomplished (Plate I, Fig. 11). As a
general rule, the harder and closer the grain of the stone, the flatter
the blade is applied to it, provided it is not below 5°; and the
lighter the pressure, the keener and smoother will be the edge.
After repeating these movements until an edge is obtained (as may
be tested by shaving the thick skin on the palm of the hand), draw
the blade upon the strop or leather in the same manner as razors
are sharpened for daily use, and in the reverse manner to that em-
ployed on the stone — that is, with the back of the blade presenting
to the most distant end of the strop.
In sharpening pointed instruments, such as cataract needles, tro-
200 OPERATIVE SURGERY.
cars, and gorgets, the same principles bold good, although some
extra attention to the shape and character of their cutting surface
will be required in order properly to adapt them to the stone. As
a trocar acts very much on the principle of the chisel, the mode in
which that instrument is sharpened by the carpenter will answer,
provided the point is kept flat to the stone— and the same manoeu-
vres will be applicable to cataract needles and gorgets when the
edges have become very round ; but under other circumstances it
will be better to manipulate with them in the manner described in
sharpening the scalpel.
AVhen an instrument has acquired a rounded and blunt edge,
grinding will generally be found necessary, and, in most instances,
this should be confided to the cutler, though the surgeon may ap-
proximate the same end, by steadily rubbing the blade upon a
coarse stone, and then proceeding to finish its edge by using one
that is finer, or even a strop.
§ 3. — Manipulation of Instruments.
Few of the qualities of an operator are more quickly noticed by a
spectator than the facility or "even grace with which his movements
are executed. But although this ease in manipulating is highly
advantageous to the patient and a valuable accomplishment to an
operator, directions in regard to it would be out of place at present,
and can be more readily comprehended in connection with each
operation.
The principles which should govern the movement of cutting
instruments in all operations, may, however, be briefly noticed.
Scalpels, bistouries, and amputating knives, acting simply as
saws, will be found to cut with the greatest facility when drawn
regularly, and with moderate but steady pressure, over the part to
be divided.
When, therefore, in using a scalpel, it is desirable to make a clean
and smooth cut, the motion given to the instrument should be one
chiefly of traction, effected by flexing and extending the thumb
and fingers in very much the same manner that a pen is moved in
writing, any great amount of motion in the wrist or downward pres-
sure being unnecessary. Indeed, as a general rule, the wrist-joint
should never participate in the motion of a scalpel, except when it
MANIPULATION OF INSTRUMENTS. 201
is requisite to change the course of an incision, or make it of
extraordinary length, and even under these circumstances a neat
manipulator will seldom feel the necessity of moving it. If the
wrist is permitted to take part in the movement of dissecting,
chopping or hacking of the tissue will usually result, or such a
division of parts as might be effected by an axe, but not by a saw.
Scissors, being formed, of two blades, are designed to act like
two scalpels pressed together; consequently, in dividing very dense
structures, a slight drawing motion enables them to cut better and
with less contusion of tissue, than the exercise of any great amount
of force in closing the blades.
Instruments specially required for punctures are fortunately few
in number. Like the chisel, they necessarily compress or contuse
the parts at their point of entrance, and should, consequently,
always possess a keen edge and be introduced gradually. The
stabbing motion sometimes given to trocars or gorgets is usually
indicative of ignorance of these principles on the part of the ope-
rator, and nearly always induces more or less sloughing at the point
punctured. A sudden elevation of the operating hand from the
surface on which it should be supported, is also an error occasionally
apparent in operators when using the scalpel, and especially of such
as study the art of manipulating with a view to the gracefulness of
the movement, rather than as an auxiliary to the perfect action of
the instrument. Like a similar motion on the part of pianists, it
may be deemed captivating to the observer, but as it necessarily
draws the knife from the portion on which it is acting, it is worse
than useless, and should be avoided. A neat operator may be
characterized as a good dissector, who accomplishes his task with
certainty and moderate quickness; and the motions of a good dis-
sector are certainly not of the jumping order, but, on the contrary,
result from the regular movements of his fingers in flexion and
extension. All manipulation of cutting instruments, to be well
executed, should therefore be entirely accomplished by these mo-
tions of the fingers, or by those of a hand which moves as if
balanced at the wrist. The motion of the elbow can never be
required in using a scalpel, and seldom with any other instrument,
except the saw or amputating knife. Great flexibility of the
fingers, and the power of causing three or four of those of the
same hand to perform different acts at the same moment, will
also add much to the neatness of a surgeon's manipulation. Thus,
202 OPERATIVE SURGERY.
the thumb, and first and second fingers, may hold the scalpel in
dissection ; the little finger serve as a point of support, and the
third finger be made to stretch a tissue, hold back a flap, and
serve as a fulcrum at the same moment— the difference of power
possessed by some operators over others being often shown in the
facility with which they accomplish these movements. A thick,
clumsy, and heavy hand can never make a neat operator, though
study of its motions, together with constant practice, may do much
to remedy its defects. The ability to use the left hand nearly as
well as the right is also occasionally not only an accomplishment,
but also a most useful qualification in an operator, and a little
practice in the daily acts of life, as in carving or dressing, will soon
enable any one to acquire it.
In order to facilitate his manipulations, the operator will also find
it advantageous to arrange his instruments upon a waiter or tray
in the order in which they will be required for service, previous to
commencing an operation.
In doing this, he should pass in review the different steps of his
operation, so as to note immediately the absence of any one that
may be required. By placing a napkin upon the tray, so as to
prevent the blades touching any hard substance, he will also do
much towards the preservation of their edges, and be prepared to
act with them in the most advantageous manner. In hospital ser-
vice, a board is usually kept prepared for this purpose, and will
generally be found to answer very well. Upon this, the operator
should spread a napkin, and then, if about to perform a circular
amputation, place upon it his tourniquet and bandage, with a pin
and scissors; then the amputating knife; then a scalpel to dissect
back the skin ; then a small catlin for the inter-osseous space, if the
limb has two bones ; next, a retractor to protect the soft parts when
sawing the bones; then the saw; next, the bone nippers, and then
the tenaculum and ligatures. It is also a good rule to have at least
two of all such instruments as are liable to be injured or rendered
unfit for service during an operation.
Some surgeons, especially in public institutions, very properly
confide the arrangement of their instruments to an assistant ; but,
when this is done, they should carefully overlook the tray before
commencing the operation. Another tray, containing the anaes-
thetic, the bandages and other portions of the dressings, as sponges,
basins, and stimulants, should also be close at hand; and if the room
PRESERVATION OF INSTRUMENTS. 203
admits of it, one tray may be placed so near the operator that he
can help himself to his instruments. But, if this is not desired, a
special assistant may hand them to, and receive them from him,
according to directions which should always be given previously ;
no other person being allowed to touch either board, after the com-
mencement of the operation, lest confusion be created, by several
persons attempting to reach them at the same moment.
§ 4. — Preservation of Instruments.
A few words in relation to this apparently simple portion of an
operator's general duties may, perhaps, save the younger surgeon
some vexation. No matter how finely polished instruments may
be, as received from the cutler, unless an operator is attentive to
this minor point, he will soon find them out of order. Thorough
cleansing after operating is, of course, essential to their preservation,
and every surgeon should, therefore, either wipe and thoroughly
dry his instruments himself before putting them away, or examine
them closely, if the duty is performed by another.
In keeping instruments ready for use, attention to the place of
deposit is also necessary ; as sometimes there is a slight dampness
in a closet, which will soon tell even when the cases are closed per-
fectly, and which will be certain to create rust when instruments
are put away without a case. Even in a warm and apparently dry
room, I have known my eye instruments to be so affected by moist-
ure as to become rusty. A practice which is pursued to some
extent in the preservation of instruments, is also one which fre-
quently destroys or impairs their utility, viz., oiling or greasing
them, when replaced in the case. This custom, as well as that of
anointing the blades with mercurial ointment, may serve a good
purpose on board ship or near the sea-shore if very lightly done ;
but, under ordinary circumstances, the development of acid in the
chemical change of the article, especially when it becomes rancid,
will soon do quite as much towards rusting a blade as a damp at-
mosphere. The most certain preservative in my experience has
been, first, to render each instrument perfectly dry ; second, to keep
it well wrapped in soft paper or cotton ; and third, to place it in a
close box, and wrap this thoroughly in hardware or thick brown
204 OPERATIVE SURGERY.
paper. These precautions, however, can only be required by such
instruments as are not in constant use.
As the author has been often consulted in relation to the kinds
of instruments most likely to be required by a young surgeon com-
mencing practice, he has selected the following as embracing in a
small space a sufficient amount for most of the operations (except-
ing amputation, stone, trephining, and eye cases) that he may be
called on to perform. It contains all that is essential for the extir-
pation of tumors, ligature of arteries, hernia, fistula in ano, hemor-
rhoids, and polypus narium, and is known among some of the
cutlers as his " Minor Case." It consists of 1 Probe-pointed curved
Bistoury. 1 Hernia Bistoury. 1 Sharp-pointed straight Bistoury.
4 Operating Scalpels of different sizes (1 large, 1 medium, and 2
smaller). 1 Tenaculum. 1 Savigny's Tenaculum. 1 Pair of Dis-
secting Forceps. 1 Eyed Probe — all in a tray.
1 Physick's Forceps and Needle. 1 Polypus or Short Forceps.
1 Tumor Forceps. 1 Pair small Bone Nippers. 2 Curved Spatulae.
2 Coils annealed Wire. 3 straight and 3 curved Needles. 1 dozen
Harelip Pins, of steel, like ordinary needles. 1 Horner's Tena-
culum, for hemorrhoids — in the bottom of the case.
1 pair sharp-pointed Scissors. 1 Silver Director. 1 Double
Canula of Levret, for polypus. 1 Physick's Canula (small) for
hemorrhoids — in the top of the case.
The cost of all these instruments, including the case, should be
about $22.
SECTION III.
THE OPERATOR'S DUTIES TO HIS ASSISTANTS.
In every important operation, the value to the patient of the
services rendered by good assistants may be regarded as nearly
equal to those of the operator, the responsibility of the surgeon
being much increased, and his labor greatly augmented, when com-
pelled to act by himself. In addition to their ordinary duties, the
necessity for one of them taking the principal part, also occasionally
occurs, as in the event of cramp or embarrassment in the operator;
and under such circumstances a good assistant is essential to the
welfare of the patient.
SELECTION AND INSTRUCTION OF ASSISTANTS. 205
Every operator should, therefore, thoroughly reflect upon the
character and qualifications of those whom he selects to assist him,
as well as upon the duty they may have to perform, choosing them
not only with reference to the physical, but also to the moral, sup-
port that they can furnish him. A doubt may arise as to the cha-
racter of the tissue operated on, or as to the propriety of continuing
the operation ; and in all such cases the decision of the question will
depend, to a considerable extent, on the skill and judgment of the
assistants, if they happen to be medical men.
§ 1. — Selection and Instruction of Assistants.
In selecting assistants, every surgeon will of course be guided by
his peculiar position ; but if he can obtain the services of his pro-
fessional brethren, and especially of those with whom he is on inti-
mate terms, he will doubtless select them. Where, on the contrary,
this is not the case, and he is compelled to resort to strangers, and
especially if, in addition, they are to be selected from the friends of
the patient, he should be especially cautious in his choice. Many
who are very brave before an operation, find their sang-froid fail
them after a little blood is lost. Others are sickened by smells or
by the flow of blood, and rendered worse than useless, by requiring
for themselves the attentions that are due to the patient. Others,
again, even among medical men, are so little conversant with the
details of operative surgery as to require instruction, or, when this
is not necessary, are so clumsy in the use of their fingers as to put
them constantly in the wrong place. Very few general practition-
ers are able to tie a ligature as quickly as a surgeon, simple as it
appears to be ; and an operator should, under such circumstances,
anticipate extraordinary difficulties, and prepare himself to meet
them. As, however, it is impossible to give more than general
directions on this subject, the surgeon must regulate his action
according to the wants of the moment.
One rule may certainly be laid down as applicable to all cases,
even when the surgeon is fortunate enough to be aided by the pre-
sence of those on whom he can rely, and that is, always to explain
to all who are to participate in the operation, the method to be
pursued, and the special duty that will be assigned to each, before
commencing to operate. Few operations in surgery are so limited
206 OPERATIVE SURGERY.
in their character as to be amenable to any universal law, and the
peculiar views of each operator should therefore be distinctly ex-
pressed, even to his colleagues, before the operation is commenced.
And though surgeons may differ in opinion as to the advantages of
one method over another, the professional assistant should remem-
ber that, as the chief responsibility of the case rests on the opera-
tor, it is for him, and him alone, to decide which plan he will adopt.
In all cases, where surgeons meet in consultation, these differences
will be made to harmonize, or be yielded to, previous to the com-
mencement of the operation ; but under few if any circumstances,
should an assistant express his individual opinion of a plan of
proceeding whilst the operator is engaged in the use of the knife.
Marked ignorance of structure, on the part of an operator, might
justify a surgeon of more extended experience in calling the ope-
rator's attention to anatomical points, or to matters likely to risk
the life of the patient. But as every operator doubtless has his own
views of the case, as well as of the best plan of operating, he should
not be troubled by useless conversation, or unnecessary fingering
of parts, or other inconsiderate or perhaps conceited interference
among those around him. I would, therefore, offer this as a rule
for all assistants, viz : That they limit themselves strictly, both in
word and deed, to the duty assigned them, except in cases of ex-
treme emergency. On the other hand, I would urge all surgeons
to remember that it is for the benefit and comfort of all parties,
that they should subsequently endeavor so to arrange their own
movements as not to encroach upon the duties previously assigned
to others. Occasionally, good surgeons err in this manner, and
delay their operations by endeavoring to do everything them-
selves, instead of relying upon their assistants for the performance
of the share previously assigned them. When good assistants are
to be obtained, let them by all means be trusted, and the patient
will be sure to benefit by the division of labor.
The instructions and special duties of assistants will be referred
to in connection with each operation.
INCISIONS WITH THE SCALPEL, OR BISTOURY. 207
CHAPTER II.
ELEMENTARY OPERATIONS.
Under this head are embraced such general manipulations as
constitute the primary portion of every operation, and especially of
those necessitating a division of the integuments ; such, for example,
as Incisions and Dissections, arrest of Hemorrhage, together with
the closing of the part and its Dressing. Although every surgeon,
in passing through his anatomical studies, necessarily acquires a
certain degree of skill in making incisions and dissections, yet a
recapitulation of the ordinary rules required for their proper per-
formance may correct such faults, either of carelessness or ignorance,
as have been unwittingly acquired. The details of each act, and
the varying positions of the knife usually described by French
writers, have, however, little of sufficient value to justify their repe-
tition, except that the employment of a numerical system in the
position of the scalpel is advantageous by saving repetition in the
description of the same act in different operations.
SECTION I.
INCISIONS WITH THE SCALPEL, OR BISTOURY.
The Scalpel usually employed in operating, resembles in most
points that generally found in the dissecting case. Its function is,
indeed, the same in both instances, though in operating, as in dis-
secting, there is a difference of opinion as to the best shape of its
blade, some surgeons preferring one that is somewhat angular
towards the point, and others liking it better when made with a
greater degree of convexity. In either case, the blade should be
firmly fastened to the handle, and the latter made plain and tole-
rably smooth, not only because this is more favorable to accuracy
of touch, but also because it can be more readily cleansed. On
the latter account, the serrated handles sometimes placed on scalpels
are objectionable.
208 OPERATIVE SURGERY.
PLATE II.
THE SIX POSITIONS OF THE HAND AND SCALPEL, EMPLOYED IN
MAKING INCISIONS AND DISSECTIONS.
Fig. 1. The First Position of the Scalpel. The scalpel is held as a
carviag-knife, so as to cut from without inwards. In this position, the
thumb and radial side of the second finger should be placed at the rivets
in the handle, whilst the ring and little finger shut the back of the handle
into the palm of the hand, and the forefinger rests upon the back of the
blade. The further this finger is extended upon the blade the greater will
be the amount of force that can be employed by the operator.
Fig. 2. A View of one Method of Incising the Skin with the Scalpel
in the First Position. A fold being raised and rendered tense by the left
hand of the surgeon and the right hand of an assistant, and the incision
made by cutting from without inwards.
Fig. 3. Another Method of Incising the Skin. The parts being made
tense by the thumb and forefinger of the surgeon's left hand.
Fig. 4. The Second Position of the Scalpel, or the reverse of the first.
In this position, the thumb and forefinger should be placed at the sides of
the handle near its junction with the blade, and the middle, ring, and little
fingers be employed in grasping the handle. A fold of the skin being
raised, is to be punctured and then incised from within outwards, when
the knife is held in this position.
Fig. 5. The Third Position of the Scalpel. In this position, the scalpel
is held as a pen between the thumb and first two fingers, whilst the hand
is supported and steadied by the other fingers. The tissues to be divided
are held by the forceps, and the scalpel made to divide them simply by
flexing and extending the fingers.
Fig. 6. The Fourth Position is the reverse of the last. The scalpel
being held as a pen, but with its edge from the surgeon, so as to cut only
by extending the fingers.
Fig. 7. The Fifth Position of the Scalpel. In this position, the scalpel
is held as a " fiddle-bow," the pulps of the four fingers being extended in
a line along one side of the handle, and the thumb placed on the opposite
side so as to correspond with the line of the fingers. This position is a
very easy one, and gives great lightness and delicacy to the incisions.
Fig. 8. The Sixth Position of the Scalpel. In this, the scalpel, or
straight bistoury, is held with the fingers flexed, and with its edge towards
the hand. The left hand in this position generally holds the director, which
is kept stationary, whilst the right passes the knife along its groove.
SSfc^ ^ .' fe
INCISION WITH THE SCALPEL, OR BISTOURY. 209
The most common positions of the scalpel, in operating, are the
six following, as employed by the French surgeons: —
First Position. — Hold the scalpel in the position of a carving-
knife, that is, with the handle in the palm of the hand and the fore-
finger pressed upon the back of the blade, and make the incision by
bearing firmly on the blade with the forefinger (Plate II., Fig. 1).
This position gives the operator an opportunity of exerting con-
siderable force, and is well adapted to the first incisions in dense
tissues, as in excising a scirrhous breast, or in the removal of an
osseous or fibrous tumor, or in the division of ligaments or tendons
and muscles, in disarticulating joints. When it is desired to render
the skin tense and make the external incision in a certain line, the
integuments should be steadied as represented in Plate II., Fig. 2.
Second Position. — Hold the scalpel with its edge upwards, and,
puncturing a fold of the skin, incise it from within outwards, by
elevating the point with the thumb and finger, pressing the handle
against the palm with the other fingers (Plate II., Fig. 4). Pre-
vious to employing the scalpel or bistoury in this position, an as-
sistant should be directed to raise a fold of the skin so as to free it
from the subjacent parts. When the integuments are thus divided,
there is but little risk of injuring deep-seated parts, and also less
pain caused to the patient than when the incision is made from
without inwards, as in ordinary dissection, or in that represented in
Plate II., Fig. 2, where a fold is raised and incised from the outside.
Third Position. — Hold and move the scalpel very much like a
pen, the point and edge being pressed downwards with sufficient
firmness to enable them to divide the parts to the desired extent.
In commencing an incision, the point of the blade should be in-
serted into the tissue by a perpendicular pressure of the fingers in an
extended position, and the knife drawn firmly towards the operator
by strongly flexing the fore and second fingers (Plate II., Fig. 5)
the incision being terminated by a perpendicular pressure of the
blade at the point where it is wished to stop, in order to prevent
the irregular scratch of the skin, or that mark which the French
call "a tail."
Fourth Position. — Hold the knife nearly in the same position
as a pen, but with its cutting edge upwards, so as to cut from the
operator (Plate II., Fig. 6). Both this and the third positions are
constantly required in every operation in which dissection is neces-
sary, as in the removal of tumors, ligature of arteries, &c.
14
210 OPERATIVE SURGERY.
PLATE III.
A VIEW OF THE DIFFERENT INCISIONS, AND OF SOME OF THE MEANS OF
CLOSING THEM AND ARRESTING HEMORRHAGE.
Fig. 1. Signoroni's Tourniquet, for arteries which are placed near bony
depressions.
Fig. 2. Bellingham's Compressor for the treatment of aneurisms.
Fig. 3. The Pear-shaped Cautery.
Fig. 4. The Button-shaped Cautery.
Fig. 5. Physick's Forceps and Needle.
Fig. 6. The " Spanish Windlass," or Garrot, made by twisting a hand-
kerchief with a short stick.
Fig. ?. A front View of the Abdomen, showing the shapes of different
incisions. 1. The V-shaped incision to form a single flap. The first in-
cision being made, the second line should commence at the proper distance
from the first, and terminate like the first. The flap is to be reverted from
the point of the V. 2. The T-shaped incision to form double lateral
flaps. Make the horizontal cut, and then let the vertical incision terminate
near the middle of the first cut. 3. An C -shaped incision. The vertical
cut being first made, the two horizontal ones should be made to terminate
at each extremity. 4. The H -shaped incision. The middle, or horizon-
tal cut being first made, the two vertical ones should be carried across its
ends, so as to form two broad flaps. 5. The crucial incision. This may
be made either by uniting the points of two V-shaped incisions, or by
elongating the vertical portion of a T. 6. The crescentic incision. 7.
An elliptical incision made by joining the ends of two crescentic cuts.
Fig. 8. Different kinds of Harelip Pins. 1. Three pins made of steel,
or simply wire, sharpened at one end. 2. The harelip pin with the mova-
ble point.
Fig. 9. Small size Bone-nippers, employed to cut off the ends of the
pins, &c.
Fig. 10. A peculiar Form of the Continued or Glover's Suture, occa-
sionally useful in deep muscular wounds.
Fig. 11. The Quilled Suture. 1. The wound. 2, 2. The quills. 3, 3.
The sutures tied around the quills so as to approximate the sides of the
wound.
Fig. 12. Several points of the Interrupted Suture. The knots should
always be tied as at I, I, laX the sides, and not over the line of the incision.
Fig. 13. Union of a Wound by Adhesive Strips. 1. The line of the
wound. 2. The strips applied at regular distances.
INCISION WITH THE SCALPEL, OR BISTOURY. 211
Fifth Position. — Hold the scalpel by placing the thumb on one
side of the handle while the four fingers are approximated on the
other, like the position of a fiddle-bow (Plate II., Fig. 7). This
position is well calculated for incisions requiring delicate touches of
the knife, as in the division of tissues over hernia, large vessels,
and other important parts.
Sixth Position. — Hold the scalpel or bistoury with its edge to
the palm of the hand, so as to cut towards the operator ; the tissue
to be divided, if near important parts, being raised upon a director
(Plate II., Fig. 8).
The multiplication of these positions of the scalpel may be carried
to any extent, but those most frequently required will be found to
be such as have just been detailed.
In every case where dissection is requisite, it is important that
the parts to be divided should be kept upon the stretch, either by
holding them with the forceps (Plate II., Fig, 5), or, where the por-
tion is of sufficient size, by seizing them with the thumb and fingers
of the hand opposite to that which holds the scalpel (Plate II., Figs.
2, 3, and 4).
Wherever, in incising the skin, it is desirable to make a regular
and smooth cut, the integuments in the neighborhood should be
kept quite smooth, or prevented from yielding before the pressure
of the scalpel, either by the operator placing his thumb on one
side of the line of incision, and his fingers on the other, Plate II.,
Fig. 3, or by employing the hands of assistants. In limited inci-
sions, the left hand of the operator is sufficient; but in those of
greater extent, as in the removal of a breast or large tumor, those
of assistants will be necessary. As the first incision generally
causes the flow of blood, one of these assistants may, at the same
time, sponge the part so as to facilitate the operator's view of the
structure.
Incisions may be made of various shapes, thus: a single line
constitutes what has been termed a simple incision, and that formed
by two or more lines a compound one. These compound incisions
may be modified to any extent, but usually they are formed by the
arrangement of straight lines, so as to form cuts like the letters v,
L, T, or H , or [, or as a +, or of curved lines, as the crescent ^s
or ellipse 0>? or double crescent ^Z^ (Plate III., Fig. 7). By these
and similar incisions, the skin may be divided into various flaps,
which, being subsequently freed from the subjacent parts by dissec-
212 OPERATIVE SURGERY.
tion, will enable the operator to act according to his pleasure. An
important rule in all these incisions is to male them sufficiently
Jon 'j, or even too free at the first cut, as the skin usually heals
readily, and a free primary incision facilitates very much the sub-
sequent dissection. Another useful rule in connection with inci-
sions, especially in parts where the cicatrix will afterwards be
apparent, as in the face, or on the neck and shoulders of young
females, is to make them so that the scar may come in the course
of the contractions of the fibres of the neighboring muscles, by
which means the cicatrix will be hid in the natural folds of the
skin ; thus, on the forehead, the incision in the skin should, if pos-
sible, be transverse, so as to correspond with the wrinkles created
by the occipito-frontalis muscle ; on the cheeks, in the line of the
levator anguli oris or levator labii superioris alaeque nasi ; and on
the neck, in front of, or behind, but in the line of the sterno-cleido-
mastoid muscle.
Incisions, or the division of parts by the Scissors, require but a
few words, as the necessity for employing them is rarely met with.
"Whenever scissors are to be used for incising parts concerned in
operations, they should be held by placing the last joint of the
thumb through one ring, and that of the second or third finger
through the other, the index or second finger being placed on the
side or above the blades. The preference should, however, be
given, in most instances, to incisions made by the scalpel, provided
there is a sufficient basis of support, as the latter will generally
make a cleaner cut, owing to their being susceptible of a keener
edge than scissors, which, in the. United States, are often imperfectly
made even by the best cutlers. The incisions of bone by the saw
or bone-nippers may be classed under those of the scalpel and scis-
sors, but will be again referred to in connection with the operations
on the bones.
DISSECTIONS. 213
SECTION II.
DISSECTIONS.
Dissections, as performed by a surgeon, constitute the greater
portion of his operative manoeuvres ; but, as they do not vary from
those employed upon the dead subject, the same general rules are
applicable both to them and to the ordinary dissections of the ana-
tomical rooms. 1st. Stretch the part to be divided, and render it
perfectly tense. 2d. Incise it by a long steady sweep of the scalpel
in the third position, with a motion similar to that made in forming
large letters with a pen. 3d. Eemove the blade of the knife as
seldom as possible from the line of incision ; so as to avoid scratch-
ing, digging, piercing, jerking, or notching the tissue. 4th. Obtain in
the case of tumors a good hold upon them, before commencing their
dissection, either by passing a needle and ligature deeply through
the part, so as to form a loop, or by seizing them with the forceps
known as Liston's "Bull Dog" (Plate I., Fig. 15), or with the tumor
forceps (Plate I., Fig. 19), or with a tenaculum, or with the ordinary
dissecting forceps, according to the size and structure of the portion
to be excised. The looped ligature, being the firmest, will in most
instances prove the best adapted to this purpose. If, in the course
of a surgical dissection, the tissues to be divided involve parts of
delicacy and importance, it will be better to employ the director
and bistoury, as is shown in the sixth position of the scalpel (Plate
II., Fig. 8), for their incision, than to trust to the ordinary motion
of the knife, unless the operator is very sure of a steady and light
hand. The support of the hand to be obtained by resting the ring
and little finger upon surrounding parts, in the third position of the
scalpel (Plate II., Fig. 5), will, in these dissections, prove of great
service.
"When, in the course of an ordinary operation, small arteries are
divided, it becomes a question whether the operator should stop in
order to take them up, or whether he should not proceed rapidly
to accomplish his object. In deciding this question, much must
depend upon circumstances ; but, as a general rule, if the part is
superficial and the arteries of no great size, as is the case in most
operations on the breast, or in removing tumors elsewhere, the
21-i OPERATIVE SURGERY.
surgeon may finish his dissection before attending to the hemor-
rhage, or direct an assistant to compress or twist the vessels as they
spring, or put his finger on them ; as it often happens that, before
the termination of the operation, the contraction and retraction
caused by the stimulus of the air, or the effect of the latter on the
liquor sanguinis, will be sufficient to arrest the hemorrhage. If, in
the dissection of complicated or deep-seated parts, the first assistant
cannot by sponging keep the part free from blood, or if the patient
will not be benefited by the depletion, then the operator had better
stop and ligate the vessels before proceeding with his operation.
SECTION III.
PUNCTURES, OR INCISIONS WITH POINTED INSTRUMENTS.
When tissues are divided by the direct pressure of a pointed
instrument, it constitutes a puncture. Punctures may be made
with a scalpel, but more frequently they are created by the use of
the lancet, sharp-pointed bistoury, or trocar. In making punctures
with either of these instruments, the depth may, if requisite, be
regulated by seizing the blade near the point, between the fore-
finger and thumb. On introducing either the Lancet or Bistoury in
making a puncture, the blade may simply be withdrawn by a move-
ment which is the reverse of that which introduced it, or the handle
may be depressed towards the surface, and the point made to cut
its way out by incising the tissues from within outwards. The
Trocar should be held with the handle supported against the palm
of the hand, and then forcibly pressed through the tissue that it is
intended to perforate. As every trocar is usually surrounded by a
Canula or tube for the evacuation of the fluid, attention should be
given to the free motion of this tube upon the blade previous to
operating, lest, after its introduction, it be found impossible to sepa-
rate the trocar from the canula.
MEANS OF ARRESTING HEMORRHAGE. 215
CHAPTER III.
MEANS OF ARRESTING HEMORRHAGE.
After every application of the knife in operating, the necessary-
division of vessels gives rise to hemorrhage, which may or may not
require attention before the surgeon proceeds with his operation.
In the extirpation of tumors, there is a diversity of opinion among
operators in relation to the advantages of tying each vessel as it is-
divided. The late Dr. George McClellan, of Philadelphia, who was
a bold operator, seldom deemed it necessary to attend to the hemor-
rhage in extirpating the mammary gland or other tumors not in-
volving the main arteries, until ready to dress the wound ; and Dr.
Gross, of Louisville, has recently 1 expressed a similar opinion,
"seldom or never stopping to tie a vessel during any operation,
however extensive or complicated, his experience having taught
him that there is in general no necessity for such a course, which
is always attended with vexatious delay and annoyance." My own
experience has led me to the same conclusion, the action of the air
and contraction of the vessels having often enabled me to omit liga-
tures which would certainly have been applied at the moment the
arteries were divided. In the extirpation of tumors this latter point
is certainly of some consequence, by favoring the speedy union of
the divided parts. I have seen from fifteen to twenty ligatures
employed in the excision of a breast, in consequence of their
prompt application to every arterial branch that bled, and also seen
cases where not more than two were required to check such hemor-
rhage as existed at the close of the operation. These superficial
vessels often appear to discharge blood very freely, whilst, in reality,
the whole amount thus lost in tumor operations would not reach ten
ounces, a quantity which is often beneficial rather than injurious to
the future condition of the patient. But if the patient is enfeebled,
or the amount of hemorrhage should exceed ten or twelve ounces,
it will be safer to employ some means to regulate the quantity that
1 Western Journ. Med. and Surg., vol. x. p. 201.
216 OPERATIVE SURGEKY.
PLATE IV.
ARREST OF HEMORRHAGE BY THE LIGATURE AND COMPRESSION OF
ARTERIES.
Fig. 1. A side view of a stump, showing the method of ligating an
artery. 1. The open mouth of the artery. 2. The tenaculum drawing
the artery out of its sheath and away from the soft parts. 3, 3. The two
knots of the ligature passed over the tenaculum, and about to surround
the artery. Both knots of a ligature should be firmly tied upon the vessel
before the tenaculum is withdrawn.
Fig. 2. The effects of torsion upon an artery. 1. The twisted portion
of the artery. 2, 2. The effects of the Torsion upon the inner and middle
coat of the vessel. 3. The external coat uninjured.
Fig. 3. The effects of the application of the Ligature. 1. The ligature
as applied. 2, 3. The internal and middle coat cut by the ligature.
4, 5. The external coat, which sustains the ligature after the other coats
are ruptured, is seen all round the vessel.
Fig. 4. The result of the application of the Ligature. 1. One of the
anastomosing branches. 2. The conical clot forming in the vessel, and
extending to the first anastomosing branch.
Fig. 5. A "View of the enlargement of the Anastomosing Branches,
and of the contraction of the Main Trunk after the application of a liga-
ture. The drawing represents the cure of a popliteal aneurism. 1. The
main artery above the aneurism. 2, 2, 3, 3. The enlarged" anastomosing
branches.
Fig. 6. The application of the Tourniquet of Petit ; a pad should be
placed over the course of the artery, and a bandage carried over it, and
around the limb, to prevent the. strap of the tourniquet from chafing the
skin. The tourniquet, with its plates closed, should then be placed
directly over the pad which is on the artery, and the strap buckled tight,
so that the separation of the plates when the screw is turned, may cause
the pressure of the instrument to come directly upon the pad and the
artery. The pad under the buckle is solely to prevent its injuring the
skin, and has nothing to do with the compression.
Fig. 7. Compression of a main artery (the femoral) by the thumbs.
Fig. 8. Surgical Curved Needles.
Fig. 9. Surgical Needles of a different shape.
Fig. 10. The Harelip Suture.— A. 1. The wound. 2. The introduc-
tion of the pin. 3. The twisted suture thrown around the pin.— B. The
suture as completed— the integuments being protected from the pressure
of the ends of the pins by an adhesive strip.
Fig. 11. A side View of a Curved Spatula, This instrument is made
of copper or steel, plated, and has two curves adapted to wounds of dif-
ferent depths.
Fig. 12. Levret's Double Canula, with a wire ligature, and applicable
to polypi.
COMPRESSION. 217
will be discharged. These means may be classified as those which are
proper before commencing the operation or before any incision is
made, and those demanded subsequent to or during its performance.
Among the first and simplest may be placed such a position of the
part as will prevent the afflux of blood ; second, compression ; and
third, the employment of ligatures, cauteries, and styptics.
SECTION I.
COMPRESSION.
The prevention of hemorrhage by means of compression is a
purely mechanical result, which may be accomplished either by
applying the thumb or fingers over the course of the main artery
supplying the part — a mode of compression that, with good assist-
ants or with a skilful surgeon, may be pursued with perfect suc-
cess — or by the use of tourniquets.
In practising compression with the hand upon the arteries of the
extremities, the thumb should be placed directly upon the vessel,
and pressure made against the bone, by placing the thumb over the
artery on one side of the limb, and grasping the other side with the
fingers ; or by placing one thumb on the vessel, and pressing upon
it with the other, as seen in Plate IV., Fig. 7. Where the artery
is so situated as to render the application of the thumb difficult,
as in the subclavian or external iliac arteries, pressure may be ap-
plied by means of a common door key, well wrapped around its
handle with muslin or flannel, and then placed over the artery,
the wards of the key being held in the hand. The advantages
claimed for arterial compression, as thus practised, is the non-inter-
ruption of the general venous circulation of the part, the course of
the blood in the artery being alone obstructed.
The next means of arresting the circulation is by the Garrot or
Spanish windlass (Plate III., Fig. 6), a contrivance which, from its
simplicity, has much to recommend it. It may be formed at a mo-
ment's notice, by twisting a handkerchief into a cord, tying a knot
in its middle, applying the latter over the course of the artery, and
then tying the free ends loosely together, introducing a stick into
the loop of the handkerchief, and twisting it tight. An additional
recommendation of this instrument is, that patients may be taught
218 OPERATIVE SURGERY.
to employ it themselves, a matter of importance in military surgery.
The tourniquet of Petit (Plate IV., Fig. 6), or Bellingham's compressor
(Plate III., Fig. 2), also answer very well when applied to the extre-
mities, and will be again referred to under the head of amputations
and aneurisms. At present, the Figures explain themselves suffi-
ciently well. A very simple method of compressing only the arte-
ries of a limb, and one easily practised, will be found in the plan
proposed by Dr. Physick, in the case of hemorrhage from the foot.
A compress was first applied over the anterior tibial artery, and
another over the posterior tibial, about two inches above the ankle ;
over these a strip of sheet copper (or tin) was passed round the leg,
and then a tourniquet applied over the copper. By tightening the
tourniquet the arteries were compressed, and the bleeding arrested,
whilst the rest of the circulation was not interrupted. 1
A special tourniquet, or Compressor, as it has been named, has
lately been brought forward by some one in the Eastern States, and
is a useful instrument for the compression of deep arteries. It is
figured in Plate III., Fig. 1, but is evidently a repetition of Signoro-
ni's tourniquet, or of that of Dupuytren. It is especially applicable
to the axillary and iliac arteries, or where it is desirable to compress
only two points of a limb. It consists of two semicircular sections,
jointed at one end, and made to move upon each other by means of
a racket piece which is acted on by a key. Pads are attached to
the opposite ends of each section, and they are thus made to press
directly upon the points to which the instrument is applied. Com-
pression for the arrest of hemorrhage either previous to, or during
an operation, should, however, be applied only for a limited time,
lest it induce mortification. When more permanent means are
necessary, the surgeon should resort to direct applications to the
wounded vessels, and employ the ligature or torsion.
SECTION II.
ARREST OF HEMORRHAGE BY LIGATURES.
In no instance, after a severe operation, can a surgeon feel him-
self secure against the risks of hemorrhage, unless he has taken care
1 Elements of Surgery, by John Syng Dorsey, M. D., toI. i. p. 61, Phila. 1823.
ARREST OF HEMORRHAGE BY LIGATURES. 219
to ligate each vessel thoroughly. To accomplish this, it is necessary
that he should resort to some means of seizing the bleeding orifice,
such as a tenaculum (Plate IV., Fig. 1), artery forceps (Plate I., Fig.
16), or curved needle (Plate IV., Fig. 8). The tenaculum is intended
to hook and draw out the vessel from surrounding parts, and is the
instrument most frequently employed in this country. The artery
forceps performs the same office, but is not so much esteemed on this
side of the Atlantic, as on the continent of Europe. The curved
needle is applied to vessels that shrink in among surrounding parts,
or where the bleeding orifice cannot be readily found, or where the
portions immediately around the point of hemorrhage must be in-
discriminately ligated in order to control the bleeding.
Without entering into the physiological effects of the application
of ligatures to arteries, it may suffice to say, that it is necessary, as
established by Dr. J. F. D. Jones, 1 that the ligature should be drawn
with sufficient firmness to cut through the internal and middle coat
of the vessel (Plate IV., Fig. 3), and that sufficient inflammatory
action be established within the artery to glue its sides together,
and render the channel impervious. If the artery is diseased, care
must be exercised lest the force thus applied cause the ligature to
cut through the vessel before adhesion has occurred. In order to
obviate such an event, it has been advised to employ a broad liga-
ture, or, as Manec suggested, to introduce a piece of bougie into the
ve^pel in order to diminish the pressure upon the coats, or to em-
ploy a portion of the adjacent muscle, as has been done by Dr.
Mutter, of Philadelphia.
When an artery in the healthy condition is to be tied, the sur-
"geon should proceed as follows : seize the open end of the vessel
with a tenaculum, by inserting the point of the instrument into its
coats, draw it out of its sheath, and separate it as much as possible
from the surrounding tissue, especially from the accompanying
nerves (Plate IV., Fig. 1). Should the latter be included, it may
give rise to violent neuralgic pains, or create neuromatous tumors,
or, by causing the ligature to remain for a long period in the wound,
interfere with the process of cicatrization.
Then let an assistant pass the middle of the ligature beneath the
tenaculum, and, bringing its two ends around the vessel, form a
i Treatise on Hemorrhage and the Use of the Ligature, -with Observations on
Secondary Hemorrhage. London, 1805.
220 OPERATIVE SURGERY.
loop, and drawing upon the ends with his fingers, tighten the knot
with the points of his thumbs, in the same manner that a cobbler
draws his ends, taking care that the knot passes below, and not
above the point of the tenaculum, and that it is drawn with suffi-
cient firmness to accomplish the division of the arterial coats re-
commended by Dr. Jones. A second knot being then tied in like
manner, one end of the ligature should be cut off within about a
quarter of an inch of the knot ; the other brought out at an angle of
the wound, and the tenaculum removed. Some surgeons remove
the tenaculum before the second knot is formed, but it is a danger-
ous practice, exposing the patient to the risks of secondary hemor-
rhage from the ligature being imperfectly applied. Subsequently,
on closing the wound, all the free ends of the ligatures should be
brought out at the lowest point, where they will favor the escape of
pus, and thus prevent the formation of abscesses. Yarious knots,
some of which have been designated as the " surgeon's knot," &c,
have been recommended for tying ligatures, but the ordinary double
knot is all that is absolutely necessary in most instances.
The advantage of cutting off one end of the ligature will be found
in the diminished amount of foreign matter necessarily left in the
wound until the ligatures separate, and this is now the general
custom of surgeons in the United States. " The practice of remov-
ing both ends close to the knot, published by Haire, of England,
in 1786, was adopted by Hennen in 1813, at the suggestion of $ne
of his associates, who believed it to have been an American inven-
tion ;' n but if this were so, it was probably at the period when animal
ligatures were used, as the practice revived by Yeitch in 1806 has
long been the only one employed in this country.
The ligature, thus applied, closing the vessel, arrests the passage
of the blood beyond it, and a clot is formed (Plate IV., Fig. 4),
which, gradually rising as high as the first anastomosing branch
above the ligature, causes the blood to pursue a winding course
around it, by dilating the collateral branches until at last it enters
the main trunk at a distance below the ligature. As this clot
contracts adhesions to the sides of the artery, its more liquid por-
tions are absorbed, and the vessel closing upon it, is soon converted
into a ligamentous cord, the amount of blood formerly transmitted
through the artery being now carried by the enlarged anastomosing
vessels. (Plate IV., Fig. 5.)
1 South's Chelius, vol. i. p. 339, Philada. edition.
STYPTICS, CAUTERIES, MEANS OF ARRESTING HEMORRHAGE. 221
The substance of which the ligature should be made, and its mode
of action, were formerly points of great interest to operators, and,
under peculiar views, it was deemed necessary that they should be
made of chamois skin, kid, buckskin, the tendon of the deer, catgut,
parchment, or lead, as suggested by Drs. Physick, Hartshorne, and
Dorsey of Philadelphia, and Jameson of Baltimore. 1 But, of late
years, the simple silk or hemp thread has been found to answer
every purpose, and is now almost universally resorted to. 2
Torsion is effected by seizing the end of the artery in forceps,
and twisting it by rotating the instrument between the fingers and
thumb, until the internal and middle coats are lacerated. (Plate
IV., Fig. 2.) Torsion is a favorite means of arresting hemorrhage
among the French surgeons, but much observation has convinced
me that it cannot be relied upon except in the case of small arte-
ries.
The credit of suggesting torsion for the arrest of hemorrhage has
generally been assigned to Amussat, of Paris, who published his
account of it in August, 1829. 3 Dr. Bushe, of New York, has,
however, disputed this claim, assigning the origin of it to Guy de
Chauliac, and quoting cases of his own, where, in December, 1826,
April, 1827, June, 1827, and July, 1828, he employed torsion "by
twisting the cut extremities of the vessels in a square-beaked for-
ceps, furnished with a sliding bar, and two nuts." 4 The credit of
suggesting this method of arresting hemorrhage belongs, therefore,
neither to Amussat, nor Bushe, though the latter is entitled to the
merit of having recalled the attention of the profession to this plan.
SECTION III.
STYPTICS, CAUTERIES, AND OTHER MEANS OP ARRESTING
HEMORRHAGE.
Among the older surgeons, much confidence was placed in the
employment of styptics for arresting hemorrhage ; but, at present,
American surgeons seldom resort to them, except in cases where
1 Dorsey's Surgery, vol. i. p. 53, Philadelphia, 1823.
2 For the manufacture of ligatures, see Smith's Minor Surgery, 3d edition, 1850.
3 Archives Ge"n6rales, tome xx. p. 606.
4 New York Medico-Chirurgical Bulletin, vol. ii. p. 212.
222
OPERATIVE SURGERY.
the ligature cannot be applied, as in oozing from a general surface,
or in bleeding from the cancellated structure of bone.
In such cases the articles occasionally employed as styptics are
the nitrate of silver, sulphate of copper, alum, tannic acid, tinctura
ferri chloridi, and matico, either in leaf or tincture, nearly all of
which act by constricting the vessel. Hemorrhage may also be
arrested by the application of either fine sponge, or dry lint, so as
to favor the formation of a clot at the end of the vessel. This, when
combined with pressure, occasionally answers a good purpose.
The heated iron, or Actual Cautery, though seldom resorted to,
may be demanded in operations upon the bones of the face, or in
other positions where the bleeding point cannot be seen. In order
to adapt the cautery to these surfaces, a great variety of shapes has
been given to it, but those represented in Plate III., Figs. 3, 4, are all
that are generally necessary. When a cautery is to be employed,
it may be heated either to a white or red heat by fire, or kept
plunged in boiling water. White heat will form an eschar which,
on separating, is likely to bring on secondary hemorrhage ; but the
red heat will only produce contraction of the vessels and tend to
produce adhesive inflammation. The propriety of using the actual
cautery in either of the conditions referred to may, however, be
regarded as doubtful. The nitrate of silver, or tincture of iron, or
plugging the part with dry lint, is all that is generally found neces-
sary, surgeons usually preferring to apply a ligature, or resort to
cold for a temporary arrest of the more serious bleeding, or leave
the wound exposed to the air for one or two hours, as suggested
many years since by Dr. Joseph Parrish, of Philadelphia, in order
to favor the closure of the minute vessels by the effused liquor
sanguinis. 1
CHAPTEK IY.
DUTIES OF A SURGEON IMMEDIATELY AFTER OPERATING.
After accomplishing the object of his operation, and arresting
the hemorrhage, the subsequent duties of the surgeon may be
all placed under the general head of the Dressing.
1 Elements of Surgery, by John Syng Dorsey, M. D., vol. ii. p. 350, Philadelphia,
1823.
DRESSINGS. 223
SECTION I.
DRESSINGS.
The object to be attained in operating being very different in
each case, it follows that the dressing must also be varied, and
special directions may therefore be reserved until the consideration
of each operation. Certain general remarks are, however, applica-
ble to every operation requiring division of the skin ; thus, attention
should always be given to the means of cleansing the part, of favor-
ing its cicatrization, and of preventing the recurrence of hemorrhage,
in all which, although various opinions exist, yet certain general
rules of practice are universally admitted. In this portion of the
surgeon's duty, even good operators occasionally appear to be de-
ficient, and show a degree of carelessness that is apparently due to
the belief that the great object of the operation is attained when they
lay aside their instruments. The education also of many of our
students is very defective on this point, it being no uncommon
event to see a class leave the operating room before the dressing is
commenced, with as much indifference as they would show if this
stage of the operation really had no value. Any surgeon, however,
who has been long engaged in practice will, it is thought, sustain
the assertion that the first and subsequent dressings of an operator
are the real tests of his surgical skill. In making them, he first
proves his claims to the high position of a surgeon, and rises above
the grade of the " cutter." Before this he was limited to the me-
chanical portion of his profession, but in the dressing and after-
treatment he has an opportunity of showing his judgment and the
resources of his science. This subject should, therefore, receive the
special attention of every surgeon or student.
Every dressing, after an operation, may be divided into two
periods : 1st, the cleansing and uniting of the wound, and its protec-
tion from external or internal irritation; and 2d, the employment
of such general means as will aid in its union.
224 OPERATIVE SURGERY.
§ 1. — Closing of Parts after an Operation.
The decision of the question of union by the first or second in-
tention, having been in a great measure settled in the United States,
by the almost universal practice of healing or attempting to heal
every incision by the process of adhesion, the first dressing should
generally be made with this object; an effort to close a part by
granulation being an exception to the rule.
In attempting union by the first intention, the removal of all
foreign matter is of great consequence, and may be effected either
by squeezing a stream of water from a sponge upon the surface to
be united, or by the direct application of the sponge itself. When
the sponge employed in this, or other cases, is to be applied
directly to the entrance of a wound, it is requisite that it should
be as soft and free from sand as possible, and the selection of a
proper article is, therefore, a measure of some importance.
Good sponge for surgical purposes should be of moderate size,
conical shape, fine texture, open cells, and sufficiently elastic to ex-
pand readily in the hand after water has been expressed from it.
The whiteness is a matter of little moment, unless the bleaching
process has been carried so far as to destroy its texture, when the
value of the sponge will be much impaired. As usually found
in the shops, all sponges contain more or less of sand, coral, &c,
the presence of which would prove highly detrimental to a tender
surface, and should, therefore, be carefully removed by the surgeon
or his assistants, some days before the sponge is to be employed.
The best method of accomplishing this, and preparing sponge for
surgical purposes, as tested by a long experience, is the following:
Select a piece of sponge of the proper size, and pound it well whilst
it is dry, so as to crush all the coral that may adhere to it. Then
wash it thoroughly, pour off the water, place it in a porcelain vessel
containing one part of muriatic acid to fourteen of water; let it
soak two or more hours, or till all the sand is softened; then wash
it in a solution of carbonate of soda — one ounce to the quart of
water — and subsequently let it soak for an hour in running water,
when it will be ready for use.
The mode of uniting a wound is generally as follows : —
To close a wound after an operation, resort may be had either to
strips of adhesive plaster, about half an inch wide, and of a length
CLOSING OF PARTS AFTER AN OPERATION. 225
sufficient to obtain a good surface for adhesion ; to the application
of collodion; to sutures, or simply to bandages; but in all cases of
extensive wounds, before closing the skin by any of these means, it
will be found useful to introduce a morsel of lint or linen between
its edges, as suggested by Dr. Physick, in order to prevent union
of the surface before the deeper parts have adhered, as this would
tend to create an abscess. In employing strips of Adhesive Plaster,
they should be first cut about a half inch wide, and of a proper
length, and warmed by wrapping them around a bottle filled with
boiling water, taking care to place the unspread side of the strip
next to the bottle. After the plaster is thus softened, one end of
the strip should be placed upon the integuments about one or more
inches from the edge of the wound, and whilst the sides of the
latter are approximated by the fingers and thumb of one hand, the
strip may be stretched across it with the other so as to draw the two
sides together. In this application, the strip should also be applied
to the most depending portion first — a short interval being left
between each piece, in order to favor the escape of any discharge
from the wound. (Plate III., Fig. 13.) In using Collodion, strips of
muslin, half an inch wide, should be moistened with it, and then
applied in a similar manner, each being held upon the skin for a
few minutes, or until it adheres. Though occasionally resorted to
with satisfaction, as a substitute for adhesive plaster, I do not
think collodion is likely to supplant the former article.
Sutures or stitches are employed to unite such parts as, from
their flaccid or movable condition, cannot be accurately held to-
gether by other means. For the formation of the suture various
needles are employed (see Plate IV., Figs. 8, 9), any of which may
be selected, according to the taste of the surgeon. The only matter
of consequence in their selection is, to see that they have good
points, keen sides, and sufficient temper to prevent their yielding
to the force necessary for their introduction. Common saddlers'
silk or linen thread is the article generally employed for the forma-
tion of the suture at the present day, though caoutchouc threads
have been deemed preferable by Mr. Nunneley, of England, and
leaden strands, employed in one form of the suture (perineal), by
Dr. Mettauer, of Virginia. Platinum sutures, have also been praised
by Mr. Morgan, of England. Under special circumstances, these
modifications of the common thread may be useful; but, in the
majority of cases requiring the use of sutures, the old plan of closing
15
226 OPERATIVE SURGERY.
a wound by passing through its edges a keen needle armed with a
good round thread, will answer quite as well. As caoutchouc, how-
ever, is readily softened by heat and pus, the loosening of the suture,
when thus made, may be an object to the operator. Dr. Mettauer
claims for the leaden suture the advantages likely to result from its
being less liable to induce ulceration, in consequence of which it will
hold its place a longer time.
The sutures now generally employed are the Interrupted, the
Twisted or Hare-lip, and, occasionally, the Quilled. The Continued
suture, and others recommended by the older surgeons, are now
seldom resorted to.
The interrupted suture is formed of a series of separate
stitches, and will be found of service whenever it is desirable to ap-
proximate large flaps, or those which present angles, as after crucial
incisions and others of a similar character.
In making this suture, the operator should seize the side of the
wound nearest to him, or its most depending portion, with the
thumb and forefinger of his left hand, so that the latter will be on
the inner side of the skin, and then introducing the needle, with its
convexity downwards and its point directed upwards, pass it from
without inwards through this flap, or side of the wound, and from
within outwards through the other part, seizing the latter portion
with the thumb below and the finger above the surface of the skin.
Then, whilst the two sides are approximated by the fingers of an
assistant, let the operator tie the ligature, if of thread or other soft
substance, by a double knot, or if of lead, twist the ends by forceps,
so as to place the knot on either side of the line of union, then cut off
both ends of the ligature, close to the wound (Plate III., Fig. 12).
When the knots of sutures are permitted to press directly upon the
line of the wound, they are liable to induce such irritation as results
in suppuration ; whilst, if tied as directed, near either the point of
exit or entrance of the needle, they may sometimes be removed
without a sign of inflammation.
In making the points of a suture, the operator should remember
not to pass the needle deeper than the integuments, if possible ; to
include enough tissue to sustain any strain that it may have to
encounter; to avoid pricking nerves or tendons, and to place the
first stitch in the middle of a longitudinal wound, the remainder
being closed by as many points as may be requisite, intervals being
left between each. In angular wounds, the first point of the suture
CLOSING OF. PARTS AFTER AN OPERATION. 227
should be made at that part where all the free ends of the flap will
come together, and subsequently elsewhere, according to circum-
stances. The interrupted suture, as well as all others, should be
aided by the application of adhesive strips or uniting bandages,
when there is any traction necessary in closing the wound, in order
to diminish the strain upon the thread, and its tendency to create
ulceration. In about three days, the stitches should be removed by
seizing the knot with the dissecting forceps, elevating it slightly
from the integuments, cutting the ligature beyond it, and then
drawing the thread carefully out; but, in large deep wounds, or in
parts of a loose and movable character, the union of the parts
should be maintained for several days subsequent to the removal
of the thread by the continued use of adhesive strips. If sutures
are allowed to remain in a part longer than four days, except where
they are passed so deeply as to include a large amount of tissue (as
in the perineum), they will generally tend to prevent rather than
favor union by adhesion, as they are apt to lead to suppuration or
ulceration. A modification of the interrupted suture, suggested
by Dr. Pancoast, of Philadelphia, and called the Plastic suture,
will be found in the account of the rhinoplastic operations, to which
it is especially applicable. Dieffenbaeh has also recommended a
Subcutaneous suture, but it is only applicable to special cases,
as nasvi, &c, and will be noticed hereafter.
The twisted or hare-lip suture is especially applicable to ope-
rations in which there has been considerable loss of integument, and
where the strain upon the simple thread would probably cause it to
tear out of the tissue; or to cases where the parts are very movable,
as in the lips, cheeks, &c. In its application, a straight pin or needle
should be held between the thumb and right forefinger, and, com-
mencing at the lowest or free edge of the wound, be passed as deeply
through the tissue as is consistent with safety, on the right side
from without in, and on the left from within outwards, the entrance
and exit of the pin being favored by sustaining the parts with the
thumb or forefinger of the left hand. Then, whilst the wound is
well approximated by pressure from the fingers of an assistant, let
the operator surround the pin with a thread, and, twisting it around
the pin in the shape of the figure 8, tie the ends together over the
line of the wound. After introducing as many other pins as may
be necessary, their points should be removed (Plate IV., Fig. 10), or
the surrounding parts protected from injury, either by a strip of
228 OPERATIVE SURGERY.
plaster, or by a pellet of wax on each end of the pin, and then the
whole strengthened, if necessary, by adhesive strips.
Various opinions are entertained by operators as to the best
material for the pins employed in this suture. Silver pins with
movable steel points were, at one time, much used, and deemed
especially suited to this mode of union; but large well silvered
pins, or the straight steel needle advised by Heister, or pieces of
wire, sharpened at the point, as recommended' by Dr. Dorscy, of
Philadelphia, or the insect-pins proposed by Dieffenbach, can be
more readily obtained, answer quite as well, and, in my opinion,
better than those with movable points. Where the solid pins are
resorted to, their points should be cut off with the scissors or bone-
nippers (Plate III., Fig. 9), in order to protect the soft tissues.
The quilled suture is, at present, seldom employed, being
limited to those cases where it is desirable to unite very thick
tissues, as in operations, lacerations, &c, of the perineum. In
making this suture, several needles should be threaded by passing
both ends of the thread through the eye of the needle, so as to form
a loop on the middle of the ligature. Then, whilst the parts are
held as directed in the interrupted suture, let the operator pass the
first needle through the left side of the part from without inwards,
as deeply as may be necessary, commencing at the middle of the
wound, and bringing it out on the right side from within outwards.
On removing this needle, let him next apply a small piece of waxed
bougie, quill, or soft wood, on the left side of the wound, passing it
through the loop; then, placing a similar piece between the free
ends of the ligature on the right side, tie the ends of the thread
loosely upon the quill ; then, on placing two or more stitches at equal
distances from the centre, draw them into firm knots upon the quills,
and the parts will be thoroughly closed by the pressure thus made
upon them. (Plate III., Fig. 11.)
Such modifications of these sutures as may be required in special
operations will be referred to under the appropriate head, and espe-
cially in the account of the Plastic operations.
A peculiar mode of closing wounds by the application of a little
serrated spring, termed by Vidal " Serres-fines," has been recently
brought into notice by the French surgeons. The spring is suffi-
ciently strong to hold the edges of a wound together, but the teeth,
at the point of pressure, are apt to induce quite as much ulceration
as that consequent on the use of the ordinary suture. As the
MEANS EMPLOYED TO FAVOR UNION. 229
"serre-fine" can now be obtained from several of the principal cutlers
in the United States, any description of it would here be unneces-
sary, and probably convey an erroneous idea of the instrument,
unless accompanied by a drawing. I have occasionally employed
them, but have not found any advantage from their use that could
not be more readily obtained from other means which were of more
easy access.
§ 2. — After treatment as one of the means employed to favor Union.
In the second portion of the duties of dressing, or the selection
of such means as are requisite to facilitate the efforts of nature in
healing the wound, lies the great skill of the operator. Unless the
surgeon is well grounded in the principles of surgery, or unless he
unites in himself the knowledge requisite for a good physician, he
may now mar the whole proceeding, all his mechanical dexterity or
anatomical knowledge proving of little avail if he is deficient in a
knowledge of the great principles of inflammation. Now it is that
judgment may be shown, even in apparently neglecting the case, or
in " masterly inactivity," too much anxiety and officiousness pre-
venting the success of an operation almost as certainly as want of
skill. The constitutional treatment at this period is, therefore,
often essential to success; the efforts of nature may require to be
restrained or stimulated; rest or motion may prove useful or inju-
rious ; loss of blood, or purging, or a full or a low diet after a capital
operation, may be the means of saving or destroying the patient;
and nothing but a knowledge of the treatment of inflammation,
together with the practical tact that experience alone can furnish,
will enable an operator to conduct himself correctly in this most
important portion of his duty.
In the third portion of the dressing, or that which has for its object
the protection of the part from external agents, the subsequent steps
will usually consist in the application of spread cerate, or of lint wet
with cold water, or of compresses and bandages ; but as this portion
of the subject belongs to Minor Surgery, the reader is referred to
the treatises on this subject for further details.
I cannot, however, omit calling attention at this time to the great
superiority of the water-dressing over the older plan of cerate, &c.
To make a water-dressing, it is only necessary to soak a pledget of
patent lint in warm, tepid, or cold water (as most agreeable to the
230 OPERATIVE SURGERY.
patient), and lay it on the part, care being taken to moisten it freely
from time to time, either by squeezing water upon it from a sponge,
or by making a siphon of cotton-wick, and placing it in a neighbor-
ing vessel, so as to secure a more steady and equable supply, by
capillary attraction. In the warm water-dressing it is also useful
to lay a piece of oiled silk on the outside of the dressing, in order
to prevent too rapid evaporation.
As connected with each dressing, the operator should next bear
in mind the occurrence of secondary hemorrhage, the changes requi-
site in the articles employed as dressing, as well as the varied
constitutional treatment rendered necessary by a change of action.
Whenever, in any dressings, he desires to remove ligatures, let him
seize the end of the thread between his thumb and forefinger, and
make very slight traction upon it. If the ulceration of the vessel
is completed, the ligature will readily separate by the least force,
but if it is not, it should be left to nature. Occasionally, however,
it happens that the ligature will remain attached to a vessel an un-
usual length of time, extending sometimes to fifty or seventy days,
either in consequence of the employment of too large or too flat a
thread, or from adhesions forming around its course, or from too
much of the surrounding tissue having been included in the knot
with the vessel. Under these, or other circumstances, when the
operator is fully satisfied that time is being lost, he may resort to
the expedient suggested by Dr. Physick, and twist the ligature
slightly from day to day ; or pass it over a compress placed at a
short distance from the wound, and then fastening the free end to
a sound part of the limb, by a portion of adhesive plaster, favor
ulceration by the gentle strain thus exercised upon the ligature.
If the tension thus exercised is moderate, it will enable the knot
to separate from the artery by ulceration, but if it is sudden or
violent, it will be liable to induce hemorrhage; judgment as to its
employment is therefore necessary. In fastening the free end of
the ligature, the position of the part to which it is attached and
its motions should be noted; thus, if a ligature coming from the
thigh should be thoughtlessly made fast to the leg whilst flexed,
the patient, in extending the limb, would be likely to tear the
thread off the vessel ; so also in the arm and fore-arm. The point
to which the ligature from an artery in either extremity is attached
should, therefore, always be above the first joint.
PART II.
OPERATIONS ON THE HEAD AND FACE.
CHAPTER I.
SURGICAL ANATOMY OF THE HEAD.
The head, as a Surgical Region, is divided into two parts : one,
the Cranium, being all that portion of the bony structure which is
occupied by the Brain; the other, the Face, being the region bounded
above by the supercilia, and below by the base of the inferior
maxilla. In the cavity of the cranium, anatomists recognize two
distinct portions: one, the superior, which is designated as the
Vault ; the other, the inferior, and usually called the Base. With
the Base of the cranium an operator has but little to do, it being
so situated and connected with vital parts of the nervous system as
to forbid the application of instruments to it, except in its lateral
and inferior portion, where, in rare cases, it is necessary to perforate
the mastoid cells in order to relieve deafness.
The Vault of the cranium is mainly important to the surgeon in
consequence of the relations existing between the bones which com-
pose it and the internal parts. The bones forming it are arranged
so as to form a cavity which is accurately filled by the brain. Being
of the class known as flat bones, they consist of two layers of com-
pact matter with an intermediate diploe or reticulated structure,
contain a large number of veins or sinuses, and are covered and
nourished by an internal periosteum, or the outer lamina of the
dura mater, as well as by an external membrane, known as the
Pericranium.
The Dura Mater, or fibrous covering of the brain, is attached to
the internal table of the bones of the skull, both by fibrous and vas-
cular adhesions, and may be regarded as necessary to the nourish-
232 OPERATIVE SURGERY.
PLATE V.
INSTRUMENTS EMPLOYED IN TREPHINING AND OTHER OPERATIONS
UPON THE BONES.
Fig. 1. The Circular Saw of Martin, of Paris. 1. The handle. 2.
The shaft. 3. The double joint. 4. The saw. This most useful instru-
ment consists of a shaft to which circular or mushroom-shaped saws may
be adapted by a screw. These saws may be made to revolve rapidly by
means of the brace, Fig. 2. In consequence of the double joint at 3, the
saw can be kept in motion no matter what may be the relative position of
the shaft to which the brace is attached, except when the two are at a
right angle. This saw is to be employed by the surgeon holding the
handle, 1, whilst the assistant turns the brace, Fig. 2, when attached to
the shaft at 2. I have used this saw in several instances, and found it an
excellent instrument. Charriere'fl Pattern.
Fig. 3. The Mushroom Saw, and Fig. 4, the Circular Saw, belonging
to Fig. 1. Charriere's Pattern.
Fig. 5. Hey's Saw. Schiveley's Pattern.
Fig. 6. Barton's Metacarpal Saw. " "
Fig. t. A fine flexible "Keyhole" Saw, for incising the bones of the
face. Schiveley's Pattern.
Fig. 8. The " Chain Saw," with the needle attached for carrying one
end round a bone. Charriere's Pattern.
Fig. 9. The Handles, to be attached to the saw after the needle is
removed. Charriere's Pattern.
Fig. 10. A Trephine of large size. 1. The crown. 2. The slide to
raise the Centre-pin. Schiveley's Pattern.
Fig. 11. A smaller Trephine. " "
Fig. 12. A short, stiff Brush to clean the teeth of the trephine.
Schiveley's Pattern.
Fig. 13. An Elevator for raising a depressed bone. " "
Fig. 14. A Lenticular Knife, for the removal of spiculae from the open-
ing made by a trephine. Schiveley's Pattern.
Fig. 15. A Scraper or Raspatory, useful in caries, &c. " "
Fig. 16. A Steel Hammer, or Mallet. Charriere's Pattern.
Fig. 17. A Steel Gouge, with the shaft passing through a wooden
handle. Charriere's Pattern.
Fig. 18. A Chisel of the same kind. " "
Fig. 19. ListOn's Strong Bone Nippers. Schiveley's Pattern.
Fig. 20. Strong Bone Forceps, for removing sequestra 'n necrosis.
Schiveley's Pattern.
SUKGICAL ANATOMY OF THE HEAD. 233
merit of this table. In its duplicatures are found several large veins
or sinuses, the principal of which, on its upper part, is the Superior
Longitudinal Sinus (Plate VIL, Fig. 1). This sinus runs from before
backwards, in the median line of the cranium, and is liable to be
injured if a trephine is applied in its course. Several arterial
branches are also found on the vault of the cranium, outside the
dura mater, and often more or less deeply imbedded in the inner
table of the skull. Of these arteries, the most important to the
surgeon is the meningea media, or middle artery of the- dura mater,
which is first noticed within the cranium, near the level of the
external angular process of the os frontis, whence it ramifies in
numerous anastomosing branches (Plate VIL, Fig. 1). This vessel,
like the longitudinal sinus, is also liable to be wounded in the
operation of trephining, and, when opened, is sometimes ligated
with difficulty, in consequence of its deep position in the bone.
Cases, however, are recorded in which hemorrhage from it and from
the superior longitudinal sinus has been arrested by pressure
with lint. 1 The Pericranium, or proper periosteum of the cranial
bones, adheres closely to their external surface, especially at the
sutures, and by its vascular connections assists in preserving the
vitality of the outer table of the skull.
Outside of the pericranium, upon the summit of the vault, is found
the tendon, and at the front and back of the same region the bellies
of the occipito-frontalis muscle, the fibres of which run nearly ver-
tically, and the course of which should direct the line of all incisions
in this region, a transverse cut being occasionally difficult to heal,
from the retraction caused by the action of the muscle. The cellu-
lar tissue between the occipito-frontalis tendon and the pericranium
is freely developed, and attaches these two parts so loosely together
that the tendon and muscle move with great facility upon the peri-
cranium. The cellular substance between the tendon and the
integuments is, on the contrary, sparsely developed, uniting the two
tissues very closely together. In this layer is found a small amount
of fat, as well as the tegumentary bloodvessels and nerves; it is also
the seat of most of the tumors found upon the scalp, the flattened
and spheroidal shape of which is mainly due to the closeness of the
structure, and its want of extensibility. This sparse cellular tissue
is one cause of the great liability of the scalp to take on erysipela-
1 See Trephining.
234 OPERATIVE SURGERY.
tous inflammation; and the rapidity with which the disease runs on
to mortification is owing to the nutritive vessels of the integuments
being compressed against the cranium, whenever effusions occur in
its dense and unyielding structure. Its character will also be
noticed in any attempt to place a ligature upon a divided vessel in
the scalp, the difficulty of drawing out the vessel being due to the
peculiarity just referred to. The skin immediately above this layer
presents the hairs and other appearances known to every one.
v In studying the structure of the scalp from the surface to the
bones, we have, therefore, 1st, the skin with its hairs and follicles ;
2d, a dense cellular structure closely adherent to surrounding parts,
and containing the fat, together with most of the bloodvessels and
nerves ; 3d, the occipito-frontalis muscle and tendon ; 4th, a loose
cellular substance, permitting free motion of the muscle and tendon
upon the parts beneath; and 5th, the pericranium closely adherent
to all parts of the bones, but especially to the sutures. Wounds of
the scalp are very apt to separate the integuments from the peri-
cranium, in consequence of its loose adhesions; but, as the tegu-
mentary vessels usually remain in the flap, it is generally only
necessary to replace the latter in its proper position in order to
enable the parts to heal. The density of the tissue, and the tend-
ency of suppurations to travel in the cellular structure between the
tendon of the occipito-frontalis and the pericranium, should always
be borne in mind in injuries or operations on this region. Sutures
employed to unite these parts should only pass to the tendon, and
not beneath it.
The anatomical relations of the Face will be referred to hereafter.
CHAPTER II.
OPERATIONS UPON THE HEAD.
The operations required for the relief of surgical affections of
this region consist of those necessary in disorders of the soft parts,
and those demanded by injuries and diseases of the bones or dura
mater. In all these cases, the surgeon will find it a useful prelimi-
nary measure to shave the part freely, before commencing his ope-
ENCYSTED TUMORS. 235
ration, except in extirpating small encysted tumors, when the
presence of the hair will be useful as a means of promoting the
adhesion of the incisions, and when the union will generally be so
prompt as to enable the patient to avoid the notice generally excited
by a shorn scalp.
SECTION I.
OPERATIONS UPON THE SCALP.
Among the diseases of the integuments most frequently requiring
surgical interference, are Encysted Tumors, and Nsevi, or Vascular
Tumors.
§ 1. — ENCYSTED TUMORS.
Encysted tumors are of various kinds, and, when found in the
scalp, are usually situated in some portion of it exterior to the
occipito-frontalis tendon, and are seldom covered with hair.
Pathology. — The variety called Atheromatous or Melicerous
contain cheesy or more liquid matter, and are generally believed to
be obstructed and enlarged sebaceous follicles, as suggested by Sir
A. Cooper. They are most frequently placed immediately beneath
the skin; consist of a perfect sac, having a smooth and shining sur-
face internally, but rougher externally; and are, more or less, filled
with cheesy or a similarly unorganized matter. Unless of long
standing and of some size, these tumors do not adhere to the peri-
cranium ; but, when more fully developed, they sometimes induce
such inflammatory action in this membrane as often results in adhe-
sion, and, in some instances, in cartilaginous degeneration of that
portion of the pericranium next to the sac. Occasionally, I have
seen these tumors induce direct absorption of the outer table of the
skull, so as to create a cup-like cavity, the edge of which was rough
and slightly elevated. No bloodvessels enter these tumors, the
organization of which is low.
Ordinary Operation of Extirpation.— If the tumor is small,
the surgeon should pass a sharp-pointed, narrow bistoury, with the
Dack to the cranium, directly through its middle, and cut it open
from within outwards. Then, after squeezing out its contents, let
236 OPERATIVE SURGERY.
him reflect the edge of the skin so as to retain it in one pair of
forceps, whilst he seizes the divided edge of the sac in another pair,
and draws it out from its cellular attachments. If the adhesions,
however, are strong, careful dissection will be necessary to free the
tumor from the pericranium, lest the latter membrane be injured
and necrosis supervene.
In large encysted tumors, it will sometimes be found necessary to
make an elliptical incision through the skin, so as to remove such
portions of it as would prove superabundant; then puncturing the
sac, proceed as before; but encysted tumors of a size requiring this
mode of operating are rare, and any excess of skin will usually
disappear soon after the removal of the sac, or cause no incon-
venience to the patient. To attempt a dissection of the entire cyst
is both tedious and useless.
Dressing. — Cleanse the part thoroughly; see that no portion of
the shining sac remains at the bottom of the wound, and tie or twist
a few hairs together over the wound in order to close it, or, if the
incision has been free, apply a compress and bandage. The hemor-
rhage seldom requires attention, or may be easily arrested by press-
ure. As these tumors are generally free from hair, shaving the
scalp is unnecessary. The hemorrhage is also so slight as seldom
to demand even a bandage.
§ 2. — ANEURISM BY ANASTOMOSIS, OR ERECTILE TUMORS.
Pathology. — A class of tumors formed chiefly by enlarged capil-
laries united together by cellular substance, and called by Mr. John
Bell, Aneurism by Anastomosis, and by Graeffe, Telangiectasis
(trxos, far; ayyttor, a vessel; ***a$tj, dilatation) — are sometimes found
on the scalp as well as in other portions of the body, and will be
now referred to as a class, the operations for their cure being nearly
the same wherever they may be developed. In most instances,
these tumors only involve the integuments, and are supplied by
one or two vessels which, entering near the centre of the structure,
have no direct vascular connection with the skin of adjacent parts.
Most frequently these aneurisms will be found of small size, though
they occasionally attain the dimensions of a small orange. Being
composed almost entirely of enlarged capillaries, the hemorrhage
from them will be free when the diseased structure is incised,
ANEURISM BY ANASTOMOSIS. 237
though it is slight, and generally amenable to pressure, when the
incisions are kept out of the new growth.
Operations. — When seated in the scalp, these tumors may be
eradicated by various means of treatment, the object of all being
to interrupt the supply of blood to the tumor, or to remove the
tumor entire from the surrounding tissues.
In small tumors, the development of moderate inflammation in
the diseased part will often suffice to produce an obliteration of its
circulation, after which, the structure will either slough out or waste
away ; but in other instances, constriction of the tumor by .ligatures
or pressure may be required to accomplish the same object, though
the most certain mode of cure will be found in extirpation. In all
cases of anastomosing aneurism, it is important to operate at an
early period, as their growth is often rapid, and the hemorrhage in
proportion to their size, especially when the tumor is at all injured
in the operation of extraction.
I. TREATMENT BY EXCITING INFLAMMATION.
Vaccination, as suggested by the Germans, may be performed
by introducing the vaccine virus into the tumor, as in the usual
operation for protection from smallpox. The resulting inflamma-
tion has, in some instances, been quite severe without resulting in
a cure, and the practice is now seldom resorted to.
Heated Needles. — Dr. Bushe, of New York, induced oblitera-
tion of the vessels and sloughing of the diseased structure by intro-
ducing numerous needles (twenty or thirty), heated to a white heat,
through different parts of the base of the tumor. 1 Dr. Valentine
Mott and others have also employed this method with success.
Operation. — The needles being heated to a white heat in the
flame of a spirit-lamp, and then passed immediately through the
base of the tumor in various directions, should be quickly with-
drawn, so as to cauterize the part and prevent any hemorrhage
from the numerous punctures. The operation is said to be pro-
ductive of but little pain, and to avoid the production of a scar.
Caustic Threads.— Dr. Nathan E. Smith, of Baltimore, has fre-
quently cured the disease by the following operation: Soak a
1 See Bibliography, p. 58.
238 OPERATIVE SURGERY.
PLATE VI.
OPERATIONS UPON THE SCALP AND SKULL.
Fig. 1. A front View of an Aneurism by Anastomosis on the forehead
of a child, showing the combination of incision and strangulation as
recommended by Liston. Four flaps formed by a crucial incision simply
through the skin, have been turned off, and two needles, armed with
double ligatures, have been passed at right angles to each other through
the base of the tumor. The loop of each ligature being then cut, so as
to form eight ends, two of them, 1 2, 3 4, 5 6, and 7 8, are to be tied
firmly, so as to strangulate the tumor in four sections. After Liston.
Fig. 2. A Comminuted Fracture of the Cranium, showing a small frag-
ment removed by the forceps, and the elevator as passed into the opening
thus made, so as to elevate the depressed portion of the skull. When
a fracture is thus comminuted, the employment of Hey's saw across an
angle of the fracture, or the application of the forceps, will often enable
the surgeon to make room for the entrance of the elevator without apply-
ing the trephine. "Whenever the latter instrument can be dispensed with,
the danger of injuring the dura mater is much diminished.
After Bourgery and Jacob.
Fig. 3. A Yiew of the removal of a necrosed portion of the Parietal
Bone, the integuments having been sufficiently dissected off from the head
to permit the necrosed bone to be seized by the forceps and elevator.
After Bourgery and Jacob.
Fig. 4. Removal of a large tuberculated Exostosis from the posterior
portion of the left parietal bone. The integuments have been everted by
a crucial incision, and the tumor sawed through vertically. Hey's saw is
seen in the act of removing it from the skull by cutting off its base.
After Bourgery and Jacob.
Fig. 5. A View of the Head of the patient operated on by Dr. Geo.
McClellan, for a large spina ventosa of the cranium, showing the relative
size of the incisions, and the depression left by its removal, as described
in the text. After McClellan.
Fig. 6. The cancellated appearance of the tumor when removed.
After McClellan.
ANEURISM BY ANASTOMOSIS. 239
thread in a saturated solution of caustic potash, and, after drying
it at a fire, pass it through a needle; transfix the base of the tumor,
and, leaving the thread in position, remove the needle. Pass seve-
ral in the same manner, and the tumor will soon waste away with-
out causing any troublesome symptoms. 1
Seton. — Dr. A. H. Stevens, of New York, following the sug-
gestion of Fawdington, of Manchester, of introducing a seton, has
operated successfully by the following modification of his proceed-
ings: A blunt-pointed needle, armed with several silk threads,
being passed from one edge of the swelling, completely beneath it,
to the other, the needle is withdrawn, and the silk thread left as a
seton in the wound. No hemorrhage usually results, if the threads
are sufficiently numerous to fill up the track of the needle; but sup-
puration ensues — and, in one case reported by Dr. John Watson, of
New York, a cure followed in which the cicatrix was only observ-
able on minute examination. 2
Ligatures. — These means have been employed by Liston, Bell,
White, Lawrence, and others, both in Europe and the United States,
in various ways, so as to cut off the circulation from the base of the
tumor by direct action upon its nutritious arteries; but, if applied
so as to include the skin, they are liable to excite intense pain and
violent inflammation of the surrounding parts, and in children, may
even excite convulsions, or severe constitutional disturbance. To
obviate these risks, it will be found advisable either to pass the
threads around the base of the tumor by means of needles intro-
duced immediately beneath the skin, as in the subcutaneous suture
of Dieffenbach, or, when the latter is but slightly or not at all
affected, to turn it back by a careful dissection, so as not to open
the tumor ; then passing two curved needles, armed with double
ligatures, through the base of the tumor, cut off the loops of each
thread and tie the eight ends together so as to strangulate it, and
cause its removal by sloughing. (Plate VL, Fig. 1.)
Dr. J. Rhea Barton, of Philadelphia, has operated successfully
with the ligature, by passing two hare-lip pins at right angles to
each other, through the base of the tumor, and then carrying a
strong thread around them, and also across the top of the tumor,
so as to strangulate all the portions included between the pins and
1 American Journal of Medical Sciences, vol. vi. N. S. p. 260, 1843.
2 See Bibliography, p. 58.
240 OPERATIVE SURGERY.
the ligature; the object of the pins being to confine the ligature
about the attachment of the tumor, as well as to compress its struc-
ture upon them.
Dr. Brainard, of Chicago, has employed Collodion in small
tumors, and reported cases of cure. As a simple remedy acting by
constricting the vessels, it may be resorted to in cases of a limited
character. It should be applied to the surface of the skin over the
tumor by means of a brush.
II. OPERATION BY EXCISION.
A careful examination of many of these tumors having shown
that they are not, in most instances, intimately connected with the
surrounding parts, the practice of excision, as originally recom-
mended by Mr. Bell, in England, and Dr. Physick, of Philadelphia,
may be safely pursued when they are of moderate size, provided
the incisions are kept in the healthy tissue. In their removal by
excision, pass a needle and thick ligature through the tumor ; tie
its ends so as to form a loop, and facilitate its elevation from sub-
jacent parts ; then, making an elliptical incision around its base,
dissect it out without cutting into its structure. In the scalp, the loss
of integument and the hemorrhage will occasionally be an objection
to this plan of treatment, especially if the tumor is large, and in
these instances the following operation may be useful.
Partial Incisions renewed at intervals. — In a case of con-
genital aneurism by anastomosis, which covered nearly the whole
of the right side of the head, Dr. Wm. Gibson, of Philadelphia,
commenced its removal by making an incision around one-third of
the base, taking up all the bleeding vessels as they were divided,
and interposing lint between the edges of the wound, so as to pre-
vent the union of the integuments and the tumor at the point of
incision; then, after an interval of a few days, he incised another
third; secured the vessels; interposed lint in a similar manner,
and, in a week afterwards, removed the tumor. 1
Dr. Physick, in a similar case, cut round the tumor, tied up the
vessels as they sprung, suffered the parts to remain with lint inter-
posed to prevent immediate union, and the tumor soon afterwards
1 Dorsey's Surgery, vol. ii. p. 272, 1823.
ANEURISM BY ANASTOMOSIS. 241
wasted away. 1 In a few instances, ligature of the carotid arteries
has been resorted to, and the tumors subsequently excised. 2
Aneurisms of the Scalp. — Dilatation of the bloodvessels of
the scalp and varicose enlargements, or large aneurisms by anasto-
mosis, with other tumors, sometimes produce a condition of the ves-
sels which, from its pulsation, resembles an aneurism, and which it
is difficult to remedy by an operation, in consequence of the hemor-
rhage that ensues. In such cases, Dr. Benjamin Dudley, of Ken-
tucky, has recommended compression by means of the common
roller and properly adjusted compresses, and has succeeded in
speedily curing cases of this kind in which the disease occupied
one-half of one side of the head and forehead, and involved all the
upper eyelid with the inner and outer canthus of the eye.
Eemarks on the Value of these Methods of Operating. —
In cases where the skin is not much involved in the disease, or
where the tumor is not larger than a walnut, or where the cicatrix
would not create much deformity, excision will, I think, be found
preferable to the other operations, the hemorrhage being in most
instances, according to my experience, readily controlled by liga-
ture or by pressure, particularly when care is taken to incise only
the healthy structure, and not to open the tumor; and there are few
surgeons who have tried excision that have not preferred it to other
means, especially when they had proper assistants.
Dr. Warren, of Boston, has long favored this operation, espe-
cially when the tumor was seated near the eyes, nose, mouth, or
other natural apertures. 3 In his practice, three cases were treated
by caustic applied externally so as to cause a slough, eight by liga-
ture, and eighty-five by excision, all successfully. 4
Where the tumor is very vascular and large, or so situated as
to create deformity by the cicatrix, the seton, as employed by Drs.
Stevens and Watson, will be found to answer a good purpose, or
cauterization by the heated needles may effect a cure, especially if
the needles be made large. Vaccination is hardly worth the trial,
unless in the hands of a timid practitioner. If the large size of the
tumor should create just apprehensions of the hemorrhage likely to
result from its prompt extirpation, the repeated operations of Drs.
1 Dorsey, loc. cit. 2 See Bibliography, p. 59.
3 Warren on Tumors, p. 461.
4 Cooper's Surg. Diet. — Appendix by Reese, of New York, article Nsevus.
16
242 OPERATIVE SURGERY.
Physick and Gibson will, it is thought, answer better than the liga-
ture of the carotids. In the cases reported by Drs. Mussey and
Warren, the cure of large vascular tumors on the scalp did not
ensue upon the ligature of the main arteries of the neck. 1
§ 3. — CEPHALHEMATOMA.
Cephalhematoma (zt$°&y, head; o^a, blood), or the bloody tumors
occasionally found on the heads of very young infants, may per-
haps require the attention of the surgeon. These tumors have been
divided by Valleix 2 into those in which the sanguineous collection is
subaponeurotic, subpericranial, or submeningeal. These tumors
differ in position, from the bloody infiltration of the scalp, which is
the result of a tedious labor, as this is most frequently seen near the
vertex; whereas the common position of cephalhematoma is the line
near, but not at, the junction of the angle of the right parietal bone
with its fellow. The subpericranial cephalaematoma is the most
common form, and demands prompt attention in order to prevent
such a separation of the pericranium from the bone as may result
in caries or necrosis. These tumors are said, by Nelaton, 3 to be
most frequently seen immediately after birth in first children.
Generally, nothing more is necessary for their cure than time and
cold applications; but when the effusion is large, and likely to
elevate the periosteum to any extent, it may become necessary to
evacuate it in order to save the bone. Under these circumstances,
a puncture which is merely sufficient to give exit to the blood,
without admitting the entrance of air beneath the scalp, is all that
is requisite. The reader who is desirous of more detailed informa-
tion on the pathology of these tumors will be repaid by perusing
the paper of Dr. Geddings, of Charleston, in the North American
Archives, vol. ii. p. 21 7. 4
§ 4. — DIVISION OF THE SUPRA-ORBITAR NERVE.
In some cases of injury of the forehead, and especially in con-
tused wounds, the supra-orbitar nerve has become involved in the
' See Bibliography, pp. 92,93. 2 Maladies des Enfans.
3 Pathol. Chirurgical. 4 g ee Bibliography, p. 59.
TUMORS OF THE SCALP. 243
cicatrix, or given rise to such a neuromatous tumor as rendered the
division of its trunk necessary, in order to relieve the neuralgic
pain resulting from the condition referred to. In such cases, the
object may be easily accomplished by a subcutaneous section.
Operation". — In order to secure the division of the main trunk
of the nerve, which is often superficial at its exit from the supra-
orbitar foramen, the surgeon should introduce a sharp-pointed and
narrow bistoury flatwise beneath the integuments, and close to the
bone, on the external or temporal side of the foramen, passing it a
few lines towards its inner side. Then, turning its edge towards the
integuments and its back to the bone, let him divide all the tissues
from behind forwards until sensation is destroyed, taking care not
to cut through the skin ; then turning the bistoury again flatwise,
withdraw it at the point of entrance, closing the orifice immediately
with adhesive plaster. Should a return of the disease lead to the
suspicion of reunion in the nerve, a dissection and excision of a
portion of its trunk may become necessary. Among the most
decided cases of relief afforded by this operation, are those reported
by Dr. John C. Warren, of Boston. 1 Dr. Warren 2 informs me that
he has divided the three branches of the fifth pair many times with
success. He has also operated on other nerves, in cases of severe
neuralgia, especially in connection with those of the jaws and
extremities, such as the infra-orbitar, sub-maxillary, and portio dura,
all of which have been divided by him with marked relief to the
neural sic disorders of their branches. 3
§ 5. — TUMORS OF THE SCALP.
The scalp, like other portions of the integuments of the body,
may become the seat of tumors — such as mollusca, encephaloid,
fibrous, encysted, &c. — though they are by no means common in this
position. When they exist, the propriety of their removal should
be decided by the prevalence at the time of erysipelas as an epi-
demic, the fact of the scalp being exceedingly prone to erysipelas,
rendering the risks of an operation greater in this region than else-
where.
1 Boston Med. and Surg. Journal for 1825. Also Bibliography, p. 66.
2 Dr. Warren in MS. 3 Bibliography, p. 66.
•
24i OPERATIVE SURGERY.
§ 6. — VENOUS TUMORS OF THE SCALP.
The Veins of the scalp sometimes become enlarged, and present
a varicose condition, which Mr. Fergusson, of England, has recom-
mended should be treated by means of needles and pressure from
ligatures, in the manner referred to in the treatment of varices of
the leg. This condition of the veins of the scalp, independent of
other complaints, must, however, be very rare, as I have never seen
an instance of it during my attendance either in the United States
or in the Parisian hospitals.
SECTION II.
OPERATIONS UPON THE BONES OF THE CRANIUM. '
The operations practised on the bones of the cranium, are those
required by diseases or injuries of one or both tables of the skull,
such, for instance, as caries, necrosis, exostosis, fracture, or for the
evacuation of bloody or serous effusions from within the cavity of
the cranium. In the diagnosis or treatment of any of these affec-
tions, the operator will find it advantageous to shave the scalp at the
point to be examined or operated on, so as to render the sensation
given by the scalp less deceptive to the touch, as well as prevent the
adhesion of the discharge and dressings to the hair. He should also
have at hand one or more of the instruments referred to, and shown
in Plate Y. In many cases, and especially when there is no wound
at the part, he will find it necessary to incise the scalp ; the incisions
required under such circumstances being either in the form of an
+ , L, V , or ^s, and so arranged that the angles, by their dependent
position, may favor the escape of subsequent collections of pus.
§ 1. — OPERATIONS FOR CARIES AND NECROSIS OF THE CRANIUM.
In operating upon the skull for either caries or necrosis, the
bone should be sufficiently, but not too freely, exposed, by dissect-
ing back the scalp to the necessary extent, and the same precepts
be observed that are applicable to these diseases in the bones of
the extremities, to wit, care taken not to disturb the pericranium
or membrane covering the bone. After this, all the softened or
OPERATIONS FOR CARIES AND NECROSIS OF THE CRANIUM. 245
dead structure should be carefully removed, by means of the ras-
patory, saw, trephine, elevator, or forceps (Plate V., Figs. 14, 15),
until the surrounding bone shows by its color and vascularity that
it is capable of taking on healthy action.
In operating for the removal from the cranium of an exostosis,
osteo-sarcoma, spina ventosa, or any bony tumor, the incision should
be so made through the integuments, as freely to expose its base,
and enable the operator to separate it from the skull with the saw,
either by cutting through its centre down to its base (Plate VI., Fig.
4), or by exposing the base and then sawing through it on a line
with the general convexity of the head.
A remarkable case of spina ventosa of the cranium having been
presented to the late Dr. Geo. McClellan, of Philadelphia, the fol-
lowing operation was practised for its removal. The tumor (spina
ventosa) was 4 inches in length, 3| inches in its short diameter, and
about If inch above the surrounding portion of the skull: —
Operation of Dr. George McClellan, of Philadelphia. — The
patient was a man twenty-two years of age, and had suffered from
various symptoms connected with the head for three years; it was
therefore decided to operate upon the tumor as follows: Two long
incisions being made at right angles, and near the centre of the
swelling, the scalp was dissected up from the whole surface, and to
some extent around the sound bone. Then, with a long, narrow
saw, held at a tangent to the circumference of the cranium, the
entire tumor was cut off at its base. The appearance of the cells
of the tumor, and of the scalp subsequent to its removal, is shown
in Plate VI., Figs. 6 and 5. Owing to the character of the tumor
as thus shown, it was deemed necessary to remove the whole mass
from the surface of the dura mater beneath it, which rendered the
operation much more tedious and difficult, but which was accom-
plished by circumscribing the whole mass of the tumor by the
circular edge of Hey's saw, and then prying it out in succes-
sive fragments, by means of an elevator, which was occasionally
aided by the bone-nipper and forceps. 1 The dura mater, when
exposed, had been so much depressed by the external development
of the tumor, as to present a deep cavity, capable of holding four
ounces and a half. In removing some spicula of bone, this mem-
brane was wounded, but the hemorrhage was arrested by pressure.
1 McClellan's Principles and Practice of Surgery, p. 340.
246 OPERATIVE SURGERY.
Very little irritation ensued on the operation. In nine days, the
compresses were loosened by suppuration, and, on removing them,
the whole surface was found to be granulating, and an orifice which
had been made in the longitudinal sinus was closed. The patient
subsequently recovered, and his case, owing to the change in his
mental disposition, attracted considerable attention from Mr. Combe
and other phrenologists.
§ 2. — TREPHINING THE CRANIUM.
As the brain fills accurately the cavity formed by the bones of
the head, any cause which diminishes the space naturally occupied
by this organ, generally impairs its functions, and leads to a train of
symptoms which may terminate life. To obviate these, and relieve
the cerebrum from pressure, the operation of perforating the skull,
so as either to restore its natural convexity, or give exit to effusions
within it, was suggested, and has been practised since the times of
Hippocrates, B.C.460, the skull being perforated either by the Trepan
or by the Trephine, and the operation named after the instrument
which was employed to accomplish it, as Trepanning or Trephining.
The Trephine is a circular saw, which is made to perforate the
skull by frequently turning the hand from pronation to supination,
the division of the bone by its application constituting the operation
of Trephining. The French surgeons of the present day, like those
of the time of Hippocrates, 1 employ a somewhat similar saw, though
it is one which, like the antique instrument, is fitted to a brace, and
worked like a brace and bit. This instrument retains the old name
of Trepan (r^rtow, I perforate), and the operation is hence called Tre-
panning. The trephine differs from the trepan not so much in the
shape of the saw, as in its being made to act by moving in a con-
tinuous circular course, rather than in alternate semicircles, as is
the case with the trepan. The sawing portion of the trephine is
named the crown, in the middle of which is the centre-pin, or point to
steady the saw in its first movements. This instrument is the one
employed in the United States, whenever it is necessary to perforate
the cranium, but is much less resorted to at the present period than
it was formerly, many of the older surgeons having deemed it right
to employ it in every possible affection of the skull, whether accom-
1 Hippocrates on Wounds of the Head, translated by Riollay, London, 1783.
TREPHINING THE CRANIUM. 247
panied by depression or not. As the trephine merely cuts an open-
ing in the skull, the other instruments hereafter named will occasion-
ally be required to elevate the bone or remove the detached portion.
When, from a depressed fracture or effusion of blood outside
the dura mater, the brain is compressed, and the surgeon is satisfied
that the removal of the compression will probably enable the brain
to recover its functions, he should prepare for the operation as
hereafter directed.
But as the propriety of trephining is often a point which it is
difficult to settle, I would offer the following synopsis of the symp-
toms which usually justify the operation : —
1st. It is generally proper to trephine the head, when the evi-
dences of compression are present, and the depressed bone can be
distinctly felt or seen through a wound in the scalp.
2d. When, though not seen, the depressed portion is positively
felt through the scalp, the hair having been previously shorn, and
every precaution taken to avoid deception either from the cedema-
tous scalp, from effusion beneath the pericranium, or from the pre-
sence of the sutures or other conformations peculiar to the patient,
as may be recognizee^ by comparing the two sides of the head.
3d. When, though no depressed fracture can be detected, the
patient has shown sudden signs of compression after a blow likely
to create either a fracture or laceration of the bloodvessels. — The
propriety of trephining, under any circumstances, is however a
question on which surgeons have long differed, some, trephining in
every case of unconsciousness, and others limiting the operation to
cases of marked compression. Without, then, presuming to sup-
pose that any individual opinion can settle this vexed question, I
would advance the expression of my own experience as being
favorable to the performance of the operation in all cases of com-
pression due to a depressed fracture, as well as to cases of epilepsy
consequent on such injuries.
Further remarks on this subject will be found at the close of the
description of the operation.
Preparation for the Operation. — 1st. Shave the patient's
head and arrange the instruments upon a board or tray in the
order in which they are designated, or in that in which the opera-
tor thinks they may be required. 2d. Place the patient so that
the head may be readily acted on without the operator stooping
too much ; take care also that the bed or table is not too high, as
248 OPERATIVE SURGERY.
this may likewise create difficulty, and fatigue the surgeon in the
manipulation of his instruments.
I. INSTRUMENTS THAT MAY BE REQUIRED FOR THE OPERATION OP
TREPHINING. 1
1. One large scalpel, to incise the scalp. 2. A pair of dissecting
forceps, to raise the flap. 3. A tenaculum or forceps, to seize the
arteries in the scalp. 4. Ligatures and needles. 5. One large and
one smaller trephine to perforate the skull, with a brush to clean
the teeth of the saw, and a probe or toothpick to test the depth of
the furrow. 6. A pair of forceps, to remove the disk of bone. 7.
A lenticular, to remove splinters in the opening. 8. An elevator.
9. A sharp-pointed bistoury or lancet, to puncture the dura mater,
when compelled to do so by extensive effusion beneath it. 10.
Hey's saw, to divide loose or angular portions of the cranium if a
perforation already exists. 11. Sponges and articles of dressing.
Ordinary Operation. — If the scalp is uninjured, and an incision
is required in order to expose the bone, it should be made by divid-
ing the scalp either in a crescentic form, as advised by Pott and Vel-
peau, or in that which is V-shaped, or crucial +, as recommended by
Dr. Physick, so that the part upon which it is proposed to operate,
may be left bare, the flaps being dissected free from the pericranium,
but the latter disturbed as little as possible. Should a wound
already exist, it may be enlarged to the necessary extent without
forming an incision of the shape above described. Having thus
exposed the bone, the trephine should be taken in the right hand,
with the centre pin projecting, and held as seen (Plate VII., Fig.
3), so that the crown can be applied either upon the edge of the
depressed bone, or sufficiently near to permit its being raised by
the elevator, when inserted through the opening cut by the trephine.
Then, turning the hand steadily and slowly from pronation to supi-
nation, and pressing firmly upon the handle so as to cause the saw
to cut itself a track in the outer table, make a few turns ; remove
the instrument, draw up or take out the centre pin— test the depth
of the track of the saw with a toothpick, and, reapplying the in-
strument, renew the sawing until the diploe is reached. This struc-
1 See Plate V.
OPERATION OF TREPHINING. 249
ture, if present, may often be recognized by the bloody character
of the sawdust, or by the more free action of the saw, though the
absence of either is no sign that the trephine has not entered the
diploic structure of the skull, as it is but often sparsely developed.
After testing again the depth of the track, saw cautiously, examin-
ing the state of the furrow from time to time, until the skull is
perforated, or nearly so, the latter being told by gently acting in
the furrow with the forceps or lever, and endeavoring to raise the
piece. When the disk is found to be sufficiently free, it may be
either pried out with the elevator or removed with the forceps, or
it may come away in the crown of the trephine without any special
effort being made for its removal. On removing the piece, the
dura mater will be seen perfectly exposed, and if the case is a de-
pressed fracture, the operator should introduce the elevator very
cautiously between this membrane and the cranium, and keeping the
point of the instrument close to the latter, use the thumb, or the sound
part of the adjoining bone as a fulcrum, so as to elevate the fractured
portion to its proper level, taking care to mould it to its former con-
vexity by pressing with the fingers upon the outside of the skull.
If, on perforating the bones, blood is found to be effused outside of
the dura mater, careful manipulation will enable the operator to
turn it out without injuring the membrane, as this is generally de-
pressed and separated from the inner table of the skull by the
effusion. If, however, the blood is evidently beneath the mem-
brane, it may be questionable whether the danger from its puncture
is not greater than that which would ensue if the effusion were left
to nature. The judgment of the surgeon, based upon the urgent
character of the symptoms, can alone decide this point. Patients
have recovered when the membrane has been punctured and even
considerably lacerated, yet no judicious operator would deem such
a result a precedent, except in cases of great emergency.
If, in the application of the trephine, any of the bloodvessels of
the dura mater are accidentally cut, the bleeding may be checked
by pressure, or by ligature, as was done by Dr. Dorsey, of Phila-
delphia, in a case in which hemorrhage from a wound in the supe-
rior longitudinal sinus was so free as to demand the application of
a dossil of lint, or by applying a ligature to the wounded vessel, as
was done in a wound of the middle artery of the dura mater, by
Dr. F. Dorsey, of Maryland. 1
1 Dorsey's Surgery, by Randolph, vol. i. p. 323, 1823.
250 OPERATIVE SURGERY.
PLATE VII.
A VIEW OF THE STRUCTURE OF THE HEAD AND OF THE OPERATION OF
TREPHINING.
Fig. 1. A side Yiew of a lateral section of the head, showing the rela-
tions of the scalp, skull, and brain, with its bloodvessels. 1. The scalp,
after the hair has been shorn. 2. The tendon of the occipito-frontalis
muscle. 3. The divided edge of the bone, showing the outer and inner
tables, and the diploic structure. 4. The shining surface of the dura
mater. 5, 5, 5. The superior longitudinal sinus, extending from the
crista galli to the Torcular Herophili. 6. The middle artery of the dura
mater, where it first passes on to the vault of the cranium. T. Its ante-
rior branch. 8. Its posterior branch. 9, 9. The lateral sinus of the
dura mater in its course along the occipital and temporal bones to empty
into the internal jugular vein. Af ter Bernard and Huette.
Fig. 2. A View of a stellated and depressed Fracture of the Cranium,
showing the point at which the perforation of a trephine should be made,
so as to elevate the depressed portion. 1. Point of perforation of the
trephine. 2. The depressed portion of the skull. After Bel1 -
Fig. 3. A lateral View of the operation of Trephining, as practised on
the right parietal bone. The patient is represented as comatose from a
depressed fracture, and lies with his head firmly supported and steadied
on a hard pillow placed well under the neck. The integuments over the
depressed portion have been incised, and dissected back sufficiently far to
expose the fracture, whilst the surgeon, holding the handle of the trephine
firmly against his palm, and with the forefinger extended upon its shaft,
is just commencing to pronate and supinate his hand, so as to work the '
crown of the instrument, and cause it to excise a portion of the skull suf-
ficient for the introduction of the elevator, or the evacuation of the clot.
Drawn from Nature.
Fig. 4. A View of the position of the Lenticular Knife, as employed
in removing any spicula left on the internal table of the skull after the
use of the trephine. 1. Position of the hand in using the lenticular.
After Bernard and Huette.
^><L"
k
OPERATION OF TREPHINING. 251
Hemorrhage from the same artery, which was deeply imbedded
in its channel in the bone, has also been arrested by Dr. Mutter,
by plugging the vessel in its bony canal with a small piece of soft
wood, as recommended by Dr. Physick. Bleeding from the inte-
guments may be readily checked by a needle and ligature, or by
the latter applied in the usual manner, with the tenaculum.
Dressing. — After the perforation has been completed, the parts
should be cleansed; the flap loosely applied over the opening,
covered by a poultice, and the case treated as a suppurating wound
until the skin has healed ; care being taken to secure the free exit
of pus from beneath the integuments, and attention given to any
signs of meningeal inflammation. In all cases, the strictest diet
should be rigidly observed until all risks of inflammation have
passed away. After recovery, the head may be protected, if the in-
dividual is exposed to injury, by using a thick-crowned hat for
several months, or until ligamentous matter closes the perforation
in the bone.
Remarks. — The propriety or impropriety of trephining, in cases
of injury or other disorders of the head, is, as has been previously
stated, a question which at all times has had able advocates on both
sides. That the application of the trephine was at one period un-
necessarily resorted to, cannot be doubted with our knowledge of
the structure of the cranium, and its relations to the brain, espe-
cially as we find it to have been employed in cases of concussion
of the brain under the idea that blood was effused at particular
points of the head, merely because the bone was discolored or
seemed too vascular. Though the result of such practice has been
to throw doubt upon the utility of the operation, there can be no
question that evil has also ensued from the opposite extreme, pa-
tients having been permitted to die when the application of the
trephine might have saved them. Judgment is therefore necessary
in order to prevent the misapplication of this, as of many other
useful remedies. In some instances, the relief afforded by the appli-
cation of the trephine has been very prompt, and in a case reported
by Dr. Quintard, of Georgia, the elevation of the depressed bone
gave instantaneous relief from insensibility, loss of power, &c.
Dr. Dudley, 1 of Kentucky, has also reported numerous cases of
prompt relief from epileptic symptoms which followed the removal
' Transact, of Med. Society of Georgia. Report of Committee on Surgery.
252
OPERATIVE SURGERY.
of a spicula, or of a depressed bone, and Dr. Ilolston, of Ohio, has
also reported numerous similar cases. 1 Dr. John Harden, of Louis-
ville, is so well satisfied of the advantages of trephining in most
cases that he proposes, at the close of an account of numerous
cases, 2 the following rule : " That in every clearly ascertained frac-
ture of the cranium with depression, the bones should be elevated
or removed whether there be a scalp wound or not." There are,
however, many surgeons who entertain a different opinion. To
furnish additional aid in cases where the experience of the operator
may be limited, the following statistics, collected with care, are pre-
sented; and though not perhaps sufficiently numerous to settle
definitely the propriety of the operation, they will yet tend to show
how the result may vary in different cases, though statistics which
do not state the circumstances of each case cannot be positively
relied on in the formation of an opinion as to the advantages or
disadvantages of any operation.
Statistics. — The following table shows the number of cases
trephined and of those not trephined, with the comparative re-
sults of each plan of treatment, although nothing is said of the
peculiarities of either set of cases, a fact which must always aid in
the decision of the operation.
Cases. Trephined.
Cured.
Died.
i
77 51
11
40
Laurie and King,
Not stated 42
28
14
H. H. Smith.
Not stated 45
11
34
Dr. Lente, N. Y.
138
50
Cases.
77
Not Trephined.
26
Recovered.
18
Died.
8 Laurie and King.
"Whether the latter injuries were more serious than those in the
former cases, is not stated.
Dr. Lente, 3 of New York, who has furnished a most elaborate
account of 128 cases of severe fractures as presented in the New
York Hospital, and a portion of which is included in the above
numbers, has arrived at the following results : —
1 Bibliography, p. 62.
2 Western Journ. of Med. and Surg., vol. ix. p. 203, 1852.
3 New York Journ. Med., vol. viii. p. 29.
STATISTICS OF THE OPERATION OF TREPHINING. 253
Out of 128 cases of fracture of the skull, 106 died. This extra-
ordinary mortality Dr. Lente regards as due to the violent character
of the accidents which caused the fracture, yet we notice that, in
45 of these bad cases, about one-fourth of those trephined reco-
vered; and that out of the 22 recoveries, one-half were trephined
successfully. The operation was performed prophy tactically, in ten
of which three were cured, and, therapeutically, in 32 of which eight
were cured.
In 26 or 20.31 per cent, of all his cases, both the brain and its
membranes were lacerated. In ten, there was hernia cerebri, of
which only two recovered. In twelve cases, where the symptoms of
compression were well marked, the patients not being in immediate
danger of death, the pupils were dilated in ten, contracted in tivo.
In five cases of those trephined, an incision was made in the dura
mater — none of these recovered.
Although these statistics are far from perfect, yet they tend to
show that in fractures of the skull attended with symptoms of com-
pression, the operation of trephining affords a better chance of re-
covery than leaving the case without an operation.
In epilepsy, trephining has been much more successful, and the
performance of the operation in well-marked cases has been followed
by the happiest results. Of fourteen cases that I have collected of
the operation in this complaint, all were reported cured but one.
It may, therefore, be assumed as a general rule by the inexpe-
rienced surgeon, that trephining, or the removal of depressed por-
tions of bone by any of the instruments in the trephining case, will
be advantageous under the following circumstances: —
1st. In bad compound fractures, where the depression can be seen
and the symptoms of compression are well marked.
2d. In simple fractures, where the depression is positively felt,
and similar symptoms exist.
3d. In bad compound fissures of the cranium, accompanied by
free hemorrhage from within the skull and attended with symptoms
of compression.
But the necessity of puncturing the dura mater in any case, should
always induce an unfavorable prognosis, or a very guarded one.
In every case that it is proposed to operate on, the surgeon should
distinctly explain to the patient's friends the serious character of the
accident, and the fatal tendency of the case, whether operated on,
or left to nature.
254 OPERATIVE SURGERY.
II. TREPHINING THE FRONTAL SINUS.
Operation. — In the rare cases in which it may be deemed neces-
sary to apply a trephine upon the frontal sinus, the operator should
proceed precisely as in the application of the instrument upon the
vault of the cranium, recollecting, however, that an opening in the
outer table of the skull, which at this point is often quite thin, is all
that is necessary.
§ 3. — PUNCTURING THE HEAD FOR HYDROCEPHALUS.
An effusion of serum within the ventricles of the brain, or in its
membranes, being usually the result of serious organic disease, but
little benefit can be anticipated from an operation which simply
looks to the removal of the effect, instead of the cause of the diffi-
culty. When, however, medical treatment has failed, tapping the
head for the removal of the fluid may be deemed worthy of trial, as
a last resort, and with a view of prolonging life, although the post-
mortem examinations in most instances have shown that the cerebral
structure was so much diseased, as to leave but little reason to anti-
cipate the general adoption of this operation. In the United States,
it has been performed by Dr. Physick, 1 by Dr. Glover, of Charleston, 2
by Dr. L. A. Dugas, of Georgia, and Dr. J. B. Whitridge, of South
Carolina, and many others. 3 Dr. Dugas tapped his patient seven
times, and drew off sixty-three ounces of liquid, the patient living
from June 25th to October 18th. When the effect of the heat of
summer upon children is recollected, it will doubtless be admitted
that life was prolonged in this case beyond what might have been
anticipated. In the case of Dr. Whitridge, the child lived from
August 31st to October 31st ensuing. Accounts of cures effected
by tapping, are also reported as performed by Dr. James Vose, of
Liverpool, in the Medico- Chirurgical Transactions, vol. ix.; by Dr.
Conquest, of England, in the Lond. Med. Gazette, March, 1838; by
Dr. West, in the same journal, April, 1842 ; as well as in the Bulletin
Gen. de Therapeutiques, vol. xxiii.; though I have not been able to
examine the latter paper. In one case reported by Dr. Conquest,
1 Philadelphia Medical Journal, vol. iv. p. 316. * Ibid., p. 403.
3 Am. Journ. Med. Sciences, vol. n. p. 536, 1837.
PUNCTURING THE HEAD FOR HYDROCEPHALUS. 255
the number of operations performed on it was five, at intervals of
from two to six weeks, and the total amount withdrawn was about
fifty-eight ounces. Dr. Conquest also appears to have had marked
success in his operations, having ten patients to live out of nineteen
operated on.' Of sixty-three cases, carefully collected from different
authors, and reported by Dr. West, of England, 3 not more than
two out of seven recovered ; six dying within four days, and only
one surviving six months. The general success of the operation
is therefore far from justifying its repetition.
Ordinary Operation. — Introduce a needle and canula, or a fine
trocar, as advised by Dr. Conquest, at the coronal sinus, midway be-
tween the crista galli and the anterior fontanel, or at any point of
the fontanel or other opening in the head, not likely to interfere
with the corpus striatum or the sinuses, and carry it deep enough to
reach the cavity containing the fluid, as may be told by the want
of resistance at the point of the instrument. This will most fre-
quently be found to be before the trocar has penetrated two inches.
Then, after allowing the fluid to escape through the canula slowly
and cautiously, make moderate compression upon the cranium
either by the turns of a roller, or by strips of adhesive plaster tightly
applied, as advised by Sir Gilbert Blane and others. — It may, I
think, be doubted whether, as a general rule, there is any advantage
in compressing the skull from the commencement of the operation,
as has been sometimes done, as the distended condition of the brain
will generally suffice to force out the liquid with sufficient rapidity,
while the gradual evacuation, by enabling the skull to adapt itself
to the diminished size of its contents, will obviate the evils some-
times seen if compression is not accurately preserved. Various
obstacles may present themselves during this operation, such as the
sudden arrest of the flow of the serum from a small particle clog-
ging the canula, or the hemorrhage of a vein, or faintness, or con-
vulsions, for all which the surgeon should be prepared; thus the
introduction of a probe will soon clear the canula, a little time check
the hemorrhage, faintness be obviated by lowering the head and
« applying ammonia to the nostrils, and the convulsions often cease
when the escape of the fluid is checked by placing the finger over
the canula. If, however, the operation is conducted as advised by
Dr. Physick, without compressing the head — that is, by allowing the
1 London Medical Gazette, March, 1838. 2 Ibid., toI. ii. April, 1842.
256 OPERATIVE SURGERY.
fluid to escape slowly through a small canula, and simply by the
contraction of the natural tissues, until it ceases to flow freely —
the pressure from the fluid within the brain will be so gradually
removed that the application of moderate external pressure will
more than compensate for its disappearance. In all cases when
a bandage is applied to a cavity containing liquid at the moment
of its being punctured, the pressure, according to the views of Dr.
Physick, evacuates the fluid so rapidly as to create a marked change
in the relation of the parts, which is not the case when the escape
of the fluid is due solely to vital contractility, and in the case of
a brain which has been much distended, may be quite sufficient to
destroy its action. Compression of the head during the operation
has, however, been strongly urged by Dr. Conquest, and his success
has certainly been very marked. After a sufficient amount of the
liquid has been evacuated (as indicated by the pulse), the puncture
should be closed, the bandage applied and kept accurately adjusted,
and a proper medical treatment, especially of mercurials, perse-
vered in.
As the subject of Paracentesis capitis has lately excited some
attention, I cite the following case, as reported by Dr. William
Pepper, of Philadelphia, as an additional illustration of the charac-
ter of these operations : —
Operation of Dr. Ed. Peace, of Philadelphia, for Para-
centesis Capitis. — Disease of the head having apparently com-
menced soon (three days) after birth in the child of a healthy
woman, and the senses being nearly destroyed, it was determined,
as the child was now seventeen months old, and must certainly sink
under the continued progress of the disorder, to attempt its relief
by paracentesis capitis, which was done as follows : —
Operation. — A small silver canula, armed with a grooved trocar,
being introduced about one inch to the right of the longitudinal
sinus, and half an inch from the superior margin of the os frontis,
the trocar was removed and followed by a jet of limpid serum, which
continued to flow until about twenty ounces were evacuated, mode-
rate pressure being maintained upon the head during the operation
by the hands of assistants. After the evacuation of this amount
and the removal of the canula, a pledget of dry lint was applied
to the puncture, and lightly secured by a strip of adhesive plaster ;
after which the whole head was permanently compressed by broad
strips of plaster, so applied as to envelop it completely. Soon
REMOVAL OF FUNGOID TUMOES OF THE DURA MATER. 257
after the operation, the pulse was good, and the child took the
breast with avidity, no untoward symptom supervening until the
fourth day after the operation, when it became more restless, with
increased heat of head, &c, and died on the sixth day. A con-
siderable amount of serum continued to flow from the puncture
throughout this period of six days. A post-mortem examination
showed that the hemispheres of the brain had been distended into
mere sacs, and that the ventricles still contained about four pints of
turbid serum. The whole amount effused was calculated to have
been eight pints and four ounces.
Among other measures which have been tried in these almost
hopeless cases, and especially in those which were chronic, is the injec-
tion of iodine, as suggested by Velpeau in diseases of the serous cavi-
ties generally. Dr. D. Brainard, of Chicago, who has recently tried
this method, employed a solution of iodine gr. y 1 th ; iodide of pot-
ash gr. |th; water f5ss, gradually increased to iodine grs. xii; ioclicl.
potas. grs. xxxvi, and water 3j ; all of which was injected, and with
apparent benefit at the time of the report. 1 But further experience
in its use is necessary, though analogy seems to present a probability
of success. As the operation of paracentesis has as yet presented
but little to encourage surgeons in its repetition, it may be well to
try the effect of long-continued and gentle pressure by means of
bandages or adhesive strips, as advised by Mr. Barnard, of England.
§ 4. — REMOVAL OF FUNGOID TUMORS OF THE DURA MATER.
The development of fungoid tumors upon the dura mater, some-
times leads to the absorption of both tables of the skull, and the
appearance of the fungous growth directly beneath the integuments.
From the nature of the parts involved, and from the observation of
the cases, many surgeons have regarded this disease as hopeless; but
as successful operations have been performed, and as the result of
post-mortem examinations has often shown that the disease is fre-
quently limited to the dura mater, or rather does not encroach upon
the brain, the propriety of operating under even these dangerous
circumstances is a question which the operator must decide for
himself at the moment. Among the cases reported, one out of three
of this apparently hopeless operation has succeeded, and the sur-
1 Transact. Am. Med. Assoc, for 1850, p. 371.
17
258 OPERATIVE SURGERY.
geon may therefore deem a repetition of it advisable, although his
prognosis should be guarded. In a case reported by Dr. J. C.
Warren, of Boston, 1 a lady, twenty-two years of age, in 1846, had
a tumor on the right side of the forehead and right temple, which
had shown itself the preceding year. The tumor was smooth, uni-
form in its appearance, diffused in the surrounding parts, had no
distinct boundary, was not discolored, somewhat elastic, not painful
nor tender, and never had been. Nothing like a depression could
be discovered in the central part. In 1847, the skin became ulce-
rated, and a fungus about the size of an egg showed itself. This
was of a red color, without sensation to the touch, without pain or
intellectual disturbance when pressed on, bled readily, and a probe
penetrated the substance of the tumor to the depth of three inches,
yet the patient recovered. The operation was performed as fol-
lows : —
Operation of Dr. John C. Warren. — An incision being made
on four sides of the tumor, so as to make four flaps of the skin, the
latter were separated from the fungous mass as exactly as possible;
the soft and cerebriform matter cut away in detached portions, the
disease traced through an irregular opening in the bone to the dura
mater, and the actual cautery applied freely to the surface. The
hemorrhage, which was great, was suppressed by two or three liga-
tures and the cautery, and the subsequent symptoms were of a
favorable character. The wound healed slowly, but after some
months closed entirely ; has remained well ever since, and the pa-
tient has had no unpleasant feelings in her head, or any other
symptoms of disease. As the case was witnessed by a great num-
ber of medical gentlemen, there can be no doubt as to the character
of the disease.
In a previous case, in which the disease developed itself in a
young man, it returned after removal, and caused death.
In the case of a lady, operated on in the Massachusetts General
Hospital in 1828, the disease also returned, but the patient did not
die until two years after the operation. 2
Dr. Gross, of Louisville, has recently published 3 the history of a
case, which, in the hands of Dr. Jas. C. Johnson, formerly of Louis-
ville, fully illustrates the fact that these cases frequently present
1 Transact. Am. Med. Assoc, for 1850, p. 403. * Warren on Tumors, p. 510.
3 History of Kentucky Surgery, p. 60, 1853.
REMOVAL OF FUNGOID TUMORS OF THE DI?RA MATER. 259
examples of great tolerance of injury, and that operations upon
them are not necessarily and promptly fatal. In this case, an old
gentleman, after suffering excruciating pain for some time, was found
to have on the top of his head a hard, firm, immovable, and indo-
lent tumor, about the size of a pigeon's egg, which increased and
became soft and pulsating, inducing the belief that it was aneu-
rismal. An operation being decided on, a crucial incision three
inches long denuded the tumor, which, on being disengaged from
its attachment to the periosteum and dura mater, and elevated from
its bed on the skull, was found to leave the latter perforated to the
extent of about a quarter of a dollar in diameter. The hemorrhage,
which was slight, was arrested, and the wound dressed in the usual
manner with adhesive strips, a compress, and bandage. On removing
the dressings on the eighth day, the tumor was found to be again
springing up, rapidly acquired the size of a hen's egg, and was
pedunculated. It was now excised a second time, but the hemorrhage
was so profuse as to create apprehension. This being checked, the
tumor reappeared in another fortnight, and was treated, by the
advice of Dr. Dudley, by a sponge, compress, and adhesive strips
lonsr enough to reach from one side of the head to the other. The
tumor, after being thus checked, again sprouted, and was treated by
nitrate of silver, butter of antimony, the knife, and actual cautery,
with but little benefit. Eighteen months subsequent to the first
operation, an empiric, by caustics, removed the entire mass, until a
cavity was left in the brain "capable of receiving a common-sized
teacup." Many pieces of bone having come away, the destruction
of the cranium had reached three inches in diameter. This patient
now travelled a long distance, and did not die until nearly two
years after the first notice of the tumor, no disorder of the brain
having been indicated at any moment. No post mortem was per-
mitted, but a manual examination indicated the presence of stalac-
tiforme exostosis, &c.
In a case which was presented to myself recently, the post-
mortem examination clearly showed that though the tumor sprang
from the dura mater, and by pressure on the compact matter of
the skull had expanded its fibres so as to form a spina ventosa
like tumor, yet the under surface of the dura mater was not de-
pressed by the tumor, and that the latter might, therefore, have
been removed without causing any greater injury to the brain than
that resulting from the application of a trephine.
260 * OPERATIVE SURGERY.
Eemarks. — Although the character of these fungous tumors of
the dura mater has long been well known, having been thoroughly
described by Louis, 1 Abernethy, and others, all of whom enter-
tained the opinion that they originated from the dura mater, or in
the bones of the cranium, yet few surgeons have deemed it advisable
to recommend an operation for their relief. Yelpeau, however, in
an able article upon the complaint, 2 states that, in his opinion, "ex-
tirpation is indicated in these cases of fungous tumors of the head
as well as in those situated elsewhere, but that they, like other
forms of cancer, also present contra-indications." From reviewing
the opinion expressed by him, in the article referred to, as well
as from the results of my own experience, it may, I think, be as-
sumed, as a rule, that, if the operation can be thoroughly per-
formed without excessive loss of blood, the chances of the return
of the disease and the ultimate cure of the patient may be placed
on a par with the operations for cancerous developments in other
portions of the body. In four cases which it has fallen to my lot
to witness, the post-mortem examination of two not operated on
satisfied me that the disease had progressed from the outer lamina
of the dura mater towards the scalp, but had not encroached on
the brain. In the other two cases, though the tumors were mode-
rately developed, no operation was deemed advisable, and the sub-
sequent result is unknown ; but when last seen, one was rapidly
progressing to ulceration. I would therefore feel disposed to attempt
the removal of these tumors by the knife, or rather by it and the use
of caustic potash, in such cases as would justify any one in ope-
rating for a malignant disease generally.
1 Me"moires de l'Acad. de Chirurgie, tome vi. p. 361, edit. Fossone, 1837.
2 Dictionnaire de Medecine, tome 10 eme ' p. 532, Paris, 1835.
GENERAL ANATOMY OF THE FACE. 261
CHAPTER III.
OPERATIONS UPON THE FACE.
The Face being composed of various parts, the operations re-
quired for their relief, when diseased, will be treated of under their
special heads after a brief anatomical description of the portion
concerned.
SECTION I.
GENERAL ANATOMY OF THE FACE.
The Face, as a surgical region, is bounded by the superciliary
ridges above, by the base of the inferior maxilla below, and is
formed by the superior maxillary, inferior maxillary, malar, nasal,
palate, and ethmoid bones, together with those of the vomer, and
inferior turbinated. Its external portion is composed of the skin,
muscles, vessels, and nerves.
The skin of the face presents nothing of special interest to the
surgeon. Its sebaceous follicles, especially upon the nose, are the
occasional seat of tumors, which require the ordinary elliptical or
crucial incisions for their removal. "When any tumor upon the
face is so situated that its removal will leave a wound in a very
movable portion of the integuments, the use of a stitch or two of
the interrupted suture will, as a general rule, prove to be a better
means of uniting its edges than the employment of adhesive plaster.
In all operations upon the integuments of the face, attention
should be especially given to the line of the incision, in order that
the cicatrix may be brought as much as possible within the folds
created by the action of the subjacent muscles, the levatores anguli
oris, zygomatici, and buccinators being those which are chiefly
interested.
The action of the levator anguli oris and of the buccinator should
also be especially recollected in the operations for harelip, their
262 OPERATIVE SURGERY.
PLATE VIII.
EYE INSTRUMENTS.
Fig. 1. Desmarre's Bifurcated Forceps, for holding the skin during the
passage Of a Suture. After Bernard and Huette.
Fig. 2. Charriere's modification of Adams's Forceps.
After Bernard and Huette.
Fig. 3. Desmarre's Forceps for holding the upper eyelid during the
removal of little encysted tumors. After Bernard and Huette.
Fig. 4. Charriere's Rat-tooth Forceps. " " "
Fig. 5. " Curved-pointed Forceps. " " "
Fig. 6. Physick's Forceps, for perforating the iris in the formation of
an artificial pupil — one end is a flattened plate and the other a punch,
the iris being cut by closing the blades. From tbe Instrument.
Fig. t. Fine-teethed Forceps, for pterygium. After Bernard and Huette.
Fig. 8. Self-acting Speculum of Drs. Ruschenberger and Goddard ; the
lower bar moves on the shaft, and is capable of resisting the contraction
of the lids. With this instrument no assistant is necessary.
Schiveley's Pattern.
Fig. 9. A Silver Spring Speculum. " "
Fig. 10. Anel's Syringe. " «
Figs. 11, 12. Anel's Points, adapted to the syringe, when injecting the
puncta lachrymalia. Schiveley's Pattern.
Figs. 13, 14. Front and side View of Ware's style for fistula lachry-
mallS. Schiveley's Pattern.
Figs. 15, 16, 11, 18, 19, 20. Fine Eye Scissors, of different shapes,
both straight and probe pointed, and adapted to the operations of ptery-
gium, Strabismus, &C. Schiveley's Pattern.
Fig. 21. A modification of Anel's Probe, for dilating the puncta in
cases Of epiphora. Schiveley's Pattern.
Fig. 22. One form of the knife sometimes used to incise the conjunc-
tiva in pterygium and Strabismus. Schiveley's Pattern.
Fig. 23. Hook of Dr. I. Hays, for seizing the muscle in the operation
for strabismus. The curve is adapted to the convexity of the ball.
■n- mi ni Schiveley's Pattern.
Fig. 24. The Elevator of Comperat, for sustaining the upper lid in
Operations for cataract. After Bernard and Huette.
f^— — — MM
ANATOMY OF THE APPENDAGES OF THE EYE. 263
contraction being the main cause of tlie difficulty experienced in
uniting the wound after the operation.
The vessels of the face are principally branches of the facial
arteries and veins, hemorrhage from which may be easily checked
by compression at the point where the artery passes over the jaw,
or by leaving the wound open to the air for a few minutes. Should
this not suffice, then the ligature may be employed, but it is better
to avoid this if possible, as the union is more perfect, and the scar
less apparent subsequently. The nerves that supply the face are
branches of the second branch of the fifth pair coming out at the
infra-orbitar foramen, or branches of the seventh pair, or portio
dura, which, emerging at the stylo-mastoid foramen, are distributed
to most of the muscles. The division of the main trunks of either
of these nerves, in removing tumors or other operations upon the
face, is apt to cause distortion of the features or loss of sensibility,
though, in some few cases, the subsequent healing of the parts has
restored the motion and sensation of the portion whose supply had
been involved in the operation. But, in nearly every instance, as
any deep incision must necessarily divide some portions of the
nerves of the part, the surgeon can do little more than bear in
mind the importance of avoiding them, if possible, or at least of
not excising their trunks if they should be divided, as union may
possibly restore their function.
The Face is subdivided into the regions of the eyes, nose, and
mouth, the anatomical details of which may be briefly referred to
before mentioning the operations practised upon them.
§ 1. — ANATOMY OF THE APPENDAGES OF THE EYE.
The appendages of the eye consist of the lids and the lachrymal
apparatus.
The lids are composed of a thin, delicate skin, in which are nu-
merous horizontal folds ; of a loose and very movable cellular tis-
sue, which latter is often the seat of encysted tumors ; of a layer of
circular muscular fibres, the orbicularis palpebrarum, and on the
upper lid of a vertical muscle, the levator palpebral, which together
create the folds of the skin just referred to; and of two tarsal car-
tilages, which are thick upon the margin of the lids, thinner at the
distance of a few lines, intermediate to the muscle and the conjunc-
264: OPERATIVE SURGERY.
tiva, and bevelled on their margin so as to secure a gutter for the
tears. The cartilages tend to prevent the puckering of the lids,
which would otherwise ensue upon the contractions of the orbicularis
muscles. The levator palpebrae muscle is situated in the upper lid
between the orbicularis and the cartilage; arising near the optic
foramen, it is attached to the edge of the cartilage near its middle.
The tensor tarsi of Horner, and the external tensor muscle of
Mosely play important parts in keeping the cartilages applied
against the ball, but do not require special attention from the sur-
geon. The conjunctiva or mucous coat of the eyeball is the last
layer of the lids. It is reflected from the ball over .the posterior
face of the lids as far as the edge of the cartilages, and by its cha-
racter as a mucous membrane favors the motion of the lid upon the
eyeball. Between this membrane and the cartilages lie the Meibo-
mian glands, or the tortuous canals, which open upon the edge of
the cartilage, and lubricate its surface, thus preventing the escape
of the tears over the lids, and also facilitating their passage along
the grooved edge of the cartilages to the puncta lachrymalia or
openings of the lachrymal ducts, found in the cartilages near the
internal canthus of the eye. The cartilages are attached at the in-
ternal canthus by the internal palpebral ligament, which is also the
point of origin of the fibres of the orbicularis palpebrarum muscle.
Eendering this ligament tense by extending the lids towards the
external canthus, furnishes a guide for the point of incision in
puncturing the lachrymal sac in epiphora or fistula lachrymalis, if
the swelling is not too great.
§ 2. — ANATOMY OF THE LACHRYMAL APPARATUS.
The lachrymal apparatus consists of the lachrymal gland which
secretes the tears, of the puncta lachrymalia which receive them,
and of the canals which conduct them into the nose.
The lachrymal gland (Plate XI., Fig. 1), is placed immediately
below and within the external angular process of the frontal bone.
Its secretion is emptied upon the eyeball by six or seven ducts which
lie between the conjunctiva and the cartilage of the upper lid. It
lubricates the part, facilitates the motion of the lids, and washes out
small foreign particles, as dust, &c, accidentally introduced between
the lid and the ball, or upon the ball. The course of the tears to-
ANATOMY OF THE LACHEYMAL APPARATUS. 265
wards the puncta lachrymalia generally carries such matter to the
internal canthus.
The puncta lachrymalia, or openings of the canalicula lachry-
malia, are found bordering on the internal end of the upper and
lower tarsal cartilage, but are distinct from it. The upper punctum
looks downwards, and the lower points upwards, and each in the
ordinary condition of the part will admit a bristle. The lachrymal
canals or ducts are situated immediately beneath the skin at the
internal canthus of the eyelids, in their posterior margins and be-
hind the orbicularis muscle. One is found in each eyelid, and is
about half an inch long, the lower being rather the longer. In
each lid the canals run perpendicularly at first, upward and down-
ward from the free edge of the lid for about two lines, after which
they converge and enter the lachrymal sac behind the internal pal-
pebral ligament. Stretching or elongating the lids outwardly to-
wards the temple will generally remove the angular commencement
of the canals, and favor the passage of a fine probe into the saccus
lachrymalis.
The lachrymal sac (Plate XI., Fig. 1), is an oblong cylindrical
cavity, or enlargement of the ductus ad nasum, situated in the de-
pression of the os unguis and of the upper part of the same depres-
sion found in the nasal process of the superior maxillary bone. It
is covered in front by the ligamentum palpebrale, as well as by a
few fibres of the orbicularis muscle. The course of the sac is first
slightly forwards and from above downwards, but from the level of
the orbit it passes obliquely backwards at an obtuse angle with its
course at first. It decreases as it descends, and below the edge of
the tendon constitutes the lining of the bony ductus ad nasum, and
is sometimes designated simply as the nasal duct. It is composed
of two layers, an external fibrous one, continuous with the perios-
teum, and an internal mucous membrane which is continued from
the puncta or even the conjunctiva, into the Schneiderian mem-
brane. On a line with the floor of the orbit there is a doubling or
O
valve formed in the membrane, and occasionally there is another at
the nasal orifice formed by the Schneiderian membrane.
The position of these folds is certainly an objection to the intro-
duction of sounds, from the nostril, into the ductus ad nasum, as
recommended by Laforest. The length of the duct varies in dif-
ferent subjects, being on an average fifteen lines, and its inferior
orifice is pretty regularly found beneath the inferior turbinated
266 OPERATIVE SURGERY.
bone about five lines from its anterior extremity (Plate XL, Figs. 1,
2), about seven lines from the bony orifice of the anterior nares,
and about eight lines from the posterior inferior corner of the orifice
of the nostril in the recent subject.
CHAPTER IV.
OPERATIONS ON THE APPENDAGES OF THE EYE.
The disorders of these parts that require operations may be
divided into such as involve the eyelids, and such as affect the
lachrymal apparatus.
SECTION I.
OPERATIONS PRACTISED ON THE EYELIDS.
§ 1. — TUMORS OF THE EYELIDS.
Several of the tumors seen in other portions of the body are some-
times found developed in the eyelids. Most frequently they are a
variety of the encysted tumor, which is seated in the cellular tissue,
and readily removed either by incision of the cyst and the intro-
duction of a sharp-pointed pencil of nitrate of silver, so as to create
a slough of the sac; or by incising the integuments and sac, and
drawing the latter out with fine forceps; or they may be dissected out,
if care is taken to avoid cutting an opening entirely through the
lids, as this is apt to prove difficult to heal, from the constant
escape of tears through the wound. An important rule in remov-
ing these tumors by the knife, is to make the incision parallel to
the course of the fibres of the orbicularis muscle, either through
the skin from without inwards, or from the inside of the conjunc-
tiva to the skin, according to the depth of the tumor. Usually, the
tumor is removed from that side on which it seems to be most
superficial, though the incision through the conjunctiva is least apt
to produce a scar.
Desmarres, of Paris, employs a pair of forceps with broad ends,
EPICANTHUS. 267
with a fenestra in one of the blades (Plate VIIL, Fig. 3), well cal-
culated to support the lid, and, at the same time, circumscribe the
tumor, and when the surgeon cannot obtain proper assistants, these
forceps will prove most valuable. Generally, however, this opera-
tion is too simple to require anything more than to close the lid,
if the external incision is practised, or its eversion if the tumor is to
be excised through the conjunctiva. Then the tumor being seized
with fine and small forceps, or a tenaculum, may be readily dissected
out. The operation of Desmarres, as well as that by eversion of
the lid and incision of the conjunctiva, is shown (Plate IX., Figs.
1,2.)
Vascular tumors of the lids are occasionally noticed, but unless
of unusual size may be treated like the encysted class, by the means
just detailed. In large aneurisms by anastomosis, or those of such
size as to promise free hemorrhage, the production of inflammation
in the tumor by the introduction of a seton through it, as practised
by Mr. Lawrence, will generally answer a better purpose. 1
§ 2. — ENCANTHUS.
This complaint, named from its position («•, in, xav$o$, the angle of
the eye), consists in an enlargement or degeneration of the carun-
cula lachrymalis. When requisite, the tumor may be removed by
seizing it with a tenaculum or forceps, and excising it with fine-
curved scissors, or with a small scalpel.
§ 3. — EPICANTHUS.
Epicanthus (tfti,, upon, *aȣo?, the angle of the eye) consists in the
formation of a fold in the skin at the root of the nose, in conse-
quence of which the internal canthus is, in a measure, concealed.
It is a rare complaint, and occasionally requires an operation in
order to enable the patient fully to expand the lids. The operation
of Von Ammon, of Dresden, consists in pinching up a longitudinal
fold of the skin, excising it at the root of the nose of a sufficient
width to efface the epicanthus, either with the knife or scissors, and
then uniting the elliptical wound thus made by a harelip suture.
(Plate IX., Fig. II.) 2
1 Lawrence on the Eye, by Hays, Philadelphia edition, 1847, p. 1G2.
2 Bernard and Huette, p. 115.
268 OPERATIVE SURGERY.
PLATE IX.
OPERATIONS UPON THE EYELIDS.
Fig. 1. Extirpation of an encysted tumor from the upper lid by an
incision on its external face. 1. The incision over the tumor. 2. Des-
marre's ring forceps. After Bernard and Huette.
Fig. 2. Extirpation of an encysted tumor in the lower lid, by an inci-
sion through its mucous membrane. 1. Desmarre's bifurcated forceps hold-
ing the lid, as everted over 2, the handle of a cataract needle. 3. Fine
forceps raising the tumor. 4. Its dissection by the straight bistoury in
the line of the fibres of the orbicularis muscle. After Bernard and Huette.
Fig. 3. The ordinary operation for ptosis. 1. A pair of forceps pinch-
ing up the necessary amount of the skin of the upper lid. 2. The hori-
zontal fold thus raised. 3. The scissors excising the raised portion, close
to the grasp of the forceps. After Bernard and Huette.
Fig. 4. The shape of the wound, 1, 2, 3, left after the removal of the
skin on the eyebrow — in Hunt's operation for ptosis.
After Bernard and Huette.
Fig. 5. The wound united by fine harelip sutures, and its effects in
elevating the lid. After Bernard and Huette.
Fig. 6. Weller's operation for ectropion of the lower lid by excision of
the middle of the tarSUS cartilage. After Bourgery and Jacob.
Fig. 1. Von Ammon's operation for symblepharon. The portion of
the lid which is adherent to the ball has been included in the base of
a V incision, 1 3, 2 3, which starting at the tarsus cartilage has been car-
ried through the lid. After Bernard and Huette.
Fig. 8. The same operation completed; the edges of the incision
through the skin and muscle of the eyelid, have been united by three hare-
lip sutures, so as to leave a triangular fold of the conjunctiva attached on
the edge of the tarsus cartilage, but otherwise free from the lid, thus
favoring its motions On the ball. After Bernard and Huette.
Fig. 9. Dieffenbach's operation for the cure of a triangular wound of
the lower lid, left in removing a tumor. 1, 2, 3. The wound. 4, 5. The
flap which is to be inclined SO as to close it. After Bernard and Huette.
Fig. 10. Jones's operation for blepharoplasty, or the formation of a new
lid by sliding up a flap from the cheek. The operation is represented as
completed. 1, 2, 3. The triangular flap raised from the cheek, and fitted
into the lid by various points of the suture. 3, 4. Closure of the wound
left by the removal of the flap from the cheek. After Bernard and Huette.
Fig. 11. Von Ammon's operation for epicanthus. 1, 2, 3. The ellipti-
cal wound resulting from the removal of a fold of skin at the root of the
UOSe. After Bernard and Huette.
:
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'
W
"*
W
SYMBLEPHARON. 269
4. — ANKYLOBLEPHARON.
This disease, so called from the preternatural adhesion of the
edges of the lids, is generally the result of inflammation. The union
may be either partial or total, and is usually found at the external
canthus, where, if partial, a director may be passed between the lids
and the eyeball, and the adhesions divided either by a probe-pointed
bistoury or by probe-pointed scissors. If they are more extensive,
and the eye is entirely closed, the lid may be raised in a vertical
fold, and a small opening made through it at the external canthus
in order to permit the introduction of the director; when the ope-
rator, after satisfying himself that the lids do not adhere to the ball
(symblepharon), may pass a bistoury along the director, and divide
the adhesions at the edges of the cartilages.
After the operation, care must be taken to prevent the reproduc-
tion of the complaint, by cauterizing the parts with the nitrate of
silver; by separation of the lids by adhesive plaster; by colly ria,
or by liniments.
§ 5. — SYMBLEPHARON.
Symblepharon (aw, with, and fae^agov, an eyelid) is an adhesion of
the lids to the ball of the eye, and generally the consequence of
violent inflammation resulting from the introduction into the eye of
caustic or other irritating substances, as a drop of oil of vitriol, or
a particle of lime, or redhot iron. Division of the adherent points
by probe-pointed pterygium scissors (Plate YIII., Figs. 16, 17, 18),
or, if slight, their laceration by a pin or cutting instrument passed
between the lids and the ball, as practised by Amussat, will gene-
rally overcome the complaint. Or a double thread may be passed
through the adhesion, and one end tied close to the sclerotica with
great firmness, and the other towards the lid less tightly, as pro-
posed by Petrequin ; but care must be exercised to guard against
the reproduction of the band.
As it has sometimes been found very difficult to prevent the
renewal of the adhesions, the ingenious operation of Yon Ammon
may be resorted to (Plate IX., Fig. 7). Circumscribe by two inci-
sions (1, 2, and 2, 3), through the whole thickness of the lid, that
portion which is adherent to the eyeball, and the triangular flap thus
270 OPERATIVE SURGERY.
separated from the remainder of the lids will follow the eye in all
its motions. Then, by two or three small pins and the twisted
suture, unite the edges of the wound, so as to leave the triangular
flap (Plate IX., Fig. 8), inside, and adherent to the eyeball, until
the wound has fully cicatrized, when the flap may be dissected from
the ball without any risk of the production of new adhesions. 1
§ 6.— PTOSIS.
Ptosis (rtrwfftj, a Falling) signifies either a total or partial inability
to raise the upper lid, and may result either from a congenital ex-
cess of integument, or from want of power in the levator palpebras
muscle, or from spasm of the orbicularis palpebrarum, in conse-
quence of which the lid droops upon the eyeball. When such other
remedial measures as are adapted to the case have failed in affording
relief, an operation may become necessary in order to accomplish
the mechanical elevation of the lid, and open the eye sufficiently for
the purposes of vision.
Operation. — To accomplish this in the ordinary method, raise a
transverse fold of the upper lid in a pair of forceps, and either with
the scalpel or scissors (Plate IX., Fig. 3) cut off the portion thus
raised, so as to leave an elliptical wound, which should not, how-
ever, include the conjunctiva, uniting the edges of the incision by
two or three fine stitches of the interrupted suture. A very im-
portant point in the result of the operation, is the correct calcu-
lation of the amount of integument to be included in the fold seized
by the forceps: if too much is raised, the patient may subsequently
suffer from ectropion, or be unable to close the lid ; and, if too little,
it may become necessary to repeat the operation.
In the operation of Mr. Hunt, of Manchester (Plate IX., Fig. 4),
the eyebrow is first shaved clean above the point at which a semi-
elliptical piece is to be excised— the extent of the flap being calcu-
lated according to the amount of the relaxed portion of the lid.
This flap may be circumscribed by an elliptical incision of the lid
and eyebrow 1, 2, 3, the lower half being made first, and the upper
dissected until it exposes the lower fibres of the musculus frontalis.
Then, on uniting the wound by three stitches of the twisted suture,
1 Bernard and Huette, p. 115.
BLEPHAROPLASTY. 271
the cicatrix will form in the eyebrow, and be subsequently concealed
by the hair (Plate IX., Fig. 5). The adhesion thus formed between
the lid and the frontal muscle will enable the patient to elevate the
lid by the contraction of the muscular fibres just referred to.
§ 7. — BLEPHAROPLASTY.
The formation of a new eyelid at the expense of some portion of
the adjacent integuments is termed Blepharoplasty (^^ov, the eye-
lid, and rtXaarcxo?, forming or formative), and may be required for
the relief of cicatrices from burns, or for the loss of the substance
of the lid resulting from the removal of large tumors, or in order
to remedy an error consequent on an extreme miscalculation of the
portion of integument removed in the operation for Ptosis just
described, or for the cure of Ectropion. Under any of these circum-
stances, the ordinary rules for plastic operations 1 must be borne in
mind, and especially the necessity of making an apparently excessive
flap at first, in order to counteract the contraction which is so apt
to follow all plastic operations, but especially those performed to
remedy the defects of cicatrices. As the different methods of ope-
rating in plastic surgery will be described subsequently, the account
at present may be limited to the operations usually resorted to in
the formation of the eyelids.
Operation of T. Wharton Jones, of England, or the formation
of a flap by stretching the integuments (Plate IX., Fig. 10). After
having pared the edges of that portion of the lid which is to be
renewed, so as to obtain a fresh surface, two incisions in a V, 1, 4,
and 2, 4, are to be made near the wound, as upon the forehead, if in
the case of the upper lid, or upon the malar or superior maxillary
bone, if for the lower; the top of the V-flap, thus formed, being
intended for adhesion to the lower portion of the lid. After thus
circumscribing the flap, it should then be dissected from the base of
the triangle 1, 2, to near the summit 4, and, when freed from the
subjacent structure, excepting at its summit, it should be gently
drawn upon until it fills in the desired space, when it may be retained
in its new position by several stitches of the interrupted suture.
The gap left in the portion from which it has been drawn may then
%
1 See Operations on the Nose.
272 OPERATIVE SURGERY.
be closed by approximating the edges and uniting tlicm with the
harelip suture. The figure represents the flap 1, 2, 3 in its new-
position, and the union of the sides of the gap 3, 4 by the harelip
suture, which thus converts a wound of some size into a mere line.
The reader will readily see, by reference to the figure, that the
wound at 3 was of the width of 1, 2 previous to its elevation. 1
In the operation performed by Dieffenbach, of Berlin, or the
formation of a flap by sliding the adjoining skin, a sufficiently tri-
angular flap, 3, 4, 5, Plate IX., Fig. 9, was raised so as to fill the gap
or wound 1, 2, 3, allowing, as before stated, for subsequent contrac-
tion, wdiich may usually be calculated at about one-third of the whole
flap. This being dissected free from its attachments, with the ex-
ception of its pedicle 3, 5, was afterwards slipped into the wound 1,
2, 3. The other gap, 3, 4, 5, from which the flap had been formed,
was then left to cicatrize as a simple ulcer. 2
In the German operations of Gr^efe and Fricke, wdiich are modi-
fications of the ancient twisting of the flap as practised in India, the
cicatrix, or diseased portion, was removed so as to leave a fresh sur-
face, 1, 2, 3, 4 (Plate X., Fig. 1). Then a properly shaped flap, 3,
5, 6, of good dimensions, and at least one-third larger than the wound,
was dissected from the adjoining sound skin, and twisted at 3, so as
to adapt itself to its position. Being subsequently attached by the
interrupted suture to the surrounding portion of the lid, the space
caused by its removal was closed by the harelip suture, as in 2, 3
(Plate X., Fig. 2). 3
§ 8. — ECTROPIUM.
Eversion of the eyelids, or Ectropium (sx^fjtco, to turn out), may
result either from adhesion of the external surface of the lids to the
surrounding integuments; from a diseased condition of the con-
junctiva, or of the tarsus cartilage; or from irregular action or want
of power in the orbicularis muscle.
In the milder cases of the disease, or those resulting from an
hypertrophied condition of the conjunctiva, much may be accom-
plished by free leeching, astringent collyria, or cauterization of the
conjunctiva in lines parallel to the fibres of the orbicularis, which,
1 Bernard and Huette. * ibid.
3 Ibid.
BLEPHAROPLASTIC OPERATION FOR ECTROPIUM. 273
though forming a linear cicatrix, is yet buried in the surrounding
folds, and causes little irritation; or by the excision of a fold in the
same direction, by raising it with the simple forceps, and removing
it with fine scissors. But in more obstinate cases, blepharoplasty,
or the formation of a new lid, must be resorted to, in order to enable
the tarsus cartilage to apply itself properly to the ball. In these,
as in all plastic operations, I repeat that it is important to avoid
making the flap too small, as its contraction will continue for weeks
subsequently ; double the amount apparently required being often
barely sufficient, after its adhesion in its new position.
I. BLEPHAROPLASTIC OPERATION FOR ECTROPIUM.
The following operations are a few of those of an original cha-
racter that have been employed in the United States: —
Operation of Dr. Wm. E. Horner of Philadelphia. — Make an
incision two inches long down to the bone parallel with, and at the
inferior margin of the orbicularis muscle (Plate X., Fig. 8, 1, 2), dis-
secting up the whole thickness of the lid from the adjoining bones,
then make another incision, 3, 4, an inch long from about the middle
of the first downwards towards the angle of the jaw. From the ter-
mination of this, direct another, 4, 5, towards the point of the nose,
so that the last two incisions shall define an angle of integuments,
6, which, being dissected up as far as its base, is to be turned into
the beginning of the first incision.
The angle 6, or that taken from the cheek, being now inserted into
the lower eyelid (Plate X., Fig. 9), and the angle 3 drawn to fill up
the gap, pins should be fixed so as to keep the parts in place.
An almost immediate correction of the deformity ensues, and ordi-
nary dressings will be found sufficient to accomplish the cure. 1
Dr. Brainard, of Chicago, in a very bad case of ectropium of
the left eye, resulting from a burn, modified Fricke's operation as
follows : —
Operation. — The eyelid being first dissected up so as to place
it in its natural position, a wound an inch and a half long by three-
quarters of an inch broad was left beneath the lid. To fill this, a
flap was taken from behind the external angle of the eye, of a cor-
1 Amer. Journ. Med. Sciences, vol. xxi. p. 106, 1837.
18
274 OPERATIVE SURGERY.
PLATE X.
OPERATIONS FOR THE RELIEF OF AFFECTIONS OF THE EYELIDS.
Fig. 1. Blepharoplastic operation of Graefe on the upper Lid, effected
by twisting the flap. 1, 2, 3, 4. The elliptical wound left in the upper
lid by the removal of a tumor, &c. 3, 5, 6. The incision circumscribing
a flap upon the skin at the external angle of the orbit, and destined to
fill Up the WOUnd. After Bernard and Huette.
Fig. 2. A View of the operation as completed ; the flap is retained in
the lid by the sutures 1, 1, 1, whilst the space 2, 3, left by the removal of
the flap, is closed by a fine harelip suture. After Bernard and Huette.
Fig. 3. Operation of Sir William Adams for Ectropium. 1. The first
incision made through the lid by cutting from within to the tarsus ; the
edge of the tarsus beyond this incision is then held by 2, the forceps, and
a triangular piece of the lid removed by 3, the scissors.
After Bernard and Huette.
Fig. 4. Dieffenbach's operation for Ectropium. 1, 2. Longitudinal
incision through the skin and muscle of the lower lid ; the mucous mem-
brane is then seized with 3, the forceps, and a fold excised with 4, the
scissors ; a suture unites all together, and the cicatrization of the con-
junctiva in the wound inverts the edge of the lid. After Bernard and Huette.
Fig. 5. Desmarre's operation for Ectropium. 1, 2. The first incision
at the external canthus. 2, 3. The second incision, which, commencing
at 3, terminates at 2. 1, 4, 3, 4. Two incisions, which, starting from
the terminations of the first, unite at 4 on a line with the reflection of the
conjunctiva from the lid to the ball. After Bernard and Huette.
Fig. 6. The same operation, as completed. " " "
Fig. 1. Operation of Janson for Entropium. 1. Adams's forceps raising
a fold of the skin of the lid near the internal canthus. 2. Scissors curved
on the flat, excising the portion thus raised. 3, 4. The same kind of inci-
sion as completed near the external canthus. Af 'er Bernard and Huette.
Fig. 8. A Yiew of Horner's operation for Ectropium in the right eye,
resulting from a burn. 1,2. An incision along the edge of the lower lid
to free it from the cheek. 3, 4. A second incision, an inch long, from the
middle of the first towards the angle of the jaw. 4, 5. A third incision
from the termination of this towards the point of the nose. 3, 6. Two
angular flaps formed by these incisions. After Homer.
Fig. 9. The termination of this operation. 1, 2. Lower edge of lid.
6. The lower angular flap raised to the edge of the lid, and fastened
at its angle by a pin. 3. The upper angular flap depressed to fill in the
gap. After Horner.
Fig. 10. Brainard's modification of Fricke's operation for Ectropium in
the left eye resulting from a burn, the flap being taken from behind the
external angle of the eye, and rotated upon its base so as to fill up the
space left by detaching the lid from the cheek. After Brainard.
Plat.
H6 2 .
f iV
R.fc.3.
m
H.6.4.
rio 9
BLEPHAROPLASTIC OPERATION FOR ECTROPIUM. 275
responding form, but somewhat larger, in order to allow of con-
traction (Plate IX., Fig. 10). This flap, being turned upon its base,
was then brought into the wound left by dissecting up the lid, and
retained there by numerous points of the interrupted suture ; the
wound created by the removal of the flap being subsequently closed
by adhesive plaster and simple dressings. In two weeks the patient
returned home relieved of the deformity.*
In the operation proposed by Sir Wm, Adams in 1812 (Plate X.,
Fig. 3), which is especially adapted to cases in which the tarsus car-
tilage is much, elongated, the edge of the lid was seized with forceps,
and a V-shaped piece, of sufficient width at its base to restore the
position of the lid (in some instances equal to four lines), removed
with the scissors. The wound, being then united by one or two
fine pins and the twisted suture, soon cicatrized.
Dieffenbach proposed to diminish the conjunctiva in order to
restore the lid to its proper position. To accomplish this, he cut
transversely through the skin on the outside of the lid, as at 1, 2
(Plate X., Fig. 4), and through all the thickness of the other tissues
until he reached the conjunctiva, when, seizing this membrane
with the forceps as at 3, he drew a fold of it out through the inci-
sion in the integuments, and excised it with fine scissors. Then,
uniting the conjunctiva and the edges of the wound by a few
stitches of the interrupted suture, the free edge of the lid was drawn
up by the process of cicatrization. 1
Desmarres, in order to avoid the cicatrix which arose from the
operation of Sir W. Adams, proceeded as follows : He first made a
horizontal incision, 1, 2, through the tarsus cartilage (Plate X., Fig.
5) at the external canthus ; then a second one from 3, at such a dis-
tance from the first as corresponded with the size of the piece of
the cartilage to be removed, carrying this incision to the termina-
tion of the first at 2. Then, uniting these by two others, 1, 4, and
3 4, he excised this portion of the lid, and, uniting the whole wound
by the twisted suture (Plate X., Fig. 6), caused the cicatrix to be
concealed in the wrinkles found at the angle of the eye.
Kemarks. — When Ectropium is very marked, and especially
when it is the result of cicatrization from the effects of burns, the
plastic operations just referred to offer the best chances of success ;
i Amer. Journ. Med. Sci., vol. x. p. 35G, 1845. Also, Hays's Lawrence on the Eye.
2 Bernard and Huette.
276 OPEEATIVE SURGERY.
but if the tissue from which the flap is formed is not perfectly
healthy, and indeed even when it has all its natural characters, the
operator, according to my experience, may look for disappointment
from its subsequent contraction, unless he is liberal in his calcula-
tions of the amount required to meet the subsequent contractions
of the flap.
§ 9. — ENTROPION.
Entropion {tvrcma^ to turn in,) is the reverse of ectropion, and
characterized by inversion of the lids, in consequence either of
some change in the part, as relaxation of the integuments or con-
traction in the conjunctiva or cartilages, or as has been urged by
Mr. Haynes Walton 1 to over action of a part of the orbicularis
palpebrarum muscle, by which the eyelashes are brought in con-
tact with the ball, and keep up a continual irritation. In this, as in
the former affection, the treatment must be regulated by the cause.
In the early stages the use of astringent collyria, or of adhesive
strips to draw the lid outwards, or similar simple measures, may
accomplish the cure if the deformity is not very great. The pro-
duction of a slough in the skin by the linear application of a piece
of soft wood wet with sulphuric acid, as proposed by Quadri, and
the subsequent cicatrization of the ulcer may also answer, though
it leaves a scar. But if these means fail, or if the disease is obsti-
nate, an operation consisting in excision of the integuments will be
required.
In many instances, the excision of the lid, as recommended in
ptosis, will be found to answer a good purpose.
OPERATIONS BY THE EXCISION OF A PART OF THE LID.
Janson, of Paris, drew the tarsus into its proper position by
raising a vertical fold of the integument with broad forceps* (Plate
VIII., Fig. 2), and, after excising it with the scissors (Plate X.,
Fig. 7), united the wound by the twisted suture, as at 4, 5, of the
same figure. If the excision of this one fold is not sufficient, two
1 Op. Ophl. Surg., Am. Ed., p. 131, 1853.
OPERATIONS BY THE EXCISION OF A PART OF THE LID. 277
or more may easily be added to it, until the lid is brought by the
cicatrices to its proper relations with the eyeball. 1
Operation of Dr. John Syng Dorsey, of Philadelphia. —
Dr. Dorsey having, in July, 1810, been led to the study of this
complaint, concluded that half the eyelid might, if requisite, be cut
off without much inconvenience, as the natural contractions of the
orbicularis palpebrarum, by throwing the skin into folds, showed
that much of the lid was naturally in excess. He therefore sug-
gested the following operation: —
Operation. — Pass a hook through the edge of the eyelid, in order
to gain a secure hold of it, and, with a pair of sharp scissors, cut out
completely all that portion of the lid from which the cilia proceed.
This wound healing readily, his patient was cured in a few days by
the contraction of the lid. In two instances, he subsequently re-
peated this operation, and obtained favorable results. 2
Mr. Saunders, about the same period, suggested his method of
operating, which was as follows : Introducing a thin plate of horn
or silver, with a curvature corresponding to that of the eyelid, and
with its concavity turned towards the globe, he stretched the lid
upon it, and made an incision through the integuments and the
orbicularis muscle immediately behind the roots of the cilia, to the
tarsus, from the punctum to the external canthus. Then dissecting
off the exterior surface of the tarsus until the orbital margin was
exposed, he cut through the conjunctiva by the side of the tarsus,
and disengaged the flap at each extremity, the only caution being
to leave the punctum lachrymale uninjured. The fungus subse-
quently formed in the cicatrix was either cauterized or excised. 3
When the inversion of the lid is due to a contraction or cicatrix
in the conjunctiva or in the cartilage, and is the result of deep ulcer-
ation, the operations of Sir P. Crampton, or of Guthrie or Tyrrell
may be employed.
Sir P. Crampton's Operation. — In this operation, the tarsus
cartilage should be divided perpendicularly at each canthus by two
incisions, each about three lines long, care being taken to avoid the
punctum, after which a transverse incision of the conjunctiva should
be made so as to unite the two vertical cuts. Two or three ligatures
being then passed through the skin at its tarsal margin, the divided
1 Bernard and Huette.
2 Dorsey's Elements of Surgery, vol. i. p. 334. 3 Ibid.
278 OPERATIVE SURGERY.
portion of the eyelid is to be carried up to the eyebrow, and the
ligatures fastened to the forehead by strips of adhesive plaster.
Mr. Guthrie's Operation. — This is a modification of Cramp-
ton's, and was performed as follows : Two perpendicular incisions,
a quarter of an inch long, having freed the tarsus cartilage from its
attachments at each end, and any vicious curvature of the cartilage
being overcome by dividing it at the place where it is bent, a fold
of skin of the length of the lid between the vertical cuts should be
removed as close as possible to its margin. The edges of the wound
being then united by fine sutures, the lid is to be secured to the
forehead, as in the preceding operation, and caustic applied fre-
quently to the perpendicular incisions, so as to cause them to heal
by granulation.
In cases due to contraction of the orbicularis palpebrarum muscle,
as suggested by Mr. Key, in 1825, and since urged by Mr. Ilaynes
Walton, the following method of operation may suffice : —
Walton's Operation. — An assistant, standing behind the pa-
tient, and making the lid tense by drawing it outwards and forwards
whilst raising the brow, the surgeon should make two incisions
through the skin and muscle, one parallel with, and as close as
possible to the roots of the cilia, and the other, so that it would
form an elliptical flap of about three lines at its greatest width and
terminate at each end of the tarsal cut, thus making an oval wound.
The flap, thus isolated, being then forcibly drawn forwards and
slowly dissected by vertical strokes of the knife, the wound should
be closed by three or four fine sutures, and the cold-water dressing
applied. The hemorrhage yields to the pressure of the finger or
cold water applied before closing the wound. In fifty cases operated
on in this manner, Mr. Walton has never seen a bad symptom.
Remarks on the Value of these Operations. — In estimating
the value of the operations just detailed as practised on the eyelids,
so much must depend upon the peculiarities of each case, that it is,
perhaps, best to leave a decision of their value to the judgment of
the moment. In deformities resulting in Ectropium, and consequent
on burns or ulcers, the tendency to contraction is so great that, in
all the plastic operations, too much integument can scarcely be
obtained. In all such instances, blepharoplasty presents the best
chances of success ; but even then the operator should be very
guarded in his prognosis. In the case of a young lady in whom the
upper lid had contracted adhesions to the edge of the orbit, in con-
OPERATIONS ON THE LACHRYMAL APPARATUS. 279
sequence of a burn, leaving the eyeball exposed to dust and other
irritation, I formed a flap from the forehead, making it more than
three times as large as the space to be filled in the lid, and, fastening
it in position, obtained union by the first intention. Yet six months
subsequently, the cicatrization of the wound from which the flap
was taken, and the contraction of the latter, had again elevated the
lid nearly to the edge of the orbit.
In Entropion, I should prefer the operation of Mr. Key, as modi-
fied by Mr. Walton, to most of the others. The operation of Dr.
Dorsey is, I think, preferable to that of Saunders, not only from its
simplicity, but from its completeness. In cases due to the contrac-
tion of the cartilages, the operation of Guthrie will generally be
preferable to the operation of Mr. Crampton.
SECTION II.
OPERATIONS ON THE LACHRYMAL APPARATUS.
The principal disorders to which the lachrymal apparatus is
exposed are scirrhus, or such other degeneration of the lachrymal
gland as may necessitate its removal ; and obstruction of the puncta
lachrymalia, thickening and stricture of the ductus ad nasum, or
suppuration and ulceration of the sac itself. At present, this
account will be limited to such operations as are required by dis-
orders of the tear passages; the removal of the lachrymal gland
being usually accomplished by such means as are employed for the
extirpation of other tumors, that is, by an incision through the lids,
and the dissection of the gland from the surrounding parts. When
the gland is removed, the loss of its secretion will be in a measure
supplied by the increased action of the conjunctiva as a mucous
membrane, its mucus being generally sufficient to favor the action
of the lid over the ball. In contraction of the puncta lachry-
malia, or of the canalicula lachrymalia, it occasionally becomes
necessary, after employing antiphlogistic measures, and mild col-
ly ria, to dilate them by a probe, or to wash out the sac and ductus
ad nasum.
Dilatation of the Puncta. — To one familiar with the anato-
mical relations of the part, catheterism of these ducts is a simple
affair, and may be accomplished by introducing Anel's probe, or,
280 OPERATIVE SURGERY.
PLATE XI.
OPERATIONS PERFORMED FOR THE OBSTRUCTION OF THE LACHRYMAL
PASSAGES.
Fig. 1. A side view of the relative positions of the different portions of
the Lachrymal Apparatus of the left Eye. The upper and lower eyelids,
with a small portion of the bones and integuments on the side of the nose,
have been removed, so as to expose the structure freely. 1. The lachry-
mal gland in its natural position at the edge of the orbit, near the external
angular process of the os frontis. The conglomerate structure of the
gland is well shown. 2. The superior punctum lachrymalium, with the
course of its canalicula, to the saccus lachrymalis. 3. The inferior punc-
tum lachrymalium in its course to the sac. The head, or enlargement of
the ductus ad nasum, sometimes designated as the saccus lachrymalis, is
seen between the lines of 2 and 3. 4. The ductus ad nasum, exposed by
removing its anterior parietes. Its course from the puncta down to the
inferior turbinated bone, and the direction to be given to instalments
introduced into it, can thus be readily understood.
After Bernard and Huette.
Fig. 2. A three-quarter View of the Face. Anel's probe has been
introduced into the upper punctum and carried into the lachrymal sac,
whence it may be made to enter the nose. The dotted line shows the
course that the instrument would take, whilst the probe in the nostril indi-
cates the position of instruments when passed into the duct from the nose,
as in the plan of Laforest. After Bernard and Huette.
Fig. 3. The position of the operator's fingers, when washing out the
lower punctum with Anel's syringe. The mode of holding the syringe so
as to prevent undue pressure on the canal, is also shown.
After Bourgcry and Jacob.
Fig. 4. Operation of puncturing the Lachrymal Sac of the left Eye in
cases of obstruction. The forefinger of an assistant is represented making
traction on the lid so as to render the position of the palpebral ligament
apparent, if the swelling and inflammation permit it. A straight narrow
bistoury has punctured the integuments and anterior face of the sac, and
whilst retained in its position, a probe has been passed along the blade of
the knife into the duct and thence into the nose. Af ter Bernard and Huette.
Fig. 5. Operation upon the right Eye ; the bistoury, after puncturing
the sac, has been retained in its position until Ware's style could be intro-
duced. Modified from Bernard and Huette.
Fig. 6. Fistula Lachrymalis, and the introduction of a bougie into the
duct through the fistulous Orifice. After Bernard and Huette.
^•N
v. -*^*9 '
OPERATIONS ON THE LACHRYMAL APPARATUS. 281
what is better, the blunted point of a fine cambric needle fastened
in a handle, or the instrument represented in Plate VIII., Fig. 21,
into the punctum, and repeating the operation from time to time,
as it may be required.
To dilate the Canals and Ductus ad Nasum. — Draw the eye-
lid towards the temple, in order to straighten the canalicula and
prevent a fold of the mucous lining from being pushed in front of
the point of the instrument. Then introduce a fine probe, or one
fastened into a light handle to facilitate its manipulation (Plate VIII.,
Fig. 21), into either punctum, by passing it perpendicularly into the
orifice, and carrying the handle towards the temple, or nearly parallel
with the lids, move it gently towards the inner canthus of the eye.
On reaching the sac, elevate the instrument from the horizontal
nearly to a perpendicular direction, and carry the handle obliquely
forwards, when the point will pass readily into the nose (Plate XI.,
Fig. 2). The figure shows the probe when it has reached the sac
and is about to pass into the duct, and the dotted line indicates its
course downwards. The introduction of a probe from the nostril
into the duct, as suggested by Laforest, is also shown in the drawing,
but the operation has little to recommend it, being opposed to the
anatomical relations of the parts, and the same end is better accom-
plished by operating from above.
To wash out the Canals and Sac. — Introduce one of the fine
points of Anel's syringe into the lower punctum, holding the instru-
ment with the forefinger upon the piston, as shown in Plate XI.,
Fig. 3. Then elongating the lid, throw in the fluid by the
motion of the forefinger, taking care not to press the point of the
syringe into the membrane lining the canals, nor to push a fold of
it in advance of the instrument. If the liquid does not pass out
of the syringe as freely as the orifice should permit, withdraw the
point a little, and again passing it forwards it will be easy to avoid
any duplicature of the membrane. Whilst injecting either punctum,
the other should be closed to prevent regurgitation. If the liquid
passes freely through the duct, the fact will soon be rendered appa-
rent by its escape either from the nose or throat of the patient,
according as the head is held forwards or backwards. The liquid
injected may consist either of simple water or of mild alterative
collyria. If the operator can only use his right hand, he must stand
either in front of, or behind his patient, according to the eye to be
operated on, that is, in front for the left eye, and behind the patient
282 OPERATIVE SURGERY.
when operating on the right; but if he is ambidexter, his position
will be immaterial.
Fistula Lachrymalis. — When inflammation of the lachrymal
sac results in suppuration, or when an abscess of this structure ul-
cerates, and opens upon the integuments, there is usually such a
constriction of the ductus ad nasum as requires the introduction of
a foreign body to dilate it and restore the patulous condition of its
channel.
Introduction of a Bougie or Style, or Canula. — The intro-
duction of any of these instruments requires the formation of an
opening through the integuments into the sac, unless the discharge
from the abscess has created an orifice by ulceration.
The ordinary operation is performed as follows : Endeavor to
render the ligamentum palpebrale prominent by drawing the lids
outwards, as it is the great point of reference, the sac lying some-
what in front and below it. When on account of the swelling or
inflammatory thickening of the integuments, the operator cannot
feel this ligament, he must be guided in his puncture by the promi-
nence formed by the distended sac, or by his knowledge of its proper
position, and especially its relation to the edge of the orbit. Having
decided on this, let him take a narrow, straight, and sharp-pointed
bistoury, and, standing in front of the patient for the left eye, and
behind him if the disease is in the right one, puncture the integu-
ments and anterior surface of the sac by pressing the point of the
knife (with its back turned towards the nose) obliquely downwards
and backwards. On entering the sac, bring the handle to a nearly
upright position, and carry it forwards, slightly towards the nose,
and downwards, so as to make the point pass backwards and
obliquely outwards and downwards (Plate XL, Fig. 4). Retaining
the bistoury in the duct, pass a probe along the knife as a director
until it reaches the nostril, and, withdrawing the bistoury, pass the
style or bougie, or canula, along the course of the probe, and with-
drawing the latter, fasten the instrument down by a piece of adhesive
plaster, or simply trust to its retaining its position in consequence
of the depth to which it has been introduced. Some surgeons, and
especially the French, prefer passing the canula of Dupuytren along
a groove made in the knife in order to conduct it into the duct with
greater certainty ; but in the United States, the style of Ware, with
the head blackened by a little varnish or sealing-wax, and employed
in the manner just directed, is almost universally resorted to. To
OPERATIONS ON THE LACHRYMAL APPARATUS. 283
guard against a change in the relations of the soft parts, consequent
on the escape of the pus, when the sac is opened, the employment
of a probe passed into the duct before the bistoury is withdrawn, if
the style cannot be passed in the first instance, will be found most
serviceable; and I have more than once seen surgeons entirely
baffled in the introduction of the style, in consequence of with-
drawing the bistoury before the probe or style was fairly in the
orifice made in the sac. From the collapse of the sac after its punc-
ture, there is also, occasionally, risk of the style passing outside of
the lining membrane or between it and the bony duct, so as to
separate the former entirely from the bone, thus leading to entire
obliteration of the cavity, as well as to disease in the os unguis.
Whenever, therefore, great difficulty is experienced in introducing
the style, caution in reference to this accident becomes necessary.
If the duct is obliterated, a perforation may be made through the
os unguis from the sac; but if it is only closely strictured, the practice
of employing caustic, as recommended by Dr. Eobert W. Haxhall,
of Eichmond, 1 will be found serviceable. The plan proposed by
Dr. Haxhall is the same as that recommended by Ducamp in stric-
ture of the urethra, viz., first to take a mould of the stricture by a
soft bougie, and then apply lunar caustic to the constricted part.
The same idea was previously suggested by Dr. Nathan Smith, of
Dartmouth College, in 1817, though he employed caustic potash in-
stead of the lunar caustic. His mode of using it is as follows : —
Dr. Nathan Smith's Operation. — Bender the tendon of the or-
bicularis (lig. palpebrale) conspicuous, cut into the sac, introduce a
probe, and find the obstruction. Then substitute a bougie armed
with a morsel of caustic potash, press the alkali upon the opposing
membrane, and the obstruction will soon be overcome, or the passage
dilated. 2
Perforation of the Os Unguis. — When the duct is so perfectly
obliterated that its patulous character cannot be restored, then it
may be necessary to make a perforation into the nostril by means
of a punch (Plate XIII., Fig. 23), or a fine trocar, or the bone may be
punctured and the fragments carefully picked out, jn order to guard
against the subsequent closure of the wound. To prevent exten-
sive fracture or laceration of the neighboring parts, the puncture
must be made with care.
1 Boston Med. Magazine, p. 147, 1832. 2 Ibid., p. 403, 1833.
281 OPERATIVE SURGERY.
PLATE XII.
OPERATIONS PRACTISED ON THE EYEBALL.
Fig. 1. Excision of a Fterygium by the Bistoury. 1, 2. The fingers
of the assistant who controls the lids. 3. The forceps seizing the ptery-
gium, and raising it from the eyeball, whilst it is excised towards the in-
ternal canthus by the bistoury introduced beneath it.
After Bourgery and Jacob.
Fig. 2. A Vertical Section through the External Face of the Right
Orbit, showing the Muscles of the Right Eye. 1. The eyeball. 2. Le-
vator palpebral superioris muscle. 3. Rectus superior. 4. Rectus ex-
ternus. 5. Rectus inferior. 6. Inferior oblique muscle near its insertion.
7. The point of origin of the recti muscles near the optic foramen. The
eyelids are seen in position. After Bernard and Huette.
Fig. 3. A side View of the Sheaths of the Muscles of the Right Eye.
1. The eyeball. 2. The sheath of the levator palpebrse. 3. Sheath of
rectus superior. 4. Sheath of rectus externus. 5. Sheath of rectus in-
ferior. 6. Sheath of inferior oblique. After Bernard and Huette.
Fig. 4. A front Yiew of the Eyeball, showing the insertions of the
Ocular Muscles into the Sclerotica, and their tendinous expansion upon
the ball. After Bernard and Huette.
Fig. 5. A front View of Hays's Operation for Strabismus, as practised
on the left eye. The sound eye has been covered by a handkerchief, and
the eyelids of the squinting eye distended by the spring speculum placed
outside of the tarsus cartilage, whilst the surgeon, raising a fold of the
conjunctiva near the internal canthus, divides it vertically with the scis-
sors. The muscle, being thus exposed, is seized and divided as shown in
Figs. 7. and 8. After Nature.
Fig. 6. The Operation of Sedillot. 1. The speculum applied inside
the lids. 2. A double hook inserted into the ball to steady it. 3. For-
ceps raising a fold of the conjunctiva, 4. Division of the conjunctiva by
slightly-Clirved scissors. After Bernard and Huette.
Fig. 7. An enlarged View of the Operation of Hays, showing the
division of the muscle. After Nature.
Fig. 8. The Muscle, as raised on a Hook. After Bernard and Huette.
Fig. 9. Division of the Muscle in Sedillot's Operation ; the chief differ-
ence being in the scissors and hook employed for this purpose.
After Bernard and Huetto.
dfc^l
A\
sktai •
OPERATIONS UPON THE EYEBALL. 285
After Treatment. — After the introduction of the style or
bougie, they may be fastened in their position by a morsel of adhe-
sive plaster, though, most frequently, the swelling of the integu-
ments will be sufficient to retain them. After the lapse of six or
eight days, the style should be removed by seizing its head with a
pair of dissecting forceps, and withdrawn by a movement which is
the reverse of that employed for its introduction. The point of a
syringe being then placed in the canal, the part should be thoroughly
washed, and the pervious character of the passage tested by the
escape of the water either from the nostrils or into the throat of the
patient. Then replacing the style, the same means should be resorted
to from time to time, until all inflammation has subsided, after which
common cleanliness is all that is requisite. The patient should,
however, wear the style for at least six months, or until the per-
meable character of the ductus ad nasum seems well established.
On finally removing it, the orifice will heal readily under the occa-
sional application of the nitrate of silver.
Eemarks. — In the early stages of inflammation in the sac or its
duct, the antiphlogistic treatment, and the dilatation of the passage
by a probe passed through the punctum into the nose, will often
suffice for the cure ; but when the disease is more advanced, punc-
ture of the sac and the subsequent introduction of a bougie or style
in the manner just detailed will be requisite. Puncturing the os
unguis is very seldom required when the surgeon is familiar with
the relative changes of position necessary for the introduction of an
instrument into the nose, audit should only therefore be attempted
as a last resort.
CHAPTEE V.
OPERATIONS UPON THE EYEBALL.
As the anatomical details of the eyeball are comparatively limited
in their relations to operative surgery, they can readily be referred
to in connection with the operations practised upon them.
The operations practised on the eyeball consist in those required
by diseases of its tunics, muscles, and humors.
286 OPERATIVE SURGERY.
SECTION I.
OPERATIONS ON THE COATS, OR EXTERNAL PORTIONS OF THE EYEBALL.
The conjunctiva covering the eyeball being a reflection of that
covering the lid, is liable, like it, to such a degree of inflammation,
as may result in thickening, granulation, ulceration, or the develop-
ment of accidental growths.
When, from violent or repeated attacks of ophthalmia, the con-
junctiva is left in a hypertrophied or simply oedematous and thick-
ened condition (Chemosis). and it is desired to excise one or two
of the largest vessels, or a small fold of the conjunctiva, it is only
necessary to raise the latter in a pair of fine forceps, and cut it off
with scissors, according to the long diameter of the ball.
Granulations, even when exuberant, generally yield to the action
of the lunar caustic, or to the sulphate of copper, applied either in
solution or in mass. The fungous growths occasionally seen after
the operation of strabismus, may also be treated in this manner,
and if a warty growth be found upon the adnata, as reported by
Dr. Physick, 1 the caustic will readily remove it.
Pterygium. — Pterygium («rfpoi/, a wing), or a vascular thickening
of a portion of the conjunctiva, on either side of the cornea, may
be removed simply by seizing the growth with a pair of fine forceps,
and excising it with the curved scissors usually known as pterygium
scissors (Plate VIII., Fig. 17), or by dividing the vessels composing-
it transversely, and then cauterizing the wound with the nitrate of
silver, so as to prevent reunion of the divided vessels.
SECTION II.
OPERATIONS ON THE MUSCLES OF THE EYEBALL.
Strabismus, or squinting (arpa^Ccoj, I squint), is a variation of the
eye from the centre of the orbit, in consequence of which the paral-
lelism of the optic axes is destroyed. This affection may result from
various causes, but only becomes a fit subject for an operation when
1 Philadelphia Medical Journal, vol. v. 1827.
OPERATIONS ON THE MUSCLES OF THE EYEBALL. 287
positively dependent on spasmodic contraction of the muscles which
move the ball. If the eye turns in, the squint is said to be con-
vergent; but if the cornea is turned outwards, it constitutes a
divergent squint. In addition to the deformity, this complaint also
impairs vision, and it is in the latter case that surgical interference
is especially demanded. If judgment is exercised in the investiga-
tion of the cause, and it is found that, on closing the sound eye, the
patient with a convergent squint can turn the other eye towards
the temple, then the operation may be attempted with confident
expectations of success; but if, when the sound eye is closed, that
which squints cannot be turned in the opposite direction to the
squint, an operation will prove of little benefit to the patient.
§ 1. — ANATOMY OF THE MUSCLES CONCERNED IN SQUINTING.
The eyeball is moved by six muscles (Plate XII., Fig. 2), two of
which are oblique and four are straight, the internal straight one
being mainly concerned in the production of the convergent or
most common form of strabismus. The straight muscles all arise
from around the optic foramen, and are inserted by broad and thin
tendons into the sclerotic coat of the eye about three or four lines
from the cornea, Plate XII., Fig. 4.
The superior oblique muscle also arises from near the optic fora-
men, but the inferior oblique takes its origin from the nasal process
of the superior maxilla at the side of the os unguis. Both are
inserted into the sclerotica, about half-way between the cornea and
the optic nerve. Between all the muscles and the conjunctiva is
found a white fibrous membrane which lines the ocular conjunctiva
throughout. This membrane extends from the palpebral ligament
in front as far as the cornea, and then turning backwards forms a
complete envelop for the sclerotica until it reaches the optic nerve,
with the neurilemma of which it appears to be continuous. On the
sclerotica it is very movable, and a layer of cero-cellular substance
is interposed between them. At the points of insertion of the
tendons, it is folded around them so as to form a fibrous sheath
(Plate XII., Fig. 3), which degenerates into cellular tissue on the
muscle. 1 This membrane is designated by Malgaigne as the Sub-
1 Malgaigne, Operative Surgery, Phila. edit., p. 288.
286 OPERATIVE SURGERY.
conjunctival Fascia, and, in most cases of squint, requires to be
divided.
In the operation for strabismus, it is, therefore, necessary to in-
cise the conjunctiva and fascia, expose the muscle or its tendon,
and divide it entirely, but without removing any portion, lest its
subsequent power be entirely destroj^ed.
§ 2. — OPERATION FOR STRABISMUS.
The credit of suggesting the operation for the relief of squinting
has been generally assigned by European writers to Stromeyer, but
in the United States it is well known that he had been anticipated,
and the operation performed many years before his account was
published, by Dr. Wm. B. Gibson, 1 of Baltimore, who in 1818, ope-
rated in four cases, though he was subsequently induced to lay it
aside from the opinion of Dr. Physick being adverse to it, the latter
gentleman fearing that it would endanger vision. To Stromeyer,
however, is certainly due the credit of having brought the opera-
tion into general notice in 1838, and to Dieffenbach belongs the
honor of having established its success beyond a doubt. In the
United States, this operation was subsequently performed by Dr.
Willard Parker, of New York, in 1840, and by Drs. Pancoast, A. C.
Post, Gross, Detmold, and Dixon, shortly afterwards, who in several
papers called attention to its utility. 2 Since then, it has been re-
peated by nearly every surgeon. As the advantages of this opera-
tion appear, however, to have been doubted by many physicians,
in consequence probably of the failures which have resulted from
imperfect operations, or those injudiciously performed, I would state
that the evidence of good operators yet continues to be favorable
to it. Dr. Pancoast, 3 who has operated in something like a thousand
cases, expresses his decided conviction that there is no operation in
surgery that yields more gratifying results ; and my own experience,
though much more limited, has led me to the same conclusion.
Various modes of operating have been employed by different
i Now Professor of Surgery in the University of Pennsylvania. See Principles
and Practice of Surgery, vol. ii. p. 375, Philad. 1841.
2 Cooper's Surg. Diet.; Appendix by Reese; article Strabismus.
3 Medical Examiner, vol. vii. N. S. p. 510.
OPERATION FOE STRABISMUS. 289
surgeons, though all have the same object, to wit, the division of
the contracted muscle, and only differ in the means employed.
Stromeyer controlled the movements of the eyeball by a fine
hook inserted into the conjunctiva, elevated a fold of the same
membrane in forceps, incised it with a cataract knife, and, raising
the muscle upon a hook, divided it with scissors or a curved knife.
Dieffenbach elevated the upper lid with Pellier's speculum, de-
pressed the lower lid by the finger of an assistant, drew the eyeball
outwards by a fine hook in the conjunctiva, elevated a fold by an-
other fine hook, incised the conjunctiva between the hooks with
curved scissors, elevated the muscle on a curved hook, and divided
it with the same scissors.
Sedillot separated the lids by a spring speculum, inserted a
hook into the sclerotica to steady the eye, elevated a fold of the
conjunctiva with forceps, and divided it with curved scissors (Plate
XII., Figs. 6, 8, 9), pursuing in the remainder of his operation the
course just detailed.
Dr. Joseph Pancoast, of Philadelphia, operates very much in
the same manner. 1 There is, however, according to my observation,
no necessity for a hook to fix the eyeball, and the following plan,
which I have frequently practised with success, and which is the
process long pursued at the Wills Hospital, for the eye, in Phila-
delphia, is much more simple. To Dr. I. Hays, senior surgeon of
the hospital, and editor of the American Journal of the Medical
Sciences, is due its introduction into that institution, where it is
now generally resorted to.
Operation of Dr. Hays. — Dr. Hays closes the eye, generally
the soundest one, with a handkerchief or bandage, in consequence
of which the affected eye becomes straight, if the case is a proper
one for the operation. Then, having separated the lids by a specu-
lum, he seizes a fold of the conjunctiva over the muscle, with a
pair of good forceps (Plate XII., Fig. 5), elevates it, incises it with
a snip of the curved scissors, divides the fascia, if necessary, in the
same way, passes a large curved hook (Plate VIII., Fig. 23), having
a convexity at least equal to that of the ball, beneath the muscle
from below upwards, and divides it with the same scissors.
Seizing the conjunctiva in this manner is quite sufficient to
1 Operative Surgery— Strabismus.
19
290 OPERATIVE SURGERY.
steady the eye, and the subsequent steps of the operation are equally
simple.
After Treatment.— A little cold water and a fine sponge usually
suffice to check the slight hemorrhage resulting from the incision,
when, if the muscle has been thoroughly divided, the patient will
generally be able to keep the eye straight. The eye should then
be left open, bathed frequently with cold water, and the patient
directed to use it, while the other is kept closed. The use of a
simple colly rium will generally relieve the conjunctival injection in
a few days, when both eyes may be used, so as to acquire a proper
parallelism of vision ; but, occasionally, a little fungous growth re-
sults from the incision, and may require excision or to be removed
by caustic, though it is not common except where the conjunctiva
has been very freely divided.
Guerin has proposed a sub-conjunctival division of the muscle
as being least likely to permit that protrusion of the ball which is
occasionally noticed when the primary incisions have been very
free; but as the ordinary operation does not induce this when pro-
perly performed, and insures the more perfect division of the fibres
of the muscle and its tendon, the plan has nothing specially to re-
commend it.
CURE OF STRABISMUS BY THE APPLICATION OF A TEMPORARY LIGA-
TURE TO THE MUSCLE OPPOSITE THE SIDE OF THE SQUINT.
Operation of Tavignot. 1 — The object of all the operations
performed for the relief of strabismus being to bring the pupil to
the centre of the orbit by elongating the contracted muscle, little
or no regard is paid to the condition of that of the opposite side,
which, from being kept constantly upon the stretch, is unable to
resist the action of the muscle which causes the squint. To obviate
this, M. Tavignot has proposed a new operation, the object of which
is to shorten the muscle which is elongated, instead of elongating
one that is contracted, as in the ordinary operation ; he therefore
operates as follows : —
First Operation.— The longest muscle (say the external rectus
1 Medical Examiner, vol. ix. N. S. p. 594 ; from Dub. Med. Press and Presse Med.
Beige.
OPERATION FOR STRABISMUS. 291
in convergent strabismus) being exposed in the usual manner, a
blunt book, with an eye at its extremity, is passed underneath the
muscle so as to detach it from the globe of the eye by lifting it up.
The hook being then carried forward, so that its concavity may
embrace the muscle at a little distance from its aponeurotic expan-
sion, a silk thread is passed through the eye of the hook, and the
latter removed, so as to leave the ligature under the muscle. By a
double twist of the ends of the thread, a simple and resisting knot
is formed, which is then tightened, and one end of the ligature
cut off, the other being brought out at the corresponding angle of
the eye and fastened by a little piece of plaster on the edge of the
orbit.
The first effect of this ligature is to render the lateral fibres of
the muscle more central, and thus induce its shortening ; whilst the
second is to develop such an adhesive inflammation as not only
permanently fixes the abnormal juxtaposition of the muscular
fibres, but also creates an adhesion of the muscle to the sclerotic
coat. As the ligature is only a temporary application, and not in-
tended to divide the muscle, it should be removed at the end of
the second or commencement of the third day, by drawing gently
on the end which remains.
Should this operation not prove sufficient, as would, perhaps, be
found to be the case in very severe strabismus, another is to be
performed thus: —
Second Operation. — The hook being passed under the muscle,
as in the first operation, the ligature is to be passed not directly
under the muscle, but under the hook, so as to embrace the muscular
expansion. Then, in order to see if the globe is perfectly restored
to its natural position, a different colored thread should be passed
through the loop of the ligature, and a single knot formed in the first
ligature so as to constrict the muscle, when the hook may be with-
drawn, and the eye left to itself. If the globe is now not brought
sufficiently back, a larger amount of muscular tissue must be em-
braced by the ligature ; but if the globe is brought too far round,
then a less amount must be inclosed — the ligature that constricts
the muscle being in either case relaxed as soon as possible. Owing
to the position of the colored thread, this relaxation can be readily
accomplished by pulling one end of the ligature with one hand,
and drawing the thread which was passed through its loop with
the other, by which manoeuvre the knot will be made to yield
292 OPERATIVE SURGERY.
readily. Then, passing the book again under the muscle, recom-
mence the operation, keeping in mind the experience just obtained
as to the amount of the muscle to be constricted.
Kemarks.— The principle of this operation is so evident as to
require no further explanation. As M. Tavignot in the account
given has furnished no cases, this method of operating requires to
be tested before its value can be estimated.
§ 3. — EXTIRPATION OF THE EYEBALL.
When, from malignant disease or other causes, it becomes neces-
sary to remove the entire eyeball, it is of great importance that as
much of the upper lid should be preserved as is possible, in order
to protect the cavity of the orbit from foreign matter as well as to
favor the subsequent use of an artificial eye.
Ordinary Operation. — The patient being either seated or lying
down, pass a large curved needle, armed with a strong ligature,
through the ball, as far back as possible ; remove the needle, and
tie the ligature in a loop, so as to give the assistant the control of
the tumor. Then incising the lids at the external commissure,
carry the incision as far as the outer edge of the orbit, and rapidly
dissect the lids from the ball by cutting through the reflexions of
the conjunctiva. Now passing the scalpel or straight bistoury along
the os planum (internal canthus), carry it around the orbit so as to
divide the attachments of the two oblique muscles, and on reaching
the external canthus remove, if requisite, the lachrymal gland.
Then, without drawing too strongly upon the ligature, lest injury
be done to the origin of the optic nerve, put the four recti muscles
upon the stretch, and, passing the knife to the bottom of the orbit
on its external side, free the attachments of the ball, and remove
it, arresting the hemorrhage if it does not yield to cold cloths, by
filling the orbit with dry lint. The advantage of the ligature over
the forceps or voiselum, as a means of controlling the tumor, will
be found in the firmness of its attachment to the ball, owing to the
fibrous character of the sclerotic coat. When scissors are preferred
to the scalpel, they may be employed as follows : —
Operation of Dr. Mettauer, of Virginia.— Dr. Mettauer, of
Winchester, Virginia, 1 has repeated Bonnet's operation in the fol-
lowing manner : —
1 Stethoscope, vol. iii. p. 104, 1853.
TUMORS IN THE ORBIT. 293
The patient being in the recumbent posture, and under the in-
fluence of chloroform, the eyelids were divided as usual at the ex-
ternal canthus, and a curved needle and ligature passed through
the ball so as to retain it in position. The eye being then drawn
forwards, an incision was made by passing one blade of a pair of
curved scissors through the conjunctiva and beneath the muscle on
the inner side of the eye, as in the operation of strabismus. The
four recti and two oblique muscles being thus divided close to their
insertions, the optic nerve was cut by passing the scissors around
it, and the eye removed.
The dressing was simply lint wet with water.
This case, two months after the operation, and another similarly
operated on by Dr. Mettauer two years previous, were well at the
time of the report.
Eemarks. — When cancer, or other disease, is limited to the
eyeball, and the cellular and adipose tissue in the orbit is health}'',
preference should be given to the mode of operating followed by
Dr. Mettauer, as it is thorough, neat, and simple; but, in other
cases, the older operation first detailed will be requisite in order to
enable the surgeon to remove all the diseased structure from the
orbit. The success of early extirpation of the eye in malignant
disease is more marked than when it has been developed elsewhere,
Dr. Robertson, of Edinburgh, 1 having cured twenty out of twenty-
three cases. This operation is not, however, so universally favor-
able in its results, similar growths being apt to appear subsequently
in the brain, or other organs, as is generally the case in operations
for malignant diseases.
§ 4. — TUMORS IN THE ORBIT.
When tumors in the orbit are of such a size as to forbid their
extirpation through the lids, it may become necessary to divide the
external canthus, dissect them out, and then unite the wound by a
stitch of the interrupted suture; a piece of linen wet with cold
water being the only dressing that is generally required. When
tumors, and especially those which resemble scirrhus, are found
upon the tarsal cartilages, their removal may be accomplished by
a V incision, or in a manner similar to that spoken of under the
operation for Ectropion.
1 Opus citat., p. 104.
294 OPERATIVE SURGERY.
CHAPTER VI.
OPERATIONS PRACTISED ON THE HUMORS OF THE EYE.
An account of the anatomical relations of the component parts
of the eyeball may be limited either to a brief enumeration of the
general characters of each portion, or extended into a minute de-
scription of the structures concerned. From the importance of the
diseases of this organ, the latter course has generally been pur-
sued by surgeons who have devoted themselves especially to this
branch of the profession. The general character of the present
work, and the necessity of affording to other subjects an equal
amount of space, must, however, preclude any attempt at a more
detailed account of them than is essential to the comprehension of
the operations practised on them.
SECTION I.
ANATOMY OF THE EYEBALL.
The eyeball is composed of six coats and three humors.
The Coats are the conjunctiva, sclerotica, and cornea, which
may be described as external ; and the choroid, iris, and retina,
which are within the former. The humors are the aqueous, crys-
talline, and vitreous.
The Conjunctiva, or mucous coat, after lining the lids, is reflected
upon the ball, and covers both the sclerotica and cornea. To the
sclerotica it is loosely attached by cellular tissue, in consequence of
which it is liable to fluid infiltration, as well as to great vascular
engorgement, either of which may raise it from the sclerotica. The
course of its bloodvessels is tortuous. To the cornea it adheres
very closely, furnishing it a thin layer, which is occasionally the
starting-point of ulcerative inflammation. The Sclerotica is a dense
fibrous coat which has, by some, been considered as an expansion
of the dura mater of the brain. In connection with the operations
ANATOMY OF THE EYEBALL. 295
performed upon the eyeball, it may be described as extending from
the optic nerve as far forwards as the circumference of the cornea,
the two being closely adapted to each other by a bevelled surface.
The resisting character of the sclerotica renders it necessary to
press an instrument against it perpendicularly and with some little
force, in order to perforate it readily. The vessels of the sclerotica
are generally arranged in straight lines; hence their engorgement
is readily distinguishable from that of the conjunctiva. The mus-
cles of the eyeball are inserted into the sclerotica, and are conse-
quently surrounded by the loose cellular tissue between it and the
conjunctiva. The Cornea is a firm and resisting coat, seated at the
front of the ball; it is composed of numerous laminae, separated
from each other by a thin pellucid fluid in the healthy condition,
but liable to become opaque from inflammation. The section of
the cornea, owing to its density, and the arrangement of its layer,
requires that the instruments employed should be of the best qua-
lity, and also that some caution be exercised by the operator, lest
he simply separate its layers instead of passing the knife entirely
through or behind them. The cornea possesses no vessels capable
of carrying red blood in the healthy condition, though in inflam-
mation its capillaries will admit it. In health, it possesses little
sensibility; but, in disease, it is occasionally exceedingly sensitive,
its incision having caused fainting, as occurred in the practice of
Dr. Physick. Dr. Horner has also reported the same fact.
The Choroid is a vascular coat placed immediately within the
sclerotica, and of equal extent with it, being closely fastened at its
anterior margin to the corresponding portion of the latter, by a ring
called the ciliary ligament. The Iris is set in the front margin of
this ligament, so that the cornea and sclerotica may be peeled off
without impairing its continuity with the choroid coat. 1 The arte-
ries of the choroid coat are the two long and the short ciliary
arteries. The long ciliary arteries pass one on either side, exter-
nally and internally, between the choroid and the sclerotica in the
middle line of the eye. They are consequently liable to be wounded
in the operations of absorption or depression of cataract, unless the
needle is made to transfix the sclerotica a line or two above or
below the plane of its transverse diameter, or very near to the cir-
cumference of the cornea.
1 Horner's Anatomy, vol. ii. p. 414.
296 OPERATIVE SURGERY.
PLATE XIII.
EYE INSTRUMENTS.
Fig. 1. Beer's Triangular Cataract Knife. After Bernard and Huette.
Fig. 2. Richter's Knife, slightly differing in the width of the blade from
that of Beer. After Bernard aild 1Iuotte -
Mr. Walton has recently shortened this knife, as stated in the text.
Fig. 3. Wenzell's Cataract Knife. After Bernard and Huette.
Fig. 4. Beer's Lancet-shaped Knife.
Fig. 5. Cheselden's Curved Corneal Knife, for incising the capsule, or
enlarging the cornea in extracting cataract. Daviel's scoop or spoon is
attached at the other end of the handle. After Bernard and Huette.
Fig. 6. Beer's Straight Knife, for enlarging the incision in the cornea
in the Operation Of extraction Of Cataract. After Bernard and Huette.
Fig. 7. Beer's Hook, for extracting the capsule. "
Fig. 8. A front View of Dupuytren's Couching Needle.
After Bernard and Huette.
Fig. 9. A side Yiew of Dupuytren's Couching Needle.
After Bernard and Huette.
Figs. 10, 11. A side and front View of Adams's Couching Needle.
After Bernard and Huette.
Figs. 12, 13. A three-quarter and side view of Scarpa's Needle.
After Bernard and Huette.
Fig. 14. A side View of Walther's Needle.
Fig. 15. Benjamin Bell's Speculum. " " "
Fig. 16. Pellier's Elevator.
Fig. 17. A modification of Wardrop's Forceps, for stretching the free
edge of the eyelids in excising the tarsus cartilage. After Bernard and Huette.
Fig. 18. A Tenotome, sometimes employed in strabismus, but better
adapted to larger muscles. After the Instrument.
Figs. 19, 20. Straight and curved Spring Scissors, for minute sections,
and applicable to operations on the conjunctiva, &c. Charriere's Pattern.
Fig. 21. Curved Forceps, for the removal of the canula, sometimes
employed in fistula lachrymalis. Charriere's Pattern.
Fig. 22. Fine blunt-pointed Forceps, for extracting the cilia in tri-
chiasis, Szc. Charriere's Pattern.
Fig. 23. Laugier's Trocar, for perforating the os unguis, or the bony
ductus ad nasum in fistula lachrymalis, when the ordinary channel cannot
be dilated. After Bernard and Huette.
Fig. 24. Bistoury for fistula lachrymalis. Schiveley's Pattern.
Figs. 25, 26. Bellocque's Canula, for tamponing the nostril, showing
the spring as Open, and also as Closed. Schiveley's Pattern.
Fig. 27. Charriere's Exploring Needle. The needle being grooved and
perforated, is passed into the cavity to be examined, and then the spring
being touched, the piston of the syringe is moved, and draws into the
syringe, through the grooved needle, some of the liquid contents of the part
into which it is thrust in the exploration. After the instrument.
OPERATIONS FOR CATARACT. 297
The Iris is placed as a diaphragm behind the cornea, on a line
with the ciliary ligament, and has the power of contracting and
expanding, as will be referred to under the operations for cataract.
The Eetina has so little connection with operations on the eye as
to require no special notice. Between the posterior surface of the
cornea and the anterior face of the iris is the Anterior Chamber of
the eye; and between the posterior surface of the iris and the front
of the lens is the Posterior Chamber, the two communicating
through the pupil, and being occupied by the Aqueous humor.
The Crystalline humor is a double convex lens, of which the
posterior convexity is the greater. It is invested by a capsule,
which is separated from it by the Liquor Morgagni. In consequence
of the adhesion of the capsule to the hyaloid membrane, and the
contact of the ciliary processes, the lens is readily maintained in its
position; all the operations upon it consequently destroy these
attachments. The Vitreous humor fills up the great bulk of the
eye, and is directly behind the lens, the latter being received into a
depression upon its anterior face. It is surrounded by the hyaloid
membrane, which is strong enough to sustain it, and also prevent
the depression of cataract, unless its cells are previously lacerated
with the needle.
SECTION II.
OPERATIONS FOR CATARACT.
In the healthy condition of the humors of the eye and of the
transparent cornea, the rays of light are so transmitted through
them as to make the proper impression upon the retina. Any
change in the transparency of the media through which these rays
pass, necessarily impairs vision, and when this change results in
opacity and is seated in any portion of the lens, it takes the name
of Cataract. Various minute divisions of cataract have been made
by ophthalmic surgeons, such as true and false, or black, white,
and green, to the details of which it is unnecessary here to refer ;
the three grand divisions of the disease, according to the structure
involved, into capsular, lenticular, and capsulo-lenticular, compris-
ing all that it is essential to describe in connection with operative
surgery. In membranous cataract, the opacity is supposed to
298 OPERATIVE SURGERY.
be limited to the capsule; in lenticular, it is either in the proper
structure of the lens, or in it and the liquor Morgagni, the latter
being very rare ; whilst the term capsulo-lenticular cataract desig-
nates both varieties, and is the most common, the affection of the
capsule alone seldom existing, except in a limited degree, without
the early development of a similar complaint in the lens. Cataract
has also been divided, according to its density, into hard, soft, milky,
and cheesy, all of which may usually be recognized by the color.
Hard cataracts are generally of a brownish or amber color, are
usually confined to adults, and are the kind especially adapted to
the operation of extraction, although depression may relieve them.
Capsular cataracts are usually soft, of a brighter and lighter color
than the preceding, and are often met with in children.
Milky or cheesy lenticular cataract is usually of a bluish or yel-
lowish-gray, or white color, mottled, and with streaks in various
directions through the structure.
Soft cataracts bulge forward, as a general rule, and, consequently,
are apparently more superficial than the hard class ; hard cataracts,
on the contrary, are deeper seated and further from the pupil. All
varieties commence with very much the same symptoms, such as
dimness of vision, and an inability to see anything distinctly direetly
in the axis of the eye, the opacity most frequently commencing in
the centre of the pupil.
Diagnosis. — The distinction of the various kinds of cataract, or
an accurate diagnosis, is of much importance, not only in order to
decide on the propriety of an operation, but also to assist the sur-
geon in the selection of the kind of operation that he may perform
for their relief. No means, within my knowledge, will prove more
conducive to this object than the application of the catoptric test of
Sanson. To accomplish this, dilate the pupil freely by means of
belladonna, placing the patient in a dark room on a low seat, and
passing a lighted candle transversely and vertically across the axis
of vision. If the cornea, capsule, and lens are clear, three reflections
of the flame will be seen, one large, upright, and superficial, formed
by the front of the cornea; one deep, pale, small, and inverted image,
formed by the posterior segment of the lens ; and one deeper and
upright figure, formed by the anterior portion of the lens and its
capsule, a little brighter than the inverted image, but not so bright
as the first. The absence of either of these images, or their absence
PRELIMINARY TREATMENT OF CATARACT. 299
at any point, will indicate the character of the disease and the por-
tion affected. 1
§ 1. — PRELIMINARY TREATMENT OF CATARACT.
As the result of the operations for cataract depend, in a great
measure, on the absence of inflammatory action, attention to the
adjuvants of the operation is essential to its favorable termination.
In every instance, strict attention should be given to the healthy
condition of the patient's system ; let the surgeon see that there is
no sign of fever, and yet that there is sufficient strength of pulse to
insure adhesion of the flap in the cornea, if extraction is to be prac-
tised. Let him also see to a thorough evacuation of the bowels, as
well as to the fact that there is no diarrhoea. As a general rule, a
strict antiphlogistic diet should be observed several days before and
after the operation ; but if the patient is advanced in life, and the
pulse becomes irritable, good diet and tonics may possibly prove
beneficial. A very general rule, given in most of the works on
ophthalmic surgery, is, "Never to operate on a patient with a foul
tongue." Yet it has occasionally occurred to me to see patients
who, from always having the tongue more or less furred, even in
ordinary health, did very well when operated on under these cir-
cumstances. Indeed, no rule of general treatment can here be
given that will not be found to have some exception to its universal
observance. Caution and judgment in this, as in other operations,
can alone properly prepare the patient's constitution.
The local treatment, previous to operating for cataract, consists
in. the employment of such collyria as will reduce the vascularity of
the various coats of the eye and diminish the risks of their inflam-
mation.
Another important step in the preliminary local treatment is the
production of such a dilatation of the pupil as will enable the
operator to obtain a good view of the lens, diminish the risk of
wounding the iris, and admit the free access of the aqueous humor,
if the operation of absorption is selected.
1 See Lawrence on the Eye, by Hays, Phila. edit, 1847, p. 90; also Smith's Minor
Surgery, for fuller details of the catoptric test.
300 OPERATIVE SURGERY.
§ 2. — DILATATION OF THE PUPIL.
Dilatation of the pupil may be accomplished by smearing the
lids, eyebrow, and temple with the extract of belladonna or stramo-
nium diluted with water to the consistence of thick cream, and ap-
plied every ten minutes for an hour previous to operating; or by
dropping into the eye a solution of the extract; or their active
principles (daturia or atropia) may be dissolved in water in the pro-
portion of one grain to the fluidrachm of water, and a few drops be
inserted about ten minutes before operating. The latter mode is
the quickest and cleanest, but not quite so certain in all patients as
the extracts.
I have occasionally employed the following formula, and found
it very prompt, and not so dirty or irritating as the extract: —
R. — Atropise gr. iss ;
Acid, nitric, gtt. ss ;
Aquae jij.
Of this, a few drops may be introduced between the lids, and
then a rag wet with the solution applied externally. The dilatation,
in two instances, was prompt, and in one continued for three days
after the operation, leaving the iris like a fine ring near the circum-
ference of the cornea.
The credit of suggesting the employment of narcotic agents for
dilating the pupil has been long assigned, by European writers, to
Himley, of Gottingen, who recommended the use of the extract of
belladonna in 1801. l Four years prior to this period, however, a
similar suggestion had been made, and published in Philadelphia,
by Dr. Samuel Cooper, a graduate of the University of Pennsylva-
nia, who, in an inaugural essay, published in 1797, 2 reported
numerous experiments on the effects of the datura stramonium on
the system generally, as well as on the pupil of the eye. 3 I have
also been informed by Dr. Benjamin II. Coates, of Philadelphia,
that Drs. Bush and Physick both taught this in their lectures, and
that the latter always resorted to the formula of Dr. Cooper for its
1 Lawrence on the Eye, by Hays, p. 366. * Littell on the Eye, p. 202.
s A Dissertation on the Properties and Effects of the Datura Stramonium, or the
Common Thorn-Apple, and on its Uses in Medicine, by Samuel Cooper, M.D., 8vo.
Philadelphia, 1797, p. 16, experiment 15.
DILATATION OF THE PUPIL. 301
preparation. 1 To the latter gentleman is, therefore, due any credit
connected with the suggestion.
Another step in the treatment of cataract, previous to operating,
is the application of a bandage on the eye opposite to that which is
to be operated on, as advised by Celsus, as it tends very materially
to steady the eye if there is any vision, especially in children.
The position of the patient, of the operator, and of the assistant,
together with the period at which the operation should be performed,
and the kind of operation to be selected, may also be placed under
the same head, and be briefly referred to at present.
The position of the patient and the surgeon depends very much
upon the kind of operation to be performed. For extraction, the
recumbent posture of the patient is the best, as it adds to his safety
by diminishing the tendency in the humors of the eye to escape
through the opening in the cornea; but, in the operations of de-
pression or absorption, it will generally be found more convenient
to place the patient on a moderately low chair, with a side light,
and let the operator sit directly before him on a higher stool or
chair without arms, so as to be at perfect liberty in his movements.
Some operators prefer following the advice of Scarpa, and employ
a stool on which they place the foot, of the same side as the ope-
rating hand, resting the elbow on the knee thus raised. Such a
position is, however, purely a matter of convenience, and one
which, to many, would prove exceedingly embarrassing. If the
surgeon's hand requires such a support to steady it, prudence
should suggest that he had better lay aside his instruments.
The position of the assistant should be behind the patient, with
one hand placed under the chin so as to steady the patient's head
against his own breast; whilst the pulps of the index and second
or ring finger of his other hand should be brought to the same
length, and to the same level, so as to raise the lid by drawing the
tarsus cartilage towards the superciliary ridge, where it should be
retained until the surgeon directs its release. If the eyelid is
moist and difficult to hold, the assistant should dry it thoroughly,
or touch the points of his fingers in a little flour or other dry pow-
der, previous to seizing the lid. A speculum, or the elevator of
Pellier (Plate XIII., Fig. 16), may be resorted to if the orbit is
1 Several copies of the Dissertation may be found in the Library of the Pennsyl-
vania Hospital, Philadelphia.
302 OPERATIVE SURGERY.
deep, but, as a general rule, the eyelid may be best kept in position
by the fingers placed as just described.
The period at which cataract should be operated on was once
deemed a matter of importance, both as respects the season of the
year, and the age., ripeness, or perfection of the opacity in the lens ;
but any season, with fine clear weather, will answer, whilst the best
period, in reference to the maturation of the cataract, is that when
its presence in both eyes is well ascertained. The existence of opa-
city being once well settled, it is best not to wait for the entire
loss of vision or perfect maturation of the cataract, as every week
after a well marked opacity is evident, is liable to increase the
density and toughness of the diseased structure, and, consequently,
add to the difficulty and risks of the operation.
Three kinds of operations are performed for the removal of cata-
ract, to wit, extraction, absorption, and depression, the selection of
either being usually decided by the following facts : —
1st. Absorption, depression, or reclination are attended with but
little risk of the loss of the eye, and may be repeated as often as is
necessary ; they are well adapted to soft or hard cataracts, in which
the anterior, chamber of the eye and the eye itself are small. De-
pression of a hard cataract, it should, however, be recollected, is
liable to produce amaurosis by paralyzing the retina; and not un-
frequently a lens, when depressed, will rise again into the axis of
vision.
2d. Extraction is an operation especially calculated for hard and
firm cataract, but requires considerable dexterity on the part of
the surgeon and his assistant, as well as a large prominent eye*
with a full anterior chamber, on the part of the patient. Of the
two operations, extraction is the more prompt and brilliant; ab-
sorption, depression, or reclination the safer. Drs. Physick and
McClellan, in Philadelphia, and Eoux, in Paris, favored extraction,
but the majority of surgeons in the United States seem to prefer
absorption or depression. From a recent publication, 1 by Mr.
Sichel, of Paris, it appears that this distinguished ophthalmologist
"has no exclusive preference for any operation, as he depresses
hard cataracts in all ages, although he prefers their extraction in
aged patients. He breaks up all soft or half soft cataracts in
patients below forty, and especially below thirty; but extracts them
1 Gazette dcs Hopitaux, No. 54.
OPERATIONS FOR CATARACT. 803
in individuals over forty, and especially over fifty, as he finds that
breaking up such cataracts in these patients is followed by swell-
ing of the lens, which compresses the internal coats of the eye and
causes violent inflammation. In patients below forty, and espe-
cially in children from six months to fifteen years, he has found the
tolerance, after the use of the needle by a skilful hand, very great."
In order to operate upon both eyes equally well, whether the
patient be placed in the sitting or recumbent posture, it becomes
necessary for the surgeon to change his position, unless he is ambi-
dexter, as he must otherwise operate upon the left eye with his
right hand, whilst in front of the patient, and on the right eye with
his left hand, if in front, on account of the prominence of the nose,
whilst, if he wishes to employ the right hand in both eyes, he will
be compelled to place himself behind the patient. Having con-
siderable facility in using the left hand, a change of position has
never been necessary in my case; and as this facility can be readily
acquired by daily exercise, an operator will ultimately find it more
satisfactory to attempt it, and practise with the left as well as with
his right hand, in order to be able always to retain his position in
front of the patient, as this offers many facilities in manipulation
as well as in sight.
§ 6. — OPERATIONS.
The operations for cataract are, as has just been stated, divided
into three kinds: absorption, or that in which the lens is dissolved
by the action of the aqueous humor; depression, in which it is
pushed below the axis of vision, and lies buried in the vitreous
humor; and extraction, in which it is promptly removed from the
eye. Reclination is a modification of depression.
I. OPERATION BY ABSORPTION.
The success of this operation being due to the power possessed
by the aqueous humor of dissolving the lens, the object of the
operator should be to lacerate it and its capsule, and throw them
forwards into the anterior chamber of the eye. The preliminary
steps in all the operations are very much the same, as respects diet
304 OPERATIVE SURGERY.
and the dilatation of the pupil ; it is, however, of more consequence
in absorption than in extraction to obtain a full dilatatiou of the
pupil, not only in order to admit the free action of the aqueous humor
upon the lens, but also to protect the iris from injury, and enable
the operator to see exactly what he is doing. The needles required
for cutting up the lens and its capsule are very varied, it being
said that there are upwards of seventy different kinds, a few of
which are shown, Plate XIII., Figs. 8, 9, 10, 11, 12, 13; they seem
to have been selected very much at the fancy of each operator,
though that of Saunders or of Scarpa is most frequently resorted
to. All that is really essential is that they should have a sharp
double edge.
Ordinary Operation. — The capsule and lens being acted on by
means of a needle introduced through the sclerotica, the operation
has hence been called scleroticonyxis. The pupil being dilated, one
eye bandaged, and the head supported against the breast of the
assistant, or else the patient lying down, the surgeon should depress
the lower lid with the index and second finger of the hand corre-
sponding with the eye to be operated on, and the assistant, at the
same time, elevate the upper lid as directed in extraction; or, if the
operator is dexterous, he may sustain both lids himself, by separat-
ing them with his thumb and forefinger.
Then, seizing the handle of the needle between the thumb, fore,
and second finger of the hand opposite to that of the eye to be
operated on, and holding the instrument like a pen, with the fingers
strongly flexed, and the little and ring finger resting against the
cheek bone, present the point of the needle perpendicularly to the
sclerotica, with its convexity upwards and its edges transverse, one
or two lines behind the circumference of the cornea, and about half
a line above or below the median line of the ball, so as to avoid the
long ciliary artery. Being satisfied with its position, and whilst the
patient is looking towards his nose, puncture the sclerotica, and
rotate the handle of the instrument a quarter of a circle between
the fingers; then turning the concavity of its point, if Scarpa's,
or the breadth of the blade, if that of Saunders, backwards, pass
it towards the centre of the eye, and depress the handle towards
the temple. When the point, dexterously managed, has reached
the centre of the pupil, turn the cutting edge of the needle to the
cataract, and cut the capsule (Plate XIY., Figs. 3, 6) and lens into
• OPERATIONS. 305
several fragments, throwing them forwards into the anterior cham-
ber, where they will subsequently disappear by dissolution.
If the cataract is soft and milky, one operation will generally
suffice, but if the lens or its capsule is more resisting, it may
become necessary to repeat the operation several times, at intervals
of a few weeks.
After Treatment. — The eye being closed and protected from
the light, cold cloths may be applied, and the same treatment pur-
sued as is directed in extraction. The pupil should, however, be
kept dilated for several days after the operation, in order to per-
mit the free access of the aqueous humor ; and it is not requisite
to enjoin such absolute rest as is directed in the operation of ex-
traction. Should inflammation of the eye supervene, it should be
treated on the general antiphlogistic plan.
When the capsule remains thickened, or when fragments do not
disappear, a repetition of the operation will generally be required.
Keratonyxts, or the operation of absorption by a needle intro-
duced through the cornea, was suggested by Conradi, but introduced
into practice to a considerable extent by Mr. Saunders, and is hence
sometimes designated as his operation. It consists in introducing
the needle through the cornea, and lacerating the capsule in front ;
but, as it is liable to give exit to the aqueous humor, induce prolapse
of the iris, and leave a scar in the cornea, the operation through the
sclerotica is preferable in the majority of instances.
II. OPERATION BY DEPRESSION OR COUCHING.
The preliminary steps of this operation being precisely the same
as those required in absorption, a repetition of them is unnecessary.
Ordinary Operation. — The position of the patient being either
sitting or recumbent, and that of the surgeon being the same as in
the preceding operation, the needle should be introduced into the
sclerotica about two lines behind the cornea, and passed directly to
the centre of the pupil between the iris and the capsule (Plate
XIV., Fig. 8). Then depressing the handle, cause the point of the
instrument to apply itself on the top of the lens, and depress it
backwards and downwards, by elevating the handle and carrying
it slightly forwards (Plate XIY., Fig. 7). After placing the lens
in the vitreous humor below the axis of vision, retain it there
20
306 OPERATIVE SURGERY.
• PLATE XIV.
OPERATION OF COUCHING CATARACT.
Fig. 1. A vertical section of the Eyeball, to show its component parts.
1. The cornea. 2. The sclerotica. 3. The choroid coat. 4. The retina.
5. The iris. 6. The anterior chamber. 7. The lens. 8. The vitreous
humor. 9. The optic nerve. Aft " Bernard and Huette -
Fig. 2. Reclination of the Lens, as shown by a vertical section of the
eye. °1. The natural position of the lens. 2. Its reclination in the
, After Bernard and Huette.
vitreous humor.
Fig. 3. The operation of absorption, or breaking up of a cataract, as
practised on the left eye. 1. The right hand of the surgeon puncturing
the sclerotic coat. This .puncture is usually made within two lines of the
circumference of the cornea, and not as far back as is represented in the
figure. 2, 2. The fingers of an assistant elevating the upper lid. 3, 3.
The fingers of the left hand of the operator depressing the lower lid and
steadying the ball. After Bour ^ and Jacob -
Fig. 4. The different positions of the needle in the operation of Couch-
ing, as performed upon the left eye. 1. The needle is now held in the
right hand like a pen, the hand supported by the little finger resting on
the cheek-bone ; the needle is also represented puncturing the sclerotica
at the usual point, that is about two lines behind the cornea, but below
the transverse diameter of the eyeball. 2. The second position of the
needle. 3. The elevation of the handle necessary for the entire couching
of the lens, or the third position of the needle in this operation.
Fig. 5. Couching of Cataract in the right eye. 1, 1. The first and
second fingers of an assistant raising the upper lid. 2, 2. The first and
second fingers of the operator depressing the lower lid. 3. The cataract
needle held like a pen in the left hand, the little and ring finger supported
on the cheek bone, and puncturing the sclerotica about two lines behind
the cornea, and a little above the transverse diameter of the ball, so as to
avoid the long ciliary artery. After Bernard and Huette.
Fig. 6. Position of the needle in the act of lacerating the front of the
capsule in the operation of absorption, as shown in Fig. 3.
After Bernard and Huette.
Fig. ?. The same operation, as the lens leaves the axis of the pupil ;
the handle of the instrument being moved gradually upwards, and the
reverse, the point of the needle will carry the lens downwards and back-
wards, until imbedded in the vitreOUS humor. After Bernard and Huette.
Fig. 8. The same operation as shown in Fig. 5, after the needle has
entered the posterior chamber, and partially depressed the lens. 1. The
relative position of the handle of the instrument to the axis of the eye at
this period. The needle, having passed between the iris and the lens, is
seen, with its concavity, resting on the top of the lens, previous to couch-
ing it. After Bernard and Huette.
14
S^
OPERATIONS. 807
a few seconds, and withdraw the needle by reverse movements
through the sclerotica, with its convexity forwards. The different
positions of the needle during the operation are shown in Plate
XIV., Fig. 4.
If the lens rises before the needle is removed, it must be again
depressed, and if it escape into the anterior chamber, and cannot be
drawn back, it may be removed by the section of the cornea, as in
the operation for extraction.
In Reclination, the lens is turned on its axis so as to be placed
horizontally instead of being depressed perpendicularly (Plate
XIV, Fig. 2).
Operation of Malgaigne. — M. Malgaigne being of the opinion
that the rising of the lens, when depressed with its capsule, was due
to the attachments of the latter being rarely totally destroyed, and
to the fact that its capsule resisted absorption, and was liable to
rise a long time after the operation, proceeds as follows : —
The patient lying down or being seated, and the surgeon placed
either before or behind him, so that he can always use his right hand,
the needle is introduced (as before directed) so as to pierce the pos-
terior and inferior part of the lens ; the capsule divided, and then the
needle being passed above the lens with its concavity looking down-
wards, a simple movement of depression suffices to cause the descent
of the lens, whence it will not rise again, as the walls of its capsule
collapse immediately. This proceeding M. Malgaigne prefers, espe-
cially when the lens is hard. 1 Bretonneau and Velpeau lacerate
freely the cells of the hyaloid membrane before depressing the lens,
in order to prepare a way for its descent into the vitreous humor,
and have found it often successful. About two months after either
the operation of absorption or depression, the patient may very
gradually commence the use of the cataract glasses, which are in-
tended to aid vision, by supplying the place of the lost lens.
III. EXTRACTION.
The operation of Extraction is especially suited to the cases of
hard cataract in adults with prominent eyes, and to operators who
possess a perfect control of their fingers. The assistant must also
1 Malgaigne's Operative Surgery, Phila. edit. p. 301.
308 OPEEATIVE SURGERY.
be one perfectly familiar with his duty. He should place himself
behind the patient, and elevate the upper lid either with his fingers
placed as before directed, or by introducing Pellier's speculum be-
neath the lid, drawing it directly upwards, making himself sure
that the lid cannot escape from his grasp, and yet holding it so as
to avoid pressure upon the eyeball, after the section of the cornea.
On one occasion, in 1839, I saw an assistant of Velpeau's evacuate
the entire contents of the eye, in consequence of pressing upon the
ball. Occasionally, and especially in timid patients, the surgeon
may find it necessary to restrain the rolling of the eye by pressure
on the ball with his fore and second or third finger, whilst depress-
ing the lower lid; but it can rarely become necessary for the assist-
ant to make any pressure upon the eye, and, as a general rule, it
should be strictly avoided. Various-shaped knives have been
recommended for this operation, and are known as those of Beer,
Wenzel, Eichter, and Ware, 1 but most surgeons resort to the trian-
gular knife of Beer in preference to the others, except under pecu-
liar circumstances. The other instrument consists in Daviel's scoop
and Cheselden's knife, together with small scissors and forceps
(Plate XIII., Figs. 5, 6, 7). The operation consists in three parts ;
incision of the cornea, laceration of the capsule, and extraction of the
lens ; although, occasionally, the first two are performed at the same
time. The incision of the cornea may be performed either at the
superior, exterior, or inferior portion of its circumference (Plate
XV., Figs. 4, 3, 1). Mr. Lawrence deems the superior section the
best, the exterior next, and the inferior the most objectionable, al-
though the easiest to perform, as it exposes the patient to a rapid
escape of the aqueous humor, to prolapse and wound of the iris, as
well as to trouble in the adjustment of the corneal flap, from the
action of the edge of the lower lid. 2 M. Sichel always extracts by
the upper section, the advantages of which, he thinks, are very great,
as the upper eyelid forms a kind of supporting bandage, which is
still further increased by his method of applying five strips of ad-
hesive plaster over the eyelids of each eye, and covering them by
graduated compresses and a bandage, in such a manner as to exert
a gentle compression on the edges of the wound, and prevents its
becoming separated during the movements of the patient. 3
1 See Plate XIII., Figs. 1, 2, 3.
2 Lawrence, by Hays, Phila. edit. 1847, p. 640.
3 Gazette des Hopitaux, No. 54.
OPERATIONS. 309
Ordinary Operation of Extraction. — The propriety of dilat-
ing the pupil previous to extracting cataract, is a question not posi-
tively settled, its advocates claiming extra safety from wounds of
the iris by the knife, and its opponents charging it with exposing
the patient to the sudden loss of the vitreous humor. Although its
dilatation certainly renders the iris more secure, yet I think a dex-
trous operator would probably prefer operating without dilatation,
as the iris would be but little exposed to injury from a knife pro-
perly managed. The general preliminary measures being, how-
ever, completed, in accordance with the views of the surgeon, the
operation may be performed as follows, varying the line of the in-
cision according as it is wished to perform the superior, exterior,
or inferior section. The former, being the best, may be taken as
the type.
The surgeon, either sitting or standing, and being either iu front
of or behind his patient, according as he is ambidexter, or operates
only with the right hand, should elevate the lid by the index and
second ringer of his left hand, separating them, and pressing their
pulps against the sides of the eyeball, if it is necessary to steady it.
Then holding the knife by its handle, with the thumb and fingers
flexed, as in the downward motion of a pen, and resting the ring
and little finger upon the cheek bone, if desirable, to support the
hand, let him insert the point of the knife perpendicularly into the
cornea on its temporal side, about half a line from its circumference,
or line of junction with the sclerotica, and, making sure that the
point of the instrument penetrates the entire thickness of the cor-
nea, and enters the anterior chamber of the eye, and that it has not
passed between its lamina, pass it parallel and in front of the iris,
in the line of the transverse diameter of the eye, over to the inter-
nal side of the cornea at a point corresponding with that at which
it entered (Plate XV., Fig. 4). If this is steadily and quickly done,
the entire section of the cornea will be readily accomplished, simply
by the width of the knife.
The assistant should now be directed to allow the lids to close.
After a few seconds' rest, they may be gently wiped and opened as
before, great care being taken to avoid pressure on the ball. Then,
the surgeon, whilst elevating the lid, should press very gently against
the ball, from below upwards, so as to render the lens prominent,
or, introduce the back of the little knife attached to Daviel's curette
beneath the edge of the corneal flap, and press its point against the
310 OPERATIVE SURGERY.
PLATE XV.
OPERATIONS FOR EXTRACTING CATARACT AND THE FORMATION OF
ARTIFICIAL PUPIL.
Fig. 1. Extraction of the Cataract from the left eye, by the inferior
section. 1,1. The first and second fingers of an assistant raising the
upper lid. 2, 3. The middle and forefinger of the surgeon depressing the
lower lid. 4. The knife held in the right hand of the surgeon ; its point,
having passed through the cornea and across the anterior chamber, is
seen at its exit near the internal canthus. After Bernard and Huette.
Fig. 2. The completion of the section of the Cornea.
Fig. 3. Extraction by the oblique section of the Cornea. "
Fig. 4. Extraction by the superior section of the Cornea. "
Fig. 5. Incision of the Capsule of the Lens, in the inferior section, by
the knife of Cheselden, as modified by Boyer, but the knife that incises the
cornea in extraction may also be made to cut the capsule as it passes
across the lens. After Bernard and Huette.
Fig. 6. Expulsion of the Lens in the inferior section. 1. The fore-
finger of the operator steadying the lower lid. 2. Gentle pressure upon
the ball by the handle of the knife applied to the upper lid.
After Bernard and Huette.
Fig. 1. Section of the Cornea, by the knife of Furnari. " "
Fig. 8. The same operation, showing the removal of the cataract by
forceps introduced through the opening in the cornea.
After Bernard and Huette.
Fig. 9. Mulder's operation for Artificial Pupil. An opening in the
cornea admits scissors, by which the four angles resulting from the crucial
incision made in the iris are excised. After Bernard and Huette.
Fig. 10. Yelpeau's operation for Artificial Pupil. The knife incising
both the cornea and iris, so as to cut a flap in the lower portion of each.
After Bernard and Huette.
Fig. 11. Pancoast's operation for Artificial Pupil in the first stage.
1. Finger of assistant holding up the lid. 2. The cataract knife punc-
turing the cornea and iris. After Pancoast.
Fig. 12. Pancoast's operation for the formation of an Artificial Pupil,
in the second stage. 1. Finger of an assistant elevating the upper lid.
2. Probe-pointed scissors incising the iris transversely, so as to form a
quadrangular pupil. After Pancoaat.
Fig. 13. Langenbeck's operation for Artificial Pupil. A small inci-
sion is made in the cornea only large enough to admit a fine hook, by
which a portion of the iris is drawn down, and left to adhere to the
wound Of the Cornea. After Bernard and Huette.
Fig. 14. Scarpa's operation by displacement of the Iris. 1. A cataract
needle is seen detaching the iris from the ciliary ligament, so as to leave
an opening On its circumference. After Bernard and Huette.
Ws*
H 10
-V
OPERATIONS. 311
capsule of the lens and lacerate it, as is shown in the inferior sec-
tion in Plate XV., Fig. 5. Generally, the lens escapes promptly
in consequence of the compression of the ball by the muscles of the
eye. If it does not, moderate pressure against the ball with the
handle of the curette (Plate XV., Fig. 6), or seizing the lens with
the forceps, Plate XV., Fig. 8, or with the curette, will facilitate
it ; but in all these movements, great caution must be exercised lest
the vitreous humor also protrude. The operator should then see
that the iris has not prolapsed or been caught between the flap and
the edge of the cornea; and, being satisfied that all is right, let him
at once close the eye, and cover it with a light bandage so constructed
as to exclude the light, without pressing upon the ball.
After Treatment. — The after treatment must be regulated by
circumstances, though generally it should be strictly antiphlogistic,
the patient being directed to keep cold cloths applied over the lids
of the affected eye, to remain quiet in a dark room, to take nothing
but liquids for food, and to avoid conversation for the first three or
five days. In most cases it will be found advantageous to keep the
lids fastened by five little strips of adhesive plaster for a day or
two, in order to prevent derangement of the wound by the motion
of the lid, especially in intractable patients. The dressing em-
ployed by Sichel in the superior section, also requires, as has just
been stated, the addition of graduated compresses and a bandage.
On the fifth day, if the lids are not red or swollen, and the patient
is free from fever and pain, the eye may be gradually opened, and
the condition of the parts inspected. If there is no prolapse of
the iris, if the pupil is clear and regular, and if there is no very
high degree of inflammation, the rigid rules before observed may
then be relaxed, and the patient simply use a shade instead of the
wet cloths, chew a little bread or vegetable food, and be allowed by
degrees to see the light. Subsequently, but not before two months
after the operation, cataract spectacles may be occasionally employ-
ed, as the patient will be compelled ultimately to use them in order
to compensate for the loss of the lens.
The performance of the inferior and exterior sections of the cor
nea are so similar to that just detailed as not to require a special
description. They are well represented in Plate XV., Figs. 1, 2, 3.
312 OPERATIVE SURGERY.
SECTION III.
ANATOMICAL RELATIONS OF THE IRIS.
The Iris, by filling up the circular space left at the anterior por-
tion of the choroid coat, constitutes a diaphragm or curtain, with
an opening near its centre capable of transmitting or excluding,
according to its size, the rays of light which pass through the cor-
nea to the retina. Being a circular septum, the iris is attached only
by its external circumference, adhering to the ciliary ligament, but
yet in such a manner that it can be separated from it by gentle
traction without injury either to itself or the ciliary body.
The Pupil, or opening in the centre of the iris, is capable of
dilatation or contraction in certain conditions of the eye, in conse-
quence of a peculiar power possessed by the iris; but whether this
power is due to the action of muscular fibres, or the result of vas-
cular or nervous action, is a point on which anatomists are not
agreed. Dr. Physick taught that the contraction and dilatation of
the pupil was due to the existence of two sets of muscular fibres,
a series of those arranged circularly causing its contraction, and a
radiated or longitudinal set producing its dilatation. As this fact has,
however, been denied by Arnold and others, it is sufficient for all
practical purposes to know that the iris possesses this power under
the stimulus of certain causes, without attempting to explain how
it is produced. The action of narcotic agents in producing dilata-
tion of the pupil, together with the experiments of Dr. Samuel
Cooper, of Philadelphia, in 1797, on the effects of Stramonium,
have been already alluded to under the article on Cataract.
When, from a partial opacity of the cornea, or from contraction
and closure of the pupil, vision is impaired, and light cannot be
freely transmitted to the retina, the operation of forming a new
pupil may be resorted to.
§ 1. — FORMATION OF AN ARTIFICIAL PUPIL.
This operation, originally suggested by Cheselden, of England, in
1728, 1 and performed by him on a boy fourteen years of age, was
1 See Observations, &c. Cheselden's Anatomy, 13th edit. Lond. 1722.
FORMATION OF AN" ARTIFICIAL PUPIL. 313
published in the Philosophical Transactions for that year, and
also in the appendix to the fourth edition of his Anatomy, as
well as in Ledran's Surgery. Mr. Cheselden furnished, however,
so brief a description of his plan as to create doubts in the minds
of his contemporaries as to the various steps of the operation, though
it was well understood that his object was the formation of an open-
ing in some portion of the iris, which should serve as a substitute
for the natural pupil.
These doubts, and the various changes produced by disease both
in the cornea and iris, together with the diversified character of the
causes creating them, have led other surgeons at different periods
to various modifications of his operation, although they have fol-
lowed the principle laid down by him ; the creation of a new point
by which the light might be transmitted to the retina being the
object of all of them.
These different modes of operating have been classified under
five heads.
1st. Division of the iris through the sclerotica, or through an
opening in the cornea, called by ophthalmologists Coretomia (xopj?,
the pupil, and ro^, a section).
2d. Excision of the iris, Corectomia {xo^ the pupil, and ix-tow,
excision).
3d. Separation or tearing of the iris from its ciliary attachments,
called Coredialysis (*op*7, the pupil, and S«au<Hs, dissolution or
loosening).
4th. Separation and excision combined, or a modification of the
corectomia of Wenzel.
oth. Distortion of the natural pupil. (Hays.)
I. CORETOMIA.
Operation of Mr. Cheselden, of England. — With a very
narrow and pointed knife or needle, cutting on but one edge, Mr.
Cheselden punctured the sclerotica about two lines from the cornea,
as in the operation of couching. Passing the needle flatwise through
the posterior chamber until its point had traversed two-thirds of its
transverse diameter, he cut through the iris from behind forwards,
by a sawing motion, and withdrew the instrument as it entered.
314 OPERATIVE SURGERY.
II. CORECTOMIA, OR EXCISION OF THE IRIS.
This operation was originally performed by Wenzel in 1780.
Operation.— Introducing a cataract knife through the cornea, as
in extraction, Wenzel carried its point through the iris, and made
a slit in it of sufficient length to permit free vision, taking special
care not to press upon the eye lest its contents should be evacuated.
On withdrawing the knife, the escape of the aqueous humor caused
a flap in the iris to bulge forwards, and this being increased by
gentle pressure with the finger on the ball, a portion of the iris was
then cut off with fine scissors.
Operation of Dr. Physick, of Philadelphia.— Dr. Physick
made a section of the cornea and iris by a cataract knife, in a man-
ner similar to that performed by Wenzel, and, introducing through
the opening a pair of forceps (Plate VIII., Fig. 6), terminating in
small plates, one of which contained a sharp circular punch, similar
to that used by saddlers, he seized the iris between the blades, and
cut out a piece by closing the plates of the instrument. 1
Operation of Beer. — After incising the cornea, Beer introduced
a fine hook or teethed forceps, seized the iris, drew it out, and cut
off the projecting portion with the scissors.
Operation of Velpeau. — Velpeau punctured the cornea with a
thin, lo'ng, double-edged knife, resembling the serpent-tongued lan-
cet ; then passing the point through the iris, from before backwards,
penetrated the posterior chamber, and, passing a line or two across
it, brought the knife out again into the anterior chamber, by cutting
through the iris from behind forwards. Passing the point again
through the cornea, he cut a flap both in the iris and cornea at the
same moment (Plate XV., Fig. 7), the flap in the iris retracting upon
itself, and leaving a triangular artificial pupil. 2 This operation is
also but a modification of that of Wenzel.
Mulder, after incising the cornea, introduced fine scissors, and cut
out the four angles of a crucial opening made through the iris (Plate
XV., Fig. 9).
Operation of Dr. Pancoast, of Philadelphia. 3 — Dr. Pancoast
1 Dorsey's Surgery, p. 347, Philadelphia, 1823.
2 Bernard and Huette, p. 153.
3 Operative Surgery, 3d edit., p. 218.
FORMATION OF AN ARTIFICIAL PUPIL. 315
having modified the operation of Maunoir, forms the artificial pupil
as follows : The patient being seated in a good light, an assistant
raises the upper lid whilst the surgeon depresses the lower and
enters the point of Wenzel's cataract knife into the cornea at the
usual place for extraction. As soon as the point is seen in the ante-
rior chamber, the handle is brought forwards and the point directed
obliquely backwards upon the iris, so as to pierce it at about half
a line from its ciliary margin, where the lens is most distant from
it, and least liable to injury. As soon as this puncture is made,
the handle is carried backwards, so as to bring the iris forwards
on the point of the knife, which is then carried on so as. to divide
both the iris and cornea, until the point of the instrument has
advanced half-way between the place of puncture of the iris and
the closed pupil (Plate XV., Fig. 11), when the instrument is to be
carefully withdrawn, the escape of the aqueous humor being very
slight when this is well done. The incision of the cornea should
be about one-fifth of its circumference, and that of the iris should
have a shape concentric with its outer margin.
The delicate probe-pointed scissors of Maunoir being then in-
serted, closed and flatwise, through the corneal opening, should be
slightly opened, and the handles turned so as to look obliquely
downwards and forwards, so that the blade next the cornea
may not injure it. Then, one blade being carried through the
puncture of the iris, behind that membrane and the other in
front, as far as the centre of the old pupil (Plate XV., Fig. 14), the
handles are to be brought directly horizontal, and the second in-
cision made by closing them. Not a drop of blood will escape,
and an artificial pupil will be at once formed, which will be widest
at its centre. The subsequent use of belladonna for a few days
assists in keeping the new pupil dilated as widely as possible.
III. COREDIALYSIS, OR LACERATION OF THE IRIS.
This operation, as suggested by Scarpa, was performed by him,
in 1801, as follows: —
Operation of Scarpa.— "The patient being seated and held as
in the operation for cataract, the sclerotic coat is to be punctured
with a needle (Scarpa's) about two lines from the union of the scle-
rotica with the cornea, and the point of the needle made to advance
316
OPERATIVE SURGERY.
as far as the upper and internal part of the margin of the iris, that
is, on the side next the nose. The instrument should then be made
to pierce the upper part of the internal margin of the iris close to
the ciliary ligament, until its point is just perceptible in the anterior
chamber of the aqueous humor; I say just perceptible, because that
part of the anterior chamber being very narrow, if the point of the
needle is made to advance ever so little before the iris it must pass
into the substance of the cornea. As soon as the point of the needle
can be seen in the anterior chamber, it should be pressed upon the
iris from above downwards, and from the internal towards the ex-
ternal angle, as if with the view of carrying the instrument in a line
parallel to the anterior face of the iris, in order that a portion of its '
margin may be separated from the ciliary ligament. This separa-
tion being obtained, the point of the needle should then be depressed
in order to place it upon the inferior angle of the commenced fissure,
which may be prolonged at pleasure by drawing the iris towards the
temple, and carrying the instrument from before backwards, in a
line parallel to the anterior surface of the iris, and the greater axis
of the eye." 1 (Plate XV., Fig. 14.)
Operation of Langenbeck. — This surgeon opened the cornea
by a small knife or needle, and then, passing a fine hook through
the wound, with its convexity presenting upwards, carried it through
the anterior chamber with the hook presenting flatwise between the
cornea and the iris to the very margin of the latter. Then, turning
its point against the iris, he transfixed it by gentle pressure, drew
the hook and the iris very carefully through the wound, drawing
upon the iris until the new pupil was sufficiently large, and, finding
that the iris when not drawn upon would remain in the wound, he
withdrew the hook and left the iris to contract adhesions in the
opening of the cornea (Plate XV., Fig. 13). It is essential to the
success of this operation that the opening in the cornea should not
be larger than is requisite for the introduction of the hook, other-
wise it will be difficult to retain the prolapsed portion of the iris in
the wound.
' Observations on the Principal Diseases of the Eyes, by Antonio Scarpa,. Translated
from the Italian, by James Briggs, Surgeon, Lond. 1806, p. 412.
FORMATION OF AN ARTIFICIAL PUPIL. 317
IV. DISTORTION OF THE NATURAL PUPIL.
Dr. Isaac Hays, of Philadelphia, in 1840, formed an artificial pupil
by the following operation: —
Operation. — The patient lying clown, the lower lid of the right
eye was depressed by an assistant, and the upper lid held by the
operator with the two forefingers so as to steady the ball with the
third finger. Then a section of the cornea, commencing near its
junction with the sclerotica, a little below its middle, and extending
so as to divide one-fourth of the circumference, was made by a
cataract knife being carried steadily and quickly forwards so as to
prevent the escape of the aqueous humor, and prevent prolapse of
the iris before the incision was completed. As soon as the knife
was withdrawn, the humor escaped with a gush, and the lids were
allowed to close, and, on separating them after the lapse of a minute
or two, the iris was found prolapsed so as to draw the lower edge
of the pupil quite to the incision. The patient subsequently enjoyed
excellent vision. 1
After Treatment. — After any operation for artificial pupil, it is
of great consequence that the antiphlogistic treatment, with the use
of belladonna or atropine, should be rigidly observed, the strictest
attention being given to the prevention of vascular excitement, by
diet, venesection, purging, and cold applications outside of the lids.
Kemarks on the Value of these Operations. — From the
variety of circumstances requiring the formation of an artificial
pupil, it is impossible for a surgeon to select any one method of
operating as preferable to the others, and his choice must, therefore,
be decided by the peculiarity of the case. The position of the pupil
must also be governed by the opacity of the cornea ; but, as a general
rule, the most eligible place for it, is as near as possible to the centre
of the old one. When it becomes necessary to create a pupil near
the circumference of the iris, the nasal is by some deemed preferable
to the temporal side, in consequence of its affording more probability
of a correspondence with the optic axis of the other eye. Mr. Gib-
son, of England, with others of extensive experience, object to this,
and deem the opening on the temporal side preferable to any other,
1 Lawrence on the Eye, edited by Hays, Philadelphia, p. 456 ; also, Bibliography,
p. 66.
318 OPERATIVE SURGERY.
as permitting a wider field of vision;' but here, as in the other
questions connected with the operation, the decision must be regu-
lated by the circumstances of the case. The inferior and external
portions are less eligible, and the superior is objectionable from
being more covered by the eyelids. As illustrative of the peculiar
advantages of one mode of operating over the other, the following
conditions of the eye may be referred to: —
1st. When the opacity is in the centre of the cornea of one eye,
the lens being round, and the iris not prominent anteriorly, and
when the other eye is sound, coretomia, or incision of the iris, will
be best suited to the case.
2d. Coredialysis, or displacement, is specially adapted to cases of
opacity of the cornea, involving a greater portion of its convexity,
but where the circumference is clear.
3d. When the capsule of the lens is affected, or the iris is adhe-
rent anteriorly or posteriorly, the other operations mentioned may
be resorted to.
The extent and importance of the subject will, however, forbid
any special recommendation of any operation; and in this, as indeed
in most of the affections of the eye, the reader will find it advan-
tageous to consult the works of those who have devoted themselves
especially to ophthalmic surgery.
CHAPTER VII.
PLASTIC OPERATIONS ON THE FACE.
The production of deformities, in consequence of the loss of
integument in various parts of the body, but especially about the
face, led surgeons, at an early period, to devise some means by
which they could remedy the inconvenience and conceal the defect.
This result has generally been obtained either by drawing upon the
surrounding parts, or by taking flaps from some more distant por-
tion, and modelling them to a proper form, so as to furnish the
amount necessary to supply that which was wanting. In all these
efforts the success of the operation depended entirely on the produc-
1 Littell on the Eye, p. 267.
METOPLASTY, RESTORATION OF INTEGUMENTS ON FOREHEAD. 319
tion of such an amount of inflammation as should result simply in
adhesion, whilst, at the same time, sufficient vitality was preserved
in the new portion to insure the preservation of its structure. On
recalling the position of the surgeons of that period, and the limited
amount of knowledge of the effects of inflammation that they pos-
sessed as compared with that acquired since the observations of Mr.
John Hunter, we cannot but regard their operations as indicating a
high degree of skill, as well as illustrative of their close observation
of the efforts of nature in healing wounds; and notwithstanding
the claims often advanced for the superior character of the surgery
of the present day, it may be doubted whether modern operators
have ever shown a higher degree of ingenuity and surgical skill
than that possessed by those of the period of Taliacotius.
Plastic surgery having originated in the attempt to remedy the
deformity arising from the loss of the nose, the detailed account
of the different operations may be best given in connection with
the section devoted to disorders of that organ ; and the following
example of the restoration of a portion of integument upon the
forehead is therefore presented, at present, merely to preserve the
uniformity of arrangement which has heretofore been observed.
SECTION I.
METOPLASTY, OR RESTORATION OF THE INTEGUMENTS ON THE
FOREHEAD.
An ingenious application of the principles of plastic surgery to a
case in which a large deficiency of the integument on the forehead
required to be supplied from the surrounding parts, has been sug-
gested and performed by Dr. John Watson, of New York, and is, it
is believed, the first operation of the kind ever practised. The
following account is condensed from a paper by Dr. Watson, 1 who
has also very politely afforded me an opportunity of having the
figures illustrating the case copied from a drawing in his portfolio.
Anaplastic Operation for a Hole in the Forehead.— A
carpenter, aat. 42, was admitted into the New York Hospital in
April, 1844, with necrosis of the os frontis of six years' standing,
1 American Journal of Medical Sciences, vol. yiii. p. 537, 1844.
320 OPERATIVE SURGERY.
PLATE XVI.
METOPLASTY AND RHINOPLASTY, OR PLASTIC OPERATIONS ON THE
FOREHEAD AND NOSE.
Fig. 1. A front view of the Face of a patient, forty-two years of age,
who had a large ulcer in the forehead, accompanied with syphilitic caries
of the frontal bone previously to being operated on by Dr. John Watson,
of the New York City Hospital. The ulcer is represented with thickened
and inverted edges, and as retaining a portion of the necrosed bone ; a
fistulous orifice is also seen at the upper border of each orbit, with another
in the left temple, through which pus escaped freely. The eyebrows and
upper eyelids are shown as slightly elevated and deformed by the adven-
titious adhesions existing around these fistula?. The bone in the centre of
the ulcer presents the ordinary characters of caries and necrosis.
Copied from a likeness taken by Dr. Watson.
Fig. 2. Represents the condition of the patient near the termination of
the treatment. A linear cicatrix is seen on the forehead, with one or two
larger points or depressions in the skin caused by its adhesion to the sur-
face Of the bone. After Watson.
Fig. 3. Represents the line of incision, together with the sutures and
lines of union in the wound immediately after the operation.
After Watson.
Fig. 4. Rhinoplasty, as practised according to the Indian method, by
Delpech. A triangular, or somewhat V-shaped flap, 1, 2, 3, has been cut
upon the forehead, so that the point of the V will correspond with the
root of the nose. At 2, an additional portion has been excised with the
flap in order to form the column of the nose, and at 4 the flap is seen
rotated upon its base, so as to be brought down in front of the nasal
cavity. To favor this rotation, and prevent the constriction of the vessels
in the flap which would otherwise result, the incision at the base of the
flap has been made slightly longer on the right than on the left side of the
nose. The numerous sutures requisite for the approximation of the flap
to the nose, together with the bougies introduced into the nostril for the
support of the alee, and to preserve the orifices of the nostril, are also re-
presented. After Bernard and Huette.
Fig. 5. A side view of the original Taliacotian operation, or that re-
vived by Grsefe, with the bandage or jacket worn to support the arm until
adhesion occurs in the base of the flap. 1, 2, 3. The flap, cut from the
skin of the arm, and attached over the nasal cavity by numerous sutures.
After Bernard and Huette.
e 1 6
METOPLASTY, RESTORATION OF INTEGUMENTS ON FOREHEAD. 321
probably the result of syphilis, contracted some twenty years pre-
vious, and of which he believed himself cured; the disease on the
forehead, according to his own account, having resulted from an
injury. At his admission, a large ulcer existed on the forehead
(Plate XVL, Fig. 1), exposing a considerable portion of the os
frontis, the greater part of the external table of which had already
exfoliated, and was held in place merely by the overlapping of the
soft parts. A fistulous opening existed at the upper border of each
orbit, and another was on the left temple, through which the pus
escaped. The upper eyelids were somewhat elevated and deformed
by adventitious adhesions around these fistula?. The exfoliated
portion of bone was removed by Dr. J. K. Eodgers, who was obliged
to enlarge the opening by a short incision in the scalp at the upper
and left angle of the ulcer ; the undermined integuments rolled in
upon themselves, from want of support, turning a portion of the
hairy scalp inwards upon the face of the sore, and adhering in a
fold along the left border of the ulcer. (Plate XVI., Fig. 1.)
Operation of Dr. Watson. — After shaving the scalp, and re-
moving the cuticle from the centre of the ulcer, by washing it with
concentrated aqua ammonias, the integuments along the left border
of the ulcer were unfolded by the free use of the scalpel.
The point of the knife was then carried completely around the
circumference of the opening, through the whole thickness of the
soft parts, so as to remove a strip of integument varying from an
eighth to a quarter of an inch in width, thus making a smooth and
fresh border for the subsequent adjustment of the flaps.
Two quadrilateral flaps, the one on the left and the other on the
right side of the opening in the forehead, were then raised by
making four incisions horizontally backwards, and nearly parallel
with each other, two on each side, one from each upper, the other
from each lower angle of the opening (Plate XYL, Fig. 3), the
flaps being detached from the pericranium.
The diseased portions of bone were then removed, as far as they
could be detected, by means of the cutting pliers. The largest of
these portions was the projecting rim of bone at the left frontal
sinus, the removal of which caused a slight depression over the left
orbit. The hemorrhage, which had been profuse, was then checked
by ligatures.
An attempt was next made to approximate the lateral flaps so as
to cover the opening, but this could only be partially accomplished,
21
322 OPERATIVE SURGERY.
as they could be made to meet only to the extent of an inch from
their lower edges, even after considerable stretching. The portions
thus approximated were secured by sutures, but left a large V-shaped
gap in the upper part of the forehead. To close this, a free incision
was carried from near the upper and right angle of the ulcer, in a
curved direction towards the crown of the head (Plate XVI., Fig.
3); the flap thus made being dissected up and rotated so as to bring
its lower and right angle downwards on the centre of the forehead,
thus supplying effectually the deformity; the edges being then
accurately adjusted by numerous points of sutures (Plate XVI., Fig.
3), strengthened by adhesive plaster, and covered by a compress
and bandage. The dressings were subsequently kept wet with
cold water. The first dressing was removed on the sixth day, and
about three-fourths of the line of incision found to have united by
the first intention. At the second dressing, on the ninth or tenth
day, cicatrization had progressed somewhat further, and in five
weeks the patient left the hospital, at which period the wound had
entirely cicatrized, with the exception of a pupillary opening com-
municating with a small point of carious bone that had been over-
looked in the operation, and had not then exfoliated. Plate XVI.,
Fig. 2, represents the patient as cured.
CHAPTEE VIII.
OF THE EXTERNAL NOSE.
SECTION I.
ANATOMY OF THE EXTERNAL NOSE.
The general relations of the nose to the surrounding parts are so
well known that reference to them in detail is deemed unnecessary.
The structure of the nose, proceeding from the outside to the
cavity of the nostril, is composed of the skin, cartilages, bones, and
mucous membrane.
The skin on the upper portion, or root of the nose, is similar to
that on the forehead, is loosely attached to the subjacent parts by
OPERATIONS UPON THE EXTERNAL NOSE. 323
a free cellular tissue, and is, therefore, very movable. At the point
and lower half of the nose, or sides of the nostril, it is abundantly-
furnished with sebaceous follicles, and is attached to the cartilages
by short fibrous filaments which render it very immovable and dif-
ficult to dissect from the subjacent parts, without injuring them.
These follicles are generally the seat of the lipomatous tumors
found in this region. When they attain such a size as to demand
extirpation, it may be accomplished by dissecting them off from the
base, taking care not to cut through the cartilages. The wound may
be subsequently closed by sutures and adhesive strips ; or, if very
extensive, as is sometimes the case, be left to heal by granulation
and cicatrization.
The cartilaginous portion of the nose is formed by a vertical
cartilage or septum, placed in the middle line of the nose, con-
tinuously with the bony septum formed by the vomer and nasal
lamella of the ethmoid bone, and of the oval cartilages or oblong
oval plates, which, forming the structure at the point, are directed
upwards and backwards from the cartilaginous septum. The con-
tact of the oval cartilages with each other forms the columna nasi.
The alas nasi, or convexities on the sides of the nostrils, owe their
shape to several small cartilages, united by ligamentous matter.
They keep the nostril patulous, and also permit its free motion.
The mucous membrane covers these cartilages as well as the
bones of the internal nose.
SECTION II.
OPERATIONS UPON THE EXTERNAL NOSE.
The operations practised upon the external portion of the nose
may be demanded either for the removal of lipomatous tumors, for
occlusion of the nostril as the result of ulceration or burns, or for
the cure of deformities arising from loss of substance.
The class of tumors usually known as Lipomatous, and described
as such, or as carcinomatous, are occasionally seen on the lower
extremity of the nose. These tumors have been very indefinitely
described by European writers, who have sometimes merely referred
to them as " an increase in the thickness of the skin, which some-
324 OPERATIVE SURGERY.
times becomes a prominent swelling," 1 or as "a hypertrophied con-
dition of the integuments and subcutaneous adipose tissue." 2 The
soundest view of their pathology will, therefore, it is thought, be
found in a paper on Polypi and other Tumors of the Nose, by Dr.
John Watson, of New York, who regards them as neither carcino-
matous nor lipomatous, but as dependent on a hypertrophy of the
integuments and cellular tissue, attended with sero-fibrinous infil-
tration and with excessive development of the sebaceous crypta?
proper to the integuments. He also regards them as mainly
dependent on enlargement of the sebaceous crypts of the nose,
being in fact analogous to the polypous growth. They are slowly
developed, unattended with pain, and occur either singly or in
groups ; are disposed to assume a pyriform shape, to become pen-
dulous, and to grow to an enormous size, reaching, in some in-
stances, to the lower lip, and in others below the base of the chin. 3
Their development is often a strictly local complaint, being limited
to the skin; does not involve the nasal cartilages; and, though
vascular, and disposed to bleed freely, they may be removed by
shaving or dissecting them off from the cartilages, care being taken
previously to introduce a finger into the nostril so as to prevent
the injury of the alse by the incisions, the ulcer, when large, being
allowed to heal by the second intention.
The relief of the contraction of the nostrils resulting from lupus,
scrofulous ulcers, or burns, requires the formation of an opening by
paring away the tissue around the nasal orifice, and an endeavor to
heal the ulcer by the use of nitrate of silver. The production of
the opening is sufficiently easy, but its preservation, even with a
free excision of the surface of the alae, is often very difficult, cica-
trization and subsequent contraction often closing it as soon as the
tubes or tentes are removed.
In a young lady, in whom both nostrils were completely closed,
as the result of scrofulous ulceration, the mucous membrane was
perfectly sound, and its secretion free enough to escape by the pos-
terior nares; yet, notwithstanding free excision, the use of sponge
tentes, caustic, &c, I failed to effect a restoration of the passage.
1 Ferguson, p. 42G, 2d edit. Philada. 1853.
2 Miller's Practice, p. 102, 3d edit. Pbilada. 1853.
3 Am. Journ. of Med. Sciences, April, 1842, p. 345.
RHINOPLASTY. 325
SECTION III.
RHINOPLASTY.
The restoration of the whole or of part of the nose constitutes a
variety of the class of plastic operations designated as Khinoplasty.
These operations are among the most tedious and painful in surgery,
and, before undertaking them, the surgeon will find it advantageous
to resort to the following preliminary measures: 1st, make the
patient fully aware of what it is necessary to suffer; 2d, inform him
of the chances of failure from want of vitality in the new portion ;
3d, of the great tendency to contraction in the new organ ; 4th, of
the probable difference in color and texture between it and the nose
in its natural condition. When the result is fully understood by
the patient, the surgeon should proceed to study most thoroughly
the probable shape and natural characters of the lost part; make
ample calculation for the shrinking of the flap, allowing, generally,
for the ultimate loss of at least two -thirds of the portion at first
taken ; and, cutting pieces of thick, or moderately stiff paper, or,
what is better, kid or soft leather, fit them to the part, or mould a
wax nose upon the deficient portion, and, by flattening it, endeavor
to obtain an accurate pattern of the shape of the integuments that
will be required, marking it upon the skin that is to furnish the new
structure by means of lunar caustic. In addition to this, let him also
prepare his patient most carefully by an appropriate general treat-
ment, and select such a period and locality as will be most likely to
ward off an attack of erysipelas. In operating for the restoration
of a nose where the bones and cartilages are all destroyed, he
should also make his patient comprehend that, as the bridge has
been destroyed, the new nose will never present the convexity of
the old one, but that, though thus defective, it may yet look better,
and render him more comfortable than he was before the operation.
The various modes of performing plastic operations, have been
arranged under three classes : 1st, the Indian method, or original
plan of the Brahmins, in which the flap is taken from the integu-
ments of the forehead; 2d, the Italian or Taliacotian operation,
where the flap is taken from an extremity, usually the arm, near
the insertion of the deltoid muscle, several days before it is applied
to the deficient portion; 3d, where it is taken from the forearmj
326 OPERATIVE SURGERY.
PLATE XVII.
RHINOPLASTY AND CIIEILOPLASTIC OPERATIONS.
Fig-. 1. Appearance of John Glover prior to the operations of Cheilo-
plasty and Rhinoplasty, as performed by Dr. Pancoast, of Philadelphia.
After Pancoast.
Fig. 2. View of liis face with the chin depressed. The mouth being
contracted into a rigid orifice, was enlarged laterally by the "stomato-
plastic operation of Dieffenbach for atresia oris, after which two flaps were
formed, as marked in the lines upon the cheeks, so as to form the upper lip.
After Pancoast.
Fig. 3. Appearance of his face after this operation, showing the posi-
tion of the sutures and the improvement in the mouth. After Pancoast.
Fig. 4. Shows the steps of the Rhinoplastic operation performed upon
him subsequently. The edges of the nasal cavity being freshened by a
grooved incision, the outline of the new nose was marked on the forehead
before cutting the flap. The dots indicate the position of the sutures.
After Pancoast.
Fig. 5. The wound in the forehead being closed by the hare-lip sutures,
the flap was reverted, and attached in the groove on the edge of the nasal
cavity by three stitches of the interrupted suture, which were tied over
little rolls of adhesive plaster, after Grsefe's method. The edge of the
septum is also attached to the upper lip. The twist in the pedicle is seen
ill the root of the nose. After Pancoast.
Fig. 6. An accurate likeness of John Glover, sixteen months after the
Operation. After Pancoast.
RHINOPLASTY. 327
with some modifications, as practised by Graefe and others among
the Germans; and 4th, the French plan, in which a piece taken
from the neighboring parts is slid over or rotated so as to cover
the deficient portion.
To these may be added the insertion of a piece directly removed
from some other portion of the body, and attached to the deficient
part.
Plastic surgery, as illustrated by the plastic operations practised
on the Face, dates from a very early period, having been long
practised in India in order to remedy the losses occasioned by the
punishment of criminals, whence the origin of the Brahmin method
of operating. In 1597, Taliacotins, of Venice, whose attention had
been largely devoted to the relief of these deformities, operated by
taking a flap from a distant part, and applying it to the part which
was to be restored, subsequently freeing it from its stem, when it
had united. Having published a volume on the subject, in which
he detailed his methods of operating, the term Taliacotian has
since been often employed to designate all plastic operations,
though it should be strictly limited to his or Branca's peculiar
plans. Grasfe, of Germany, modified this method in 1815, resorting
to immediate union of the flap ; whilst Labat, Serre, and others, in
France, in 183-1, published long accounts of their success by means
of flaps taken from adjoining parts. In the United States, the
Taliacotian operation had nearly fallen into oblivion, when it was
successfully revived, in 1837, by Dr. J. Mason Warren, of Boston,
who modified the operation of Grsefe by taking the flap directly
frojn the forearm instead of the arm. Since then, rhinoplasty in
different forms has been frequently resorted to with varying success,
by Drs. Joseph Pancoast and Thomas D. Mutter, of Philadelphia;
and the original Taliacotian operation for restoration of the end of
the nose has since been performed by Dr. Horner, of the same
city, but without success, owing to the sloughing of the edges
of the flap. In nine cases operated on by Dr. Pancoast, of Phila-
delphia, and united with what he terms the "plastic suture" (p. 331),
the parts uniformly united by the first intention ; the operator
attributes his marked success mainly to the use of this excellent
suture. 1
As the Brahmin method is preferable to that of Taliacotius, when
the forehead is capable of furnishing the flap, I mention it first.
1 Med. Examiner, vol. viii. N. S. p. 344, 1852.
328 OPERATIVE SURGERY.
§ 1. — INDIAN OR BRAHMIN METHOD OF RHINOPLASTY.
Operation of Dr. J. Mason Warren, of Boston.— "The pa-
tient, a young man, aged 28 years, had lost, from ulceration, the
whole nose, cartilages, septum, and bones. In the place of the nose
there existed an opening, about one inch in diameter, bordered by
a firm cicatrix; and, the septum being destroyed, the cavities of the
two nostrils were thrown into one. The four front teeth with the
alveolar processes had also been lost, and there was an opening
between the lip and the upper jaw through which a probe might be
passed from the mouth into the nasal cavity. The favorable cir-
cumstances connected with the case were the healthy state of the
integuments surrounding the opening of the nasal fossa, the great
height of the forehead, the whiteness and delicacy of the skin, and
the good state of the patient's health.
"Operation, Sept. 7th, 1837. — A piece of pasteboard, cut in the
shape of the letter V, that is, triangular, and with a projection from
its base, corresponding with the column a of the nose, was placed
upon the forehead, and a trace made around it with the nitrate of
silver, as recommended by Lisfranc, in order that it might not be
effaced by the blood. A trace was also made around the opening
of the nasal fossa, at the points where it would be necessary to
remove the integuments for planting the new skin taken from the
forehead. This was done the night previous to the operation. The
clothing being arranged, the patient was laid on a table with his
face towards the window and the operator behind him, so as to have
the full command of the head. The traces made by the nitrate of
silver were about two-thirds of an inch apart between the eyebrows ;
each side of the triangular portion of the skin was three inches and
a quarter in length, with a base of three and a half inches, and the
projection from the columna of the nose, which was to be taken
entirely from the scalp, previously shaved, was an inch and a half
long, and two-thirds of an inch wide.
"The head being firmly supported by two assistants, the incision
was commenced between the eyebrows and the flap of skin dissected
up so as to isolate it entirely from the skin of the forehead, except
where, for the purpose of nutrition, it was left adherent at the root
of the nose. The incision on the left side, between the eyebrows,
was extended a little further down than on the right, the better to
INDIAN OR BRAHMIN METHOD OF RHINOPLASTY. 329
facilitate the twisting of the flap. This incision included the skin,
subcutaneous cellular tissue, and a portion of the occipito-frontalis
muscle, care being taken not to raise the periosteum from fear of
necrosis. The flap, thus dissected and twisted round to the left side,
was carefully wrapped in a compress of linen cloth, and before the
operation was proceeded in further, attention was given to diminish-
ing the large wound made in the scalp (forehead) (Plate XVI., Fig.
4); little hemorrhage had taken place, and the temporal arteries
which had been cut very soon retracted and ceased bleeding. The
angles of the wound were now brought together by the twisted
suture, two pins being employed on either side. Its edges between
the eyebrows were also approximated in a similar manner, and by
this means the wound in the forehead was at once diminished to
less than half its original size ; it was still further reduced by the
use of a few strips of adhesive plaster; and a little scraped lint
filled up the remainder of the wound. Some spread cerate was
placed over the whole surface with a pledget, and the dressing
was secured by a bandage round the head.
" The next object was to fasten the borrowed skin in its place.
In order to do this, it was necessary to freshen the borders of the
opening in the nasal fossa, the traces of which, as stated, had been
previously made with the nitrate of silver. For this purpose, a
short, narrow knife, somewhat similar to a cataract-knife, was used
(resembling the original knife of Taliacotius), and a strip of integu-
ment a third of an inch broad, including all that had been indurated
in the old cicatrix, removed. The knife was also passed between
the lip and upper jaw, in which existed, as before stated, an open-
ing large enough to pass a probe, and the adhesions between the
two for the space of an inch entirely cut away, for the double pur-
pose of giving the columna of the nose a more deep and firm adhe-
sion, as well as to close up by inflammation the unnatural commu-
nication between the mouth and nasal cavity.
" The flap was now brought down into its place, its angles a little
rounded with the scissors, the better to simulate the alae of the nose,
and the whole secured in its place by pins and points of the inter-
rupted suture." In a subsequent operation, the interrupted suture
was used, and is generally preferable.
" From that portion of the skin which was to form the columna,
the epidermic side was pared a little, so that it might form an adhe-
330 OPERATIVE SURGERY.
sion, not only underneath to the jaw, but on its sides to the quad-
rangular wound made for it in the upper lip.
"A little scraped lint was now placed under the ends of the pins,
and a strip of oiled lint introduced into each nostril to prevent ad-
hesion ; another strip was placed upon the nose to preserve its tem-
perature, and the dressings were confined by a band of adhesive
plaster fixed to the forehead above and partially divided in the
middle, so that it might descend on each side of the nose to the
lip." 1
A double T bandage, made of narrow tape, the horizontal por-
tion of which is applied to the upper lip, and the two vertical por-
tions carried over the root of the nose, will also serve a good pur-
pose and be free from the objections to the use of adhesive plaster. 2
Operation of Dr. J. Pancoast, of Philadelphia. 3 — After
marking out the flap, as described in the preceding operation, Dr.
Pancoast prefers to cut out a second model in adhesive plaster and
fit it into the space just marked out on the forehead by placing its
apex perpendicularly between the eyebrows ; or, if the forehead is
low, to place it in an oblique instead of a vertical direction, so as
to avoid cutting into the hairy portion of the scalp. After thus
delineating the flap on the forehead, the points for the sutures, and
their corresponding places on the sides of the nasal opening, should
be dotted with ink or colored varnish (Plate XVIL, Fig. 4), so as
to insure the accurate adjustment of the flap to the nose. The
peduncle of the flap at the root of the nose should also be calcu-
lated so as to leave it from a half to five-eighths of an inch wide, in
order to permit the rotation, and also preserve the nourishment of
the flap by one or both of the angular arteries of the nose.
The first step, now, consists in freshening the edges of the stump
of the nose, so as to leave a groove for the reception of the flap,
the nostrils having been previously filled by lint so as to prevent
the blood flowing back into the throat.
The second is the dissection of the flap from the forehead and the
closing of the wound (made by its removal) with twisted sutures,
compress, &c.
In the third step, the flap is brought down to its place and re-
tained there by the following suture, to which the operator attri-
1 Boston Med. and Surg. Journ., vol. xvi. p. 69, 1837.
2 See Smith's Minor Surgery.
8 Operative Surgery, 3d edit. p. 350, et supra, 1852.
INDIAN OR BRAHMIN METHOD OF RHINOPLASTY. 331
butes much of the happy results that have attended his nine opera-
tions, all of which united by the first intention. This suture he
forms in the following manner: —
Pancoast's Plastic Suture. — Three waxed silken ligatures,
armed with a needle at each end, are to be placed in the groove at
each side of the nostril, by passing one needle from without in-
wards through the inner wall of the groove, and then from within
outwards, at a point about one-eighth of an inch above its first
puncture, so as to leave this needle and that attached to the oppo-
site end of the same ligature, resting on the cheek, the loop on the
inner side of the groove being thus made to embrace about one-
eighth of an inch of its inner surface (Plate XVIL, Fig. 4). Then,
when the edge of the flap is adjusted to the groove, the two needles
are to be passed through the margin of the flap from within out-
wards, so that, when drawn tight, the ligature will necessarily sink
the edge of the flap to the bottom of the groove, and bring the
upper and under surface of the edge of the flap in contact with the
outer and inner edge of the groove, and thus facilitate the union ;
after which the ligatures are all to be tied over small rolls of adhe-
sive plaster, after the manner of Grsefe and Labat, so as not to
strangulate the parts included in the loop (Plate XVIL, Fig. 5).
After applying greased lint internally and externally, the warm-
water dressing was continued on the nose, and the pedicle near the
forehead not divided for five or eight weeks.
Eemarks. — In the performance of these operations, great atten-
tion should be given to the following points : —
1st. To mould a good nose (in soft wax) to the nasal cavity, and
then flatten it out, in order that it may serve for a model.
2d. To obtain a sufficiently large and full flap from the forehead,
of the shape, but not the size of the model, as it is almost impos-
sible to anticipate the amount of the subsequent contraction of the
new covering of the nose.
3d. To dissect up all the integuments of the forehead above the
periosteum, the latter being left untouched.
4th. To make a good groove on the sides of the nostril, and bevel
the edges of the flap, so as to fit it accurately.
5th. To unite the edge of the flap to the sides of the groove
by Pancoast's plastic suture.
6th. To unite the column of the new nose to the gum, and to
332 OPERATIVE SURGERY.
bevel its edges so as to prevent their union with the margins of the
flap which form the alas of the nostril.
7th. To guard against contraction of the orifices of the nostras,
or their union with the septum, either by the use of rolls of greased
linen, by the introduction of a piece of catheter, or by bevelling
off the edge of the alas, and turning it into the nostril so as to form
a sort of hem to the edge of the orifices, as suggested by Lai tat.
8th. If the nasal orifices contract, then to pare them off and treat
the surface with nitrate of silver until healed, taking care to dis-
tend the opening during the process.
The greatest care in nursing is also essential, especially for the
first few days, lest the patient should, by any inconsiderate move-
ment, disturb the flap before union has occurred.
The following operation is another example of the variety seen
in these plastic operations : —
Cheiloplasty and Khinoplasty. — Operation of Dr. J. Pan-
coast, of Philadelphia. — A man, aged fifty-three, had lost all
the soft parts of the nose and whole of the upper lip, from the com-
missures of the mouth to the canine fossa of each side, as well as
the septum narium and the turbinated bones, the cavities of the
antrum Highmorianum and of the sphenoidal sinuses being ex-
posed. His appearance, with his mouth closed, is shown (Plate
XVII., Fig. 1). The mouth, when opened, presented a rigid circu-
lar orifice three-fourths of an inch in diameter.
Operation. — The mouth was widened after Dieffenbach's method
(Plate XX., Fig. 7), after which the free surface of the gum was
freshened. An incision was then made obliquely upwards and out-
wards for a quarter of an inch from the point where the gum was
covered by integuments, and from the end of this another cut was
made for about the same distance, nearly parallel with the incisions
for widening the mouth, but inclined a little downwards. The
cheeks being now loosened from the gum and malar bone by inci-
sions on the side of the mouth, the flap of skin and subcutaneous
fatty matter was raised from the surface of the muscle by beginning
the dissection at the angle next the nose (Plate XVII., Fig. 2).
The arterial branches, which were divided, having been twisted,
the flaps were drawn downwards and forwards over the raw sur-
face of the gum and fastened . together with the hare-lip suture
(Plate XVIL. Fig. 3), the inner edge of the rotated flaps being thus
united in the middle line of the lip. The face being then dressed
TALIACOTIAN OPERATION - . 333
with lint wet with lead-water and laudanum, the patient recovered
in about two months. The nose was subsequently formed as fol-
lows : —
The hair being shaved from the temple and forehead, the nasal
orifices closed with lint to prevent the entrance of blood, and the
patient lying down with the head supported by a pillow, a flap was
raised from the forehead, as shown in Plate XVII., Fig. 4, the skin
being divided at a single sweep of the knife, the blade of which
was inclined outwards so as to cut a bevelled edge. The apex of
the flap, which was about five-eighths of an inch wide, rested be-
tween the eyebrows, and the tongue-like portion which was to form
the columna nasi, extended up into the scalp. The base of the
flap was nearly three inches wide, in order to allow for its subse-
quent contraction. The flap, after being dissected up, was then
turned down on the left side and wrapped in linen, whilst the wound
in the forehead was closed by four interrupted sutures, after which
the flap was applied to the freshened edges of the new lip and
gums, the whole being held in position by the plastic suture before
described, and tied over rolls of adhesive plaster as in Grgefe's
method (Plate XVII., Fig. 5). Union having occurred, the pedicle
of the flap was divided five weeks subsequently, by passing a
director under it, after which it was smoothly fitted down to the
roots of the ossa nasi, in a cavity which was made for its reception
by excising a portion of the subjacent integuments. By the twelfth
day, union was perfect, and the patient left the hospital so much
improved that, sixteen months subsequently, his likeness was taken,
as represented on Plate XVII., Fig. 6.
Kemarks. — This very fortunate case, though forcibly illustrating
the skill and dexterity of the accomplished operator, can only be
regarded as an example of the fortunate cases, and though it may
stimulate others to repeat it, should not induce any surgeon to be
sanguine in his general prognosis of this class of operations.
§ 2. — TALIACOTIAN OPERATION.
Operation. — In the Italian or Taliacotian operation, as it is more
frequently termed, the nose, upper and lower lips, or ear, have all
been restored by means of flaps taken from other portions of the
body, and especially from the integuments of the arm.
334 OPERATIVE SURGERY.
In operating for the restoration of a nose, Taliacotins made two
parallel incisions in the integuments of the arm over the belly of
the biceps muscle, at such distances from each other, and of such
lengths as seemed likely to furnish a sufficient flap, allowance being
made for the subsequent shrinking of about two-thirds of the por-
tion taken, cutting it so as to free the skin from the fascia. The
incisions corresponded with the vertical portions of the letter H ;
or he elevated the skin by broad forceps, and then transfixed it, as
in the ordinary introduction of a seton in the neck. In either case,
after passing the knife beneath the skin from one incision to the
other, he introduced a piece of linen spread with cerate in order
to prevent adhesions between the flap and the subjacent parts, and
allowed the wound to suppurate for ten or fifteen days, in conse-
quence of which a contraction of the width of the flap was effected,
whilst it was also thickened and rendered more organizable. A
bandage, consisting of a jacket, with a hood for the head, and a
sleeve to contain and support the arm (Plate XVI., Fig. 5), with
bands to hold it fast to the head, so that the flap could be steadily
kept attached to the nose, being next prepared, the edges of the
surface to be restored were freshened by paring off the cicatrix, by
means of a thin and broad-bladed knife, the flap freed from the arm
by its upper extremity, the arm brought up to the head, and the
fresh end of the flap attached to the raw surface of the nose by
means of numerous points of the interrupted suture ; after which
the bandage was tightened, and the arm left attached to the head
(Plate XVI., Fig. 5).
After fifteen or more days, when union had taken place, the at-
tachment of the flap to the arm was divided and trimmed so as to
fill up the remainder of the deficient portion, this end being retained
in its position by a few turns of a bandage, passed from the head
around the nose, lip, or ear, according to the part operated on. 1
Remarks. — This operation, though applicable to all parts of the
face, is especially adapted to the restoration of the tip of the nose,
the loss of portions of the lips and ears being more readily supplied
by flaps taken from the adjacent parts by either sliding or rotating
them upon their base.
1 Gaspnris Taliacotii Borroniensis. De Curtorum Chirurgiae per insitionem, additi
cutis traducis, instrumentorum omnium atque deligationum iconibus et laterilis.
Venetiis, 1597. This book, together with many other rare and ancient medical works,
may be found in the Loganian portion of the Philadelphia Library.
TALIACOTTAN OPERATION. 335
With some slight modifications, the Taliacotian operation was
successfully performed by Dr. J. Mason Warren, of Boston, in April
1840. 1 In this case, the flap separated from the arm on the fifth
day, union having then occurred.
By a modification of the French method, Dr. J. Pancoast, of
Philadelphia, has also succeeded in restoring the middle of the nose,
together with the ala of the left side. In this case, a great portion
of the hard palate, the sockets of the upper incisor teeth, the car-
tilaginous septum, superior lateral cartilages, inferior turbinated
bones, together with a considerable portion of the inferior oval
cartilages, and the integuments of the nose, had been destroyed by
scrofulous ulceration, the tip and margin being drawn upwards and
also depressed inwards by the cicatrization (Plate XVIIL, Fig. 3).
Pancoast's Operation. — The patient being laid on a table with
his head supported by pillows, the integuments of the depressed
cicatrix, just below the ossa nasi, were dissected off so as to obtain a
bevelled raw surface, to receive the margins of the flaps, and the
end of the nose separated from the ossa nasi by pushing a sharp-
pointed, straight bistoury, with the back to the cheeks, across the
cicatrix, and cutting outwards. It was also found necessary to
divide some adventitious adhesions within the nostril, and to ex-
tend the incision of the cheek outwards and downwards through
the root of the oval cartilages, before the tendency to retraction of
the tip could be overcome.
A triangular flap of integuments being then marked out on each
cheek just below the malar protuberance, of a size calculated to fill
the breach, the outer limb of each triangle was rounded so as to
give a prominence to the ridge of the nose, when the base of the
flaps were brought together, and the edges of the flaps bevelled
inwards towards their centre, so as to furnish an oblique surface,
by which they might rest in the raw edges of the nose (Plate
XVIIL, Fig. 4). Being dissected up with as much subcutaneous
cellular substance as could be taken without involving muscular
fibres, the hemorrhage was arrested by torsion, and the flaps twisted
upon the pedicle, from below upwards, so as to make the lower
margin of the flap on the cheek become the upper on the nose.
The flaps were then united by their bases upon the dorsum of
the nose, and by their sides to the adjoining parts (Plate XVIIL,
1 Boston Med. and Surg. Journ., vol. xxii. p. 261.
336 OPERATIVE SURGERY.
PLATE XVIII.
RHINOPLASTY OPERATIONS.
Fig. 1. Restoration of one-half of the Nose and part of the Cheek by
a flap taken from the Forehead by Dr. Pancoast. Seen as adjusted.
After Pancoast.
Fig. 2. Side view of the same with the Flap in sitH, showing the ar-
rangement of the SUtureS Upon the cheek. Af ter Pancoast.
Fig. 3. Likeness of a Patient operated on by Dr. Pancoast, of Phila-
delphia, for the removal of a Deformity caused by the destruction of the
hard Palate, Septum Narium, and all the soft parts of the Nose, with
the exception of the lip and columna, these being distorted and fastened
to the lower end of the ossa nasi. After Pancoast.
Fig. 4. A view of the Gap left in the Nose of Fig. 3, after the dissec-
tion of the cicatrix and depression of the tip of the nose. The outlines
of the flaps cut from the cheeks to fill up the gap are also shown.
After Pancoast.
Fig. 5. A side view of the same, showing the application of the Sutures
and the closure of the wounds left in the formation of the flaps.
After Pancoast.
Fig. 6. A front view of the same, showing the arrangement of the
Twisted Sutures to both the nose and the wounds left in the cheeks.
After Pancoast.
!
/ ■
TALIACOTIAN OPERATION. - 337
Fig. 6), by small palladium pins and the twisted suture. The nos-
trils were lightly stuffed with oiled lint, and the wounds on the
cheek united by harelip sutures, applied so that the stress should
be towards the canthus of the eye, and not upon the middle of the
eyelid, which might have caused ectropion, when lint, wet with
warm water, and covered with oiled silk, completed the dressing.
At the first change of dressing, complete union was found to have
taken place everywhere except at the median line, where there was
some suppuration.
After some further additions to remedy defects arising from
ulceration and contraction, the nose, ten months after the operation,
looked quite natural. In his subsequent operations, Dr. Pancoast
employed the plastic suture instead of the twisted, as he has found
it preferable to most of the others. 1
Kestoration of the Al^e Nasi may be accomplished either by
a half flap of the Indian method, by the Taliacotian operation, or, if
the loss is very limited, by a piece taken from some other part, and
immediately attached in the opening, an operation which has fully
succeeded in the hands of J. Mason Warren, of Boston. 2
§ 3. — RESTORATION OF THE COLUMNA NASI.
Liston's Operation. — In deficiency of the columna nasi, the late
Mr. Liston took the flap from the upper lip in the following man-
ner. The point of the nose being raised, and its apex freshened
at its attachment, by two vertical incisions on each side of the
centre of the lip, he cut a flap of the entire thickness of the part,
wide enough to allow of shrinking, when the frsenum being freely
dissected off, the flap was everted upwards, so that its mucous
membrane presented outwardly. Then removing the membrane
from the top of the flap, the latter was attached by a pin, through
its end, to the apex of the nose, and fastened by the twisted suture,
uniting the lip as in the harelip operation. Exposure to the air
soon changed the mucous membrane, and after a time it resembled
the original structure of the columna. 3
1 Pancoast's Operative Surgery, Philad. 1844, p. 350, and Amer. Journ. Med.
Sciences, vol. iv. p. 337, New Series, 1842.
2 Boston Med. and Surg. Journ., vol. xxii. p. 268, 1840.
* Liston's and Mutter's Surgery, p. 168, Philad. 1846.
22
338 OPERATIVE SURGERY.
For many other plastic operations, and for much valuable expe-
rience, the reader may advantageously consult the papers of Drs.
Warren, Pancoast, and Mutter, as quoted in the Bibliography, all
of which contain drawings explanatory of the various steps in the
operations, and are creditable specimens of the ingenuity of these
surgeons in relieving shocking deformities.
Value of these Operations. — In estimating the value of Rhino-
plastic operations generally, and especially that for the restoration of
the entire nose, much must depend upon the nature of the deformity.
Most frequently, or when the operation is at all proper, the deficiency
will be very great, and under such circumstances even an imper-
fect-looking nose will be deemed by most patients better than none.
But, when it is remembered that the integument of the new organ
will retain most of the ordinary appearances of skin, whilst that of
the natural nose possesses a large number of follicles ; that the hair
upon the flap is apt to grow and require the frequent use of the
tweezers for its extraction; that the new nose will generally be
paler than the surrounding skin, and that, except in the Taliacotian
operation, a cicatrix of some size will be visible at the part from
which the flap has been taken, the surgeon may well hesitate and
think whether, with the risk of failure or an imperfect success, it
may not be better to import from Paris, or elsewhere, an artificial
nose, the manufacture of which has now attained considerable per-
fection. If, on its reception, the patient's vanity is not gratified,
the operation may be then undertaken with less chance of censure,
should the result not entirely correspond with his or her antici-
pations. In the successful cases, which are those mainly reported,
there is certainly great cause for satisfaction, and especially in
those reported by Drs. Pancoast, Mason Warren, and Mutter; but,
as this class of operations has been at different periods lauded
highly, and then fallen into disrepute, is it not probable that the
number of failures, or abortive attempts, will again throw it into
comparative oblivion? Plastic operations for the restoration of
small deficiencies have been and are positive triumphs of science ;
but that for the restoration of an entire nose is by no means so
well established, notwithstanding the eclat attached to the successful
cases ; at least, those which have been seen by the author have not
presented captivating specimens of the nasal organ.
ANATOMY OF THE INTERNAL NOSE. 339
CHAPTER IX.
OF THE INTERNAL NOSE, OR THE NASAL CAVITIES.
SECTION I.
ANATOMY.
The internal nose consists of two large fossae in the middle of
the superior maxillary bones, which present a very irregular sur-
face. These fossae, or cavities, are separated by the vertical septum,
which, in the natural condition of the part, is a plane surface, and
corresponds with the inner side of the nostril. The upper part of
each fossa is formed by the cribriform plate of the ethmoid bone,
the cells of which diminish very much the width of this portion of
the cavity, so that the space between the upper and middle turbi-
nated bones and the septum narium is frequently not more than
three lines.
The bottom or floor of the nostril is formed by the palate process
of the superior maxillary and palate bones, and is concave and
about half an inch wide.
The external face is very irregular, presenting a number of con-
vexities or prominences (Plate XIX., Fig. 1), which are intended
to afford a greater surface for the lining or olfactory membrane.
Among these prominences, that caused by the convexity of the
inferior turbinated bones is very apparent, and tends much to
diminish the breadth of the nostril throughout its whole depth.
The middle meatus of the nose, or the space between the middle
and inferior turbinated bones, contains the orifice of the antrum
Hi<*hmorianum. This orifice is usually situated about the middle
of the bone, but its precise situation and direction are so uncertain
that it is stated, by an accurate anatomist, 1 to be found with some
difficulty in the subject, though quite apparent in the skull.
The inferior meatus of the nose is between the lower turbinated
1 Special Anat. and Histology, by Wm. E. Horner, M. D., vol. ii. Phila. 1861.
340 OPERATIVE SURGERY.
bone and the floor of the nostril. At the anterior part of this
meatus, about five lines from the anterior extremity of the turbi-
nated bone, is the orifice of the ductus ad nasum.
This orifice is found at the upper part of the inferior meatus,
about eight lines from the floor of the nostril.
The mucous membrane lines the whole nose, penetrates into the
several sinuses and cavities communicating with it, and is continuous
at the nostrils with the skin, and at the posterior nares with the
lining membrane of the pharynx.
The posterior orifice of the nostrils, or the posterior nares, is
divided, like the anterior, by a vertical septum (vomer). Its per-
pendicular diameter is about an inch, but its transverse diameter is
only six lines (Velpeau), points which should be remembered in the
introduction of the tampon for the arrest of epistaxis.
SECTION II.
OPERATION ON THE NASAL CAVITIES.
Eemoval of Foreign Bodies. — The introduction of beans,
beads, grains of coffee, cherry-stones, ribbon, &c, into the nostrils
of children, sometimes gives rise to considerable trouble in their
extraction, especially when the article is one capable of swelling
from heat and moisture. In every instance, however, it is desirable
to attempt it at as early a period as possible, in order to avoid
the turgescence and serous infiltration of the lining membrane of
the nose.
Unless of considerable size, these bodies are seldom arrested
upon the floor of the nostril ; more frequently they will be found
between the inferior or middle turbinated bones and the septum ;
and, in attempting their removal from this position, the delicacy of
these bones should be borne in mind.
A piece of annealed wire, covered with thread, such as is used by
the milliners in the manufacture of ladies' bonnets, and formed into
a loop, will often prove a simple and efficient instrument for the
removal of the substance, when there is but a small space at its side
through which to pass an instrument.
Foreign bodies may be extracted either from the front of the
nostril or pushed back into the throat, according to their proximity
ARREST OF HEMORRHAGE FROM THE NOSTRIL. 341
to one or other of these orifices. As they seldom fill up the entire
front of the nose, a curette or curved probe, or Leroy's instrument
for removing fragments of calculi from the urethra, may generally
be passed on one side of the article, so as to enable the operator to
draw it forward. If jammed between the inferior turbinated bone
and the septum, gentle pressure from above downwards, by placing
it upon the floor of the nostril, will facilitate its subsequent removal
either by the instruments before named, or by polypus or common
dressing forceps. If, however, the foreign substance should be a
piece of ribbon, or something similar, which has been stuffed high
up in the cavity, washing out the nostril by a stream of water from
a syringe, will often dislodge one end and enable the operator to
seize and draw it out with his forceps.
§ 1. — ARREST OF HEMORRHAGE FROM THE NOSTRIL.
Bleeding from the nostril, when excessive, and when the use of
powdered galls or tannic acid, or matico, or gum Arabic, or alum,
has failed, may usually be arrested by plugging up both the ante-
rior and posterior extremities of the nostrils, so as to prevent the
escape of the blood, and cause the formation of a clot.
Plugging the Nostril with Bellocque's Instrument. — This
instrument (see Plate XIII., Figs. 25, 26) consists of a curved silver
tube, in which is placed a piece of watch-spring of sufficient length
to reach from the uvula to near the front teeth. To one end of this
spring is attached a silver button, with an eye capable of readily
receiving a ligature; to the other is screwed a probe, which is in-
tended to push out the spring.
Operation. — After preparing a little pellet of charpie, of a size
corresponding with the opening in the posterior nares, and after
passing a long ligature through the eye of the button at the end
of the spring, and drawing the latter fully within the canula,
pass the tube along the floor of the nostril, keeping it close to
the side of the septum, until it reaches the uvula. Then, pushing-
forward the spring, the button will readily pass into the mouth,
its passage in front of the uvula being facilitated by the fore-
finger introduced into the mouth. "When the button is near the
teeth, one end of the ligature should be drawn out of the mouth,
and a pellet of charpie attached to it by tying the ligature round
342 OPERATIVE SURGERY.
PLATE XIX.
ANATOMY OF TnE INTERNAL NOSE, TOGETHER AVITII THE OPERATIONS
FOR NASAL POLYPI.
Fig. 1. A vertical section of the Head, in its median line, so as to show
the interior of the Nose, Mouth, and Throat, 1. The middle tur-
binated bone. 2. Inferior turbinated bone. 3. Anterior and cartilagi-
nous portion of the nostril. 4. Middle palatine suture. 5. Roof of
the mouth. 6. An ear catheter passed along the floor of the nostril
and entering the orifice of the Eustachian tube. 7. Middle meatus
of the nose. 8. Inferior meatus, near the nasal orifice of the ductus
ad nasum. 9. The sound of Laforest introduced into the duct. 10.
Section of the uvula. 11. Bellocque's canula passed along the floor of
the nostril and soft palate, behind the uvula into the pharynx. The spring
has been protruded, and the ligature with the pellet of charpie attached
is about to be drawn back into the posterior nares in order to close one
side, as in tamponing the nostril. 12. The epiglottis cartilage. 13.
Section of the oesophagus. 14. Genio-hyoglossus muscle. 15. Origin
of genio-glossus muscle. 16. Section of lower jaw at the chin. IT.
Structure of the chin. 18. A probe introduced into the buccal orifice of
the duct of Steno. After Bernard and Huette.
Tig. 2. A front view of the manner in which the loop is seized and
drawn forwards in the operation of tamponing the nostril.
After Bourgery and Jacob.
Fig. 3. A vertical section of the Nose, showing the application of a
ligature around a guttural polypus by means of the " porte" of Charriere.
1. The ligature passed in a loop through the nostril. 2. The " porte"
which has seized it in the pharynx, and directed it around the base of the
tumor. This instrument opens at the end by means of a spring, so that it
can seize or be detached from the ligature without difficulty. The fore-
finger of the surgeon will often do quite as well.
After Bernard and Huette.
Fig. 4. Section of the Face, so as to show the removal of a pyriform
nasal polypus, by means of the wire ligature and double canula as prac-
tised by Physick. After Bell.
Fig. 5. A side view of Dr. Mott's operation for the removal of a large
nasal polypus, which filled the entire nostril. The integuments have been
incised and dissected back, whilst the dotted lines show the course of the
saw through the bones. After Mott.
■
o
■ **»|*
POLYPI IN THE NOSTRILS. 343
its middle. (Plate XIX., Fig. 1.) Then, on withdrawing the
spring into the canula, and removing it from the nose, the pellet
will be drawn up into the posterior nares, so as to leave one end
of the ligature in the mouth, and the other in the nostril. It only
remains to plug up the front of the nostril, and tie the two ends of
the ligature rather loosely in a loop near the teeth, or to carry
them towards the cheek and fasten them with adhesive plaster.
Should the surgeon not be able to obtain Bellocque's canula, he
may readily carry a ligature through the nostril and mouth by
means of a common elastic catheter; the ligature being passed
through the eye of the instrument, and the latter withdrawn after
the pellet is in position. In either case, after the lapse of several
hours, the lint in front of the nostril should be removed by the
fingers or forceps, and that from the posterior nares displaced either
by pressing it into the throat by a probe, whence it may be drawn
by the thread left attached to it for this purpose, or it may be
drawn out simply by employing the end of the ligature left in the
mouth.
§ 2. — POLYPI IN THE NOSTRILS.
Pathology. — In order to appreciate the value of the different
modes of treatment which have been proposed for the relief of po-
lypi, it is necessary that reference should be briefly made to their
structure and general position. Various divisions of polypi have
been described by writers, and especially by Dupuytren, in all of
which more attention has been given to their consistence than to
their general pathological characters. In an excellent paper by Dr.
John Watson, of New York, 1 much has been added to our know-
ledge of the origin and structure of these tumors, and I cannot
present the reader with any details more valuable than those fur-
nished by his article. From this, the following account is, there-
fore, condensed.
Kinds of Polypi. — Six kinds of polypi may be noticed in con-
nection with the surgical affections of the nostril.
1st. The mucous or soft polypus, caused by the accumulation of
mucus within the muciparous follicles, and arising either from a
change in the consistence of the mucus itself, or from obliteration
1 Amer. Med. Journ., vol. iii. p. 325, New Series, 1842.
344 OPERATIVE SURGERY.
and obstruction of the ducts; resembling, in this respect, the seba-
ceous and encysted tumors of the scalp and other portions of the
body, all of which, like polypi, may become pedunculated if acted
on by the weight of the contents of the sac.
2d. The polypus from hypertrophy, induration, and infiltration
of the mucous and submucous tissues of the nostril, and similar to
the tumors frequently seen near the lower part of the rectum.
These tumors are, in fact, a prolapse of the thickened and infiltrated
Schneiderian membrane, and attended with an effusion of fluid into
the subjacent cellular tissue, as the result of inflammation.
3d. Fleshy polypi or caruncular excrescences, of a florid red color,
and though not painful except when irritated, possessed of a certain
degree of sensibility. These are less disposed to assume a pedun-
culated attachment than any other benign form of polypi. Similar
growths have been found at the inner edge of the meatus urinarius
of the female, and in the external meatus of the ear, by Sir A.
Cooper, and others have seen them in the rectum.
4th. Fibrous polypi, supposed by Yelpeau to have their special
origin in the fibrous tissue covering the bones in the nasal cavity,
and to lie between the bone and the proper mucous tissue. When
very large, these are usually found projecting into the posterior
fauces, though the other forms may also project either forwards or
backwards. These tumors are, as stated by Dr. Watson, invariably
attached by a firm and fibrous pedicle.
5th. Gelatinous polypi, which are of rare occurrence, Dr. Wat-
son having seen but one. In this case, the disease appeared to have
originated in the antrum between the mucous membrane and the
bone, and then to have encroached on the surrounding parts. It
was surrounded by a sort of imperfect capsule, with subdivisions of
cellular tissue, some of which were exceedingly delicate, and all of
them filled with a gelatinous, semi-fluid substance of a transparent
pale white or amber color. At some points, this matter was more
like soft calf s-foot jelly, without any visible envelop, but here and
there the tumor contained opaque, grumous, bloody deposits. The
bones retained their proper character, and had not degenerated, and
all the surrounding tissues were simply affected by the pressure of
the tumor.
6th. External polypi, generally called lipoma, and referred to in
a previous page.
7th. Carcinomatous polypi, most frequently originating in the
POLYPI IX THE NOSTRILS. 345
periosteum or bony structure of the upper jaw, and, sooner or later,
invading and deranging surrounding tissues.
Seat of Polypi. — This is to be ascertained mainly by dilating
the nostril, by introducing the blades of the dressing forceps, or by
a speculum, or by directing the patient to blow through the nostril
so as to force them forward.
Most frequently, polypi arise from the membrane spread over the
turbinated bones, or near the orifice of the maxillary sinus, being
seldom found on the septum, and also as rarely arising from the
floor of the nostril. The first two forms are generally confined to
the tissues lining the external and upper wall of the nostril. The
third form, though not so strictly limited, is often found near the
external orifice of the nostril at or below the turbinated bones.
The fourth is most frequently found to arise in the posterior fauces
immediately behind the top of the septum, or probably from the
septum itself. 1 In a case which I attended in consultation with my
friend, Dr. J. M. Wallace, the tumor extended from this point along
the body of the sphenoid bone, and left it perfectly denuded of its
periosteum, as was shown after its removal.
The fifth, or gelatinous polypus, as already seen, arises in the
antrum Highmorianum, and the sixth, though frequently arising on
the nasal surface of the upper maxillary bone, is restricted to no
definite point of attachment.
Operations. — The mucous polypi may frequently be eured by
the plan proposed by Dr. Watson, of puncturing them and evacu-
ating their contents, after which the sac wastes away. The ex-
traction of other polypi may be attempted either by the polypus
forceps, by the wire ligature and double canula of Physick
(Plate IV., Fig. 12), or by the knife, caustics sternutatories, &c,
being comparatively limited in their application, or resorted to
either as palliative means, or as adjuvants to other plans of treatment.
Eemoval by the Forceps. — The patient being directed to blow
his nose, and being seated before a good light, with his head well
supported, introduce the forceps closed, and, with the width of the
blades corresponding to the vertical diameter of the nostril, grasp
the tumor as near as possible to its base; then, rotating the in-
strument in the hand so as to twist the tumor, pull it away with a
jerk as soon as it is felt to }~ield to the torsion movement.
1 Watson, loc. citat.
346 operative surgery.
Strangulation and Extraction by the Wire Ligature and
Double Canula.— This plan, which is that most frequently re-
sorted to in the United States, and which is the least liable to
injure the bony structure, is practised as follows: Pass a piece
of well annealed iron wire through the barrels of the canula,
and fasten one end firmly around one wing of the instrument.
Then, seizing the free end of the wire, push or pull it through
one of the barrels of the canula until a loop of the proper size
is formed at the end which is to be passed into the nostril.
On carrying this into the nose with the loop parallel with and
close to the septum, turn it transversely beneath the fundus of the
tumor, and endeavor to slide it over and up to the pediculated
portion (Plate XIX., Fig. 4); after which the free end of the wire
should be seized with forceps similar to those used by bell-hangers,
and drawn as tightly as possible. If the polypus is not too dense
in its structure, this will constrict its pedicle to a mere shred, and
it only remains to tear it away at the end of the canula, in the loop
thus tightened. After a few minutes, the patient should be again
directed to blow his nose, especially on the side affected, when, again
forming a loop, fish about in the nostril for another tumor, which
is to be extracted as before.
In large polypi, and especially where they protrude by the poste-
rior nares, it may become necessary to strangulate them and leave
them to slough off. When the wire ligature can be made to sur-
round the tumor, the more perfect strangulation accomplished by it
should cause the surgeon to give it the preference. But its large
size will occasionally preclude its use in this manner. In the case
of a large polypus which projected behind the soft palate as low
as the extremity of the uvula, and filled completely the posterior
nares and cavity of the nose, Dr. Physick, after vainly attempting
to extract it with the ligature and forceps, passed a portion of tape
made stiff by means of a piece of silver wire into the nose and
throat, and getting it around the base, tied the tumor in this man-
ner. In a similar case in which I assisted Dr. Wm. Gibson, a violin
string was passed around the base by means of Bellocque's canula,
and both ends brought out of the nostril, when they were passed
through the barrels of a canula and the tumor strangulated, as in
the usual application of the wire ligature. The canula was kept in
the nostril until the third or fifth day, when the tumor sloughed off.
Operation of Dr. Mott.— In a large fibrous polypus, which
ANATOMY OF THE EXTERNAL POETION OF THE MOUTH. 347
filled the nostril, Dr. Valentine Mott removed the tumor after the
ligature had failed, by making a section of the soft parts from the
inner canthus of the eye to near the angle of the mouth, and saw-
ing out the greater part of the os nasi, ascending ramus of the
superior maxillary and inferior turbinated bone. 1 (Plate XIX.,
Fig. 5.)
Excision. — Except in the very rare cases of exceedingly firm
polypi, or those near the nasal orifice, this operation is seldom prac-
tised. When resorted to at the anterior orifice, the tumor should
be hooked forwards, and excised either with a probe-pointed bis-
toury, or with scissors, though the first is preferable.
In all these operations, if the subsequent hemorrhage is excessive,
tamponing the nostril may be required.
Value of these Operations. — In most cases, the wire ligature
and double canula will prove most serviceable, next the forceps, and
lastly excision, simple polypi requiring only to be punctured, or
their coats to be ruptured by sternutatories, in order to evacuate
their contents.
CHAPTER X.
SECTION I.
ANATOMY OF THE EXTERNAL PORTION OF THE MOUTH.
In studying the parietes of the mouth, two parts are to be sepa-
rately noticed : first, its orifice as formed by the lips, and second,
its sides as constituted by the cheeks. The tissues composing both
these portions are the skin, cellular substance, fat, bloodvessels,
muscles, and nerves, together with the mucous membrane.
The skin and cellular substance present nothing requiring a spe-
cial description. The muscles of this region are the orbicularis oris,
closing the orifice of the mouth ; the zygomatici and levatores anguli
oris, which draw back its angles; the buccinator, which dilates its
cavity, and forms the greatest portion of the sides of the cheek;
1 Am. Journ. Med. Sciences, vol. v. p. 87, 1842.
348 OPERATIVE SURGERY.
and the masseter, which assists in closing the jaws, being inserted
into the lower jaw in advance of its angle. The depressors and
levators of the lips complete the enumeration.
The principal bloodvessels are the facial artery and vein, with
their branches, both of which pass on to the face, side by side, over
the surface of the inferior maxilla, directly in advance of the ante-
rior edge of the masseter muscle ; being at this point quite super-
ficial, they may be readily compressed by the pressure of the ringer
against the jaw just in advance of the muscle. The nerves are the
branches of the seventh pair (portio dura), which are widely distri-
buted over the face after it emerges from the parotid gland (Plate
XXIV., Figs. 1, 2), and the infra-orbitar (second branch of the fifth
pair), which, coming out through the infra-orbitar foramen of the
superior maxillary just below the middle of the orbit, is also freely
distributed to all the tissues. Expression and motion are due to
the portio dura, and sensation to the branches of the fifth pair.
The salivary glands (Plate XXIY., Fig. 1), although opening into
the mouth, are yet so situated as to be rather intermediate to the
head and neck; and the description may, therefore, at present, be
limited simply to their ducts as mainly belonging to the region
under consideration, the position and operations practised upon the
glands themselves being reserved for the account of the neck, owing
to the importance of their vascular connections with this part.
The duct of Steno, or the parotid duct, departs from the anterior
edge of the gland, a few lines below the zygoma, traverses the outer
face of the masseter, and perforates the buccinator muscle and the
lining membrane of the mouth, so as to have its orifice opposite the
second large molar tooth of the upper jaw (Plate XIX., Fig. 1). Its
position may be accurately marked by drawing a line from the tip
of the nose to the lobe of the ear (Physick). The duct of the sub-
maxillary gland may be found opening by a small projecting orifice
on the anterior margin of the fraenum linguae. The ducts of the
sublingual open either into that of the submaxillary, or directly into
the mouth, on either side of the frasnum. 1
The further details of this portion of the face, being of but little
practical value to the surgeon, may be omitted, with a simple refer-
ence to the explanations of the figures (Plate XIX., Fig. 1, and
Plate XXIV., Figs. 1, 2).
1 Horner's Anatomy.
SIMPLE HARELIP. 349
SECTION II.
OPERATIONS ON THE LIPS.
The operations upon the lips are chiefly those required for the
cure of harelip, of cancer, of contraction or closure of the mouth,
and for cheiloplasty or the formation of a new lip.
§ 1. — SIMPLE HARELIP.
The congenital defect of union in the two halves of the lip, termed
Harelip, may usually be remedied by paring off or freshening the
vertical portion of each half, and then uniting them by suture.
"Various modes of accomplishing this have been proposed by sur-
geons, but differ mainly in the character of the incision. Without,
however, referring to these in detail, this account may be limited to
that which I have generally found successful.
Operation. — The child, being either firmly held, or with its
arms bandaged to its side or tied up in a bag, the end of which is
drawn around its neck, should be placed in a semi-recumbent
posture, or, if lying down, raised up from time to time during the
operation, so as to prevent the escape of blood into its throat and
stomach, as this is apt to induce fever. Then seizing the left half
of the lip with the left forefinger and thumb, dissect it freely from
its attachment to the gum, and seizing the right half in the same
manner, dissect it also freely from the gum, this free dissection of
the lip from its attachments being essential to success, by diminish-
ing the subsequent strain on the line of union. After freeing the
lip very fully at this point, next introduce a spatula of shingle,
or other soft wood, beneath the lip, and have its free extremity
held by an assistant. Then seizing the left half at its free angle,
with a tenaculum or forceps, extend the flap upon the spatula, and,
commencing at the nostril, cut through the lip, so as to make the
incision to its lower edge, in a slightly semicircular or bent direc-
tion, like an A jointed or bent outwards at the crosspiece, the
joint or angle being near but not quite in the centre, as proposed
by Dr. J. Ehea Barton, and also by Guerin 1 (Plate XX., Fig. 1).
1 Gazette MeMicale, June, 1844.
350 OPERATIVE SURGERY.
PLATE XX.
OPERATIONS PRACTISED ON THE LIPS AND MOUTH.
Fig. 1. A front view of a single Harelip with the lines of the inci-
sion for freshening the edges as advised by Dr. Rhea Barton. 1,1. The
Semi-elliptical incisions. Modified from Bernard and Huette.
Fig. 2. Operation of Mirault, of Angers, for single Harelip. 1. The
flap cut from one side. After BerDard and Huette.
Fig. 3. The same operation, showing the line of union and position of
the principal pin. After Bernard and Huette.
Fig. 4. Front view of a double Harelip, showing the septum or ante-
rior edge of the inter-maxillary bone, containing the two central incisor
teeth. After Bernard and Huette.
Fig. 5. Application of the single Harelip Suture to the case, shown
in Fi°\ 1. After Bernard and Huette.
Fig. 6. The union of the parts, after the operation of double Harelip,
when both sides are to be united at the same time. The risk of sloughing
of the central part from excessive inflammation or want of vitality, is an
objection to this mode of Operating. After Bernard and Huette.
Fig. 7. A contracted Mouth consequent on ulceration, showing Dief-
fenbach's operation. 1, 2. The integuments as left by the two incisions
which start from 3, the mucous membrane remaining untouched. 3.
Point for the introduction of the scissors. 4, 5. The lines of incision.
The ulceration has exposed the gums and teeth at the opposite corner of
the mouth. After Bernard and Huette.
Fig. 8. View of a Mouth, as contracted in consequence of an ulcer.
1, 2. The two points at which the sharp-pointed scissors were introduced
so as to divide the integuments on both the upper and lower lip, towards
the median line. The mucous membrane, being subsequently divided,
was reflected over the edges of the incision and fastened to the skin by
Several points of the interrupted suture. After Bernard and Huette.
Fig. 9. The appearance of Fig. 8 after the integuments have been re-
moved.
1. The mucous membrane untouched. This is to be divided in the
median line of the mouth, and reflected so as to form a rounded edge to
the new lips. After Bernard and Huette.
L_
*iJt*
SIMPLE HARELIP. 351
This edge of the lip being then seized by the assistant, the coronary-
artery may be compressed between the thumb and forefinger, so
as to check the bleeding.
The opposite half being now treated in the same manner, the
wound will exhibit two almost semi-elliptical cut surfaces, so ar-
ranged as to present their concavity towards the median line of the
fissure. (Plate XX., Fig. 1.)
Then, passing a ligature through the lower edge of each flap,
and drawing upon it, adjust accurately the angles of the incision
to the same level, and giving the ligature into the hand of an
assistant, so as to preserve their position, pass a sharp-pointed
steel or insect pin through the flaps from left to right, taking
care not to carry it through the mucous membrane. After sur-
rounding this pin with a twisted suture, next introduce a second
or even a third pin, and approximate the surfaces of the incision
well up into the nostril by other ligatures (Plate XX., Fig. 5),
when the ligature first introduced at the lower edge of the lip, and
which should have been held by the assistant during this time,
may be withdrawn.
Dressing. — After cleansing the lip, and cutting off the points
of the pins, the sutures should be firmly supported by strips
of adhesive plaster, slit so as to allow the ends of the pins to
pass through them, and extended from the front of one cheek
across the lip to the other cheek, in order to take the traction off
from the pins. Four days subsequently, the latter must be with-
drawn by a rotatory movement, without, if possible, disturbing
the ligatures or plaster, as may be readily accomplished either by
nicking the latter over the head of the pins, or by drawing them
through the slits made in the strips previous to their application.
On the fifth day, the cheeks being well supported by an assistant,
these strips may be removed, and new ones applied every three
days during the first week or two, until the union is accomplished.
Throughout, or at least until the sixth day, the child, if unweaned,
must be fed with a spoon, but after this it may be allowed to suck
with the plasters on. During the first twenty-four hours after the
operation, it is also especially necessary that the patient should be
watched, lest hemorrhage occur, and the blood, escaping into the
mouth, be carried into the stomach, without the bleeding being
suspected. If, however, the pins are inserted in the lip deeply
enough to pass behind the coronary arteries, the compression of
352 OPERATIVE SURGERY.
these vessels by the ligature will allow but little probability of he-
morrhage.
Remarks.— The advantages of the semi-elliptical incisions over
those which are straight, will be found in the absence of the notch
in the lip, usually consequent on the contraction of the wound, the
angular character of the incisions preventing the linear shortening
of the cicatrix. The value of the temporary ligature in the free
edge of the lip will also be found in the greater accuracy with
which the angles can be adjusted before inserting the first pin.
Mirault, of Arjgers, France, operates as follows : By a straight
incision he pares off one-half of the fissure (Plate XX., Fig. 2).
Then, incising the other portion (generally the left), he cuts it so as
to leave a pedicle of the membrane on the free edge of this flap,
which, being carried across the fissure and united to the opposite
half, prevents the formation of any notch or depression (Plate XX.,
Fig. 3).
Malgaigne, in order to avoid the notch on the free surface of
the lip, makes a curved incision from above downwards, so as to
pare off the mucous covering of the fissure, but without cutting it
free from the inferior angle or that continuous with the margin of
the lip. Leaving the portion thus pared off adherent, and depend-
ing by this pedicle, he unites the wound by pins and the twisted
suture. Then, trimming and shortening the pediculated portion
with the scissors until there is only a piece in each half long enough
to fill up the notch, he unites them on a level with the lip by a
small and fine pin. 1
Remarks. — Judging from personal observation, Harelip is a
very common complaint, it having occasionally happened to me
to have three patients under treatment at one time, and in one
winter at the Clinic of the University of Pennsylvania, ten were
treated in the course of six months. Out of the large number that
have been seen (I should think more than fifty), but two failures have
occurred, after pursuing the plan above stated, and in one of these
(double) the result was undoubtedly due to an attack of cholera
infantum, of which the child died. After the operation, as per-
formed by the scissors and the ordinary straight incision, I have
seen several (five?) failures. As respects the period for the opera-
tion, I have generally selected the earliest possible time, after the
1 Operative Surgery, hy Brittain, p. 334, Philadelphia edition.
SIMPLE HARELIP. 353
tissues seemed to be firm, usually soon after the third month of
infancy, and I have always deemed it necessary to continue the
adhesive strips a week after the removal of the pins.
Dr. J. Mason Warren, of Boston, as well as several other sur-
geons, also prefer an early period for their operations, but resort to
the interrupted suture in place of employing the harelip pins.
Dr. A. L. Peirson, of Salem, Massachusetts, has succeeded in
several cases, where he operated within the first twenty-four hours
after birth, and advocates 1 this early operation, as being especially
advantageous, from the tendency of the infant to sleep at this period.
M. Guersent, Surgeon of the Children's Hospital in Paris, has
also recently performed the same operation successfully on an in-
fant only one day old. 2
Dr. J. Mason Warren has permitted nursing during the process
of healing, in the case of an infant one month old, on whom he had
operated, and employed three sutures without inconvenience, it
being evident that there was no strain on the lip during the act of
sucking. 3
§ 2.— DOUBLE HARELIP.
In the variety of the disease known as Double Harelip, there is
usually a double fissure in the lip and palatine portions of the
mouth, together with a tubercle or intermediate structure resem-
bling and corresponding with the inter-maxillary bone of animals
(Plate XX., Fig. 4). The projecting extremity of this bone usually
contains either the germs of the incisor teeth, or the teeth them-
selves, according to the age of the patient, and is often a source of
difficulty, by causing the interruption of the circulation through
the middle flap.
Ordinary Operation. — If the central flap is to be preserved, it
should be first freed from its attachment to the gum, but with judg-
ment, lest its vitality be impaired from want of base. Then one of
its edges being freshened with the scalpel and wooden spatula, the
opposite half of the fissure should be freed from its attachment and
1 Bost. Med. and Surg. Journ., vol. xlvii. p. 134.
2 South. Med. and Surg. Journ., vol. vii. p. 641.
3 Amer. Journ. Med. Sciences, Oct. 1851.
23
354 OPERATIVE SURGERY.
also freshened, as in the operation just detailed; the remaining
portion of the operation being performed as in that for simple
fissure. After a few weeks, when the union is firm, the remaining
half of the lip may be operated on in a similar manner, or, if cir-
cumstances induce the surgeon to think it advisable, both sides may
be united at the same time by transfixing them with the pins, as
represented in Plate XX., Fig. 6.
Remarks. — Some surgeons prefer, in double harelip, the per-
formance of the operation on both sides of the fissure at the same
period, but, in my experience, this has seemed more liable to failure:
1st, because the stress upon the pins, or upon the newly-formed
cicatrices after their removal, is much greater when both sides are
thus operated on; arid 2d, from the inflammation or compression of
the middle flap by the ligatures being more apt to induce sloughing.
To operate first on one side and then repeat it on the other, will, it is
thought, in most instances, prove preferable. When the incisor teeth
project outwardly, it will generally be necessary to extract them, or
to cut oft' the inferior anterior extremity of the projecting inter-
maxillary bone before proceeding to the incision in the lips. But in
children, unless the portion of the alveolar processes to be removed
is limited, the germs of the permanent incisors will be entirely de-
stroyed. When the projection necessitates interference, I prefer
therefore the plan proposed by Blandin, of excising, with bone nip-
pers or strong scissors, a triangular piece of the septum, with its
base downwards, behind the alveolar processes, and then bending
or forcing back the projecting portion, as any attempt to push back
this end of the bone by bandages alone is very apt to induce such
inflammation in the soft parts as will necessitate their removal.
The fissure so often seen in the hard palate, in connection with
both simple and double harelip, may subsequently require an ope-
ration, though it will often be much diminished or cured, simply by
the contraction and constriction of the bones consequent on the
union of the fissure in the soft tissues of the lip, especially if the
patient is operated on at the early period mentioned. The treat-
ment of the fissure in the soft palate will be referred to under the
head of Staphyloraphy.
CANCER OF THE LIP. 355
§ 3. — CANCER OF THE LIP.
This affection may be seen either in the form of a scale or scab
of an epithelial character, as a shot-like tumor, as a larger indura-
tion, or as an extended ulcer. The treatment will, of course, vary
according to the character or development of the complaint. In the
simpler or epithelial variety, the protection of the surface from the
action of the air and the secretions of the mouth, will sometimes
enable the parts to heal, and prevent the increased deposit which
is so liable to ensue in a cancerous diathesis upon any increase
of circulation in the part. Among the articles employed for this
purpose, collodion seems to have been most frequently tried; but,
as it is not very thick, it is not easy to prevent its cracking in the
motions of the part. Dr. Dugas, of Georgia, 1 has lately recom-
mended a solution made by dropping small fragments of gutta
percha into a vial containing chloroform, until the solution acquires
the consistence of thick mucilage ; then with a camel-hair pencil
applying this solution to a sore, which, during eighteen months,
had resisted chloroform and many other applications, he found that
in less than a month it was well. When the surgeon is satisfied
that the removal of the tumor will retard the progress of the dis-
ease, he may excise it by an elliptical incision around its base, in
the same manner that he would remove a tumor in any other part
of the body ; but as these cancerous affections are apt to invade the
surrounding tissues, and the parts here involved possess much vital-
ity, he should be especially careful to cut away such an amount of
the adjacent sound parts as will insure the entire removal of the
complaint. As the best and simplest mode of operating, he may
proceed as follows: —
Ordinary Operation, — Make, either with the scissors or scalpel,
a V incision of such a size as is necessary for the entire removal of
the disease, with its base corresponding to the free margin of the
lip. If the scalpel is used, a wooden spatula should be placed so
as to support the portion cut, during the incision ; after which the
wound may be united as in harelip. From the great extensibility
of the cheeks, very considerable portions of the lips, and especially
of the lower one, may be removed without deformity ; and I have
1 New Orleans Monthly Medical Register, vol. ii. p. 7, 1852.
356 OPERATIVE SURGERY.
seen two patients, in each of whom I had removed a piece over one
inch in width at the base of the V, three years previously, for
cancer, and in both of whom it is difficult to see any deficiency.
Should the disease require the loss of more tissue than can be
supplied by approximating the sides of the incision, resort must be
had to the formation of a new lip, or to the operation of Cheilo-
plasty, as hereafter shown.
§ 4. — ENLARGEMENT OF THE MOUTH.
The operation of re-establishing the orifice of the mouth is one
that is occasionally rendered necessary in consequence of its con-
traction or closure from the cicatrices resulting from ulceration or
burns. Among the best plans of operating in these cases is the
very ingenious one of the late Professor Dieffenbach, of Berlin.
Dieffenbach's Operation. — Wishing to preserve enough of the
mucous membrane to cover the edge of the incisions required in
enlarging the mouth, Dieffenbach introduced into the patient's
mouth the forefinger of one hand, and sticking the point of one
blade of the sharp-pointed scissors into the cheek a line or two
beyond the point at which he wished to make the new angle of the
mouth, he transfixed all the tissues except the mucous membrane
(Plate XX., Fig. 8). On pushing the point forwards to the con-
tracted orifice, he was enabled to incise all this texture in the line
(3, 5) of the free edge of the lower of the new lips; then, reintro-
ducing the point of the scissors at its first place (3) of entrance, he
divided these textures also, with the exception of the mucous mem-
brane, in a line (3, 4) corresponding with the free edge of the
upper lip.
The triangular piece (3, 4, 5,) being then carefully dissected off
from the lining membrane of the mouth (1, 2), the latter was left
uninjured (Plate XX., Fig. 9).
On dividing this membrane in the middle, to within two lines of
the angle of the first incisions, it only remained to attach it neatly
by sutures to the bleeding surface in order to complete the mouth.
On two occasions I repeated this operation (Plate XX., Fig. 7)
with entire satisfaction; and many other surgeons, especially Dr.
Mutter, have reported similar instances of success. 1
1 Am. Journ. Med. Sciences, vol. xx. p. 342.
CHEILOPLASTY. 357
After union has taken place, the resemblance of the new mouth
to a normal one is often excellent.
§ O. — CHEILOPLASTY.
Plastic operations for the restoration of the lips may be required
in diseases of either of them, though it is most frequently demanded
in that of the lower lip. In either case, the operation is termed
Cheiloplasty. In the upper lip it may be performed by adapting a
flap taken from the arm to the deficient portion, as in the old Talia-
cotian operation ; but the greater facility afforded by approximating
the edges of the deficiency, as in the ordinary harelip operation,
renders this mode of operating a rare occurrence.
The Taliacotian operation has also been applied to the lower lip,
but there is as little to recommend it in this as in the former case,
and the loss of substance from cancerous degeneration or ulceration,
when so extensive as to require any plastic operation, may be more
readily supplied by either of the following methods: —
Operation of Dr. J. Pancoast, of Philadelphia. — In a case
of cancer of the lower lip, Dr. Pancoast excised the diseased margin
of the lip by an incision which entirely circumscribed it. A ver-
tical incision was then made in the middle line of the chin nearly
down to the level of the os hyoides, and crossed by a horizontal
cut over the base of the lower jaw-bone. The four angular flaps,
thus formed, being now dissected up from the jaw and the angles of
the crucial incision, or the ends of the flaps removed so as to leave
a lozenge-shaped space (Plate XXI., Fig. 3), the margins of the up-
per flaps were brought to the level of the angles of the mouth, and
united on the median line by the twisted suture, after which the
lower flaps were united, so as to cover the point of the chin. 1
Operation of Chopart. 2 — Chopart, in a case of cancer of the
lower lip, included all the diseased structure between two parallel
vertical incisions, which, commencing at the margin of the lip, ex-
tended down to near the os hyoides. These incisions formed a
square flap, which was dissected off from the chin from above down-
wards (Plate XXI., Fig. 4). The diseased portion being then cut
1 Pancoast's Operative Surgery, p. 35G, Phila. 1844.
* Bernard and Huette, p. 179.
358 OPERATIVE SURGERY.
PLATE XXI.
THE OPERATIONS OF CHEILOPLASTY AND GENIOPLASTT.
Fig. 1. A side view of Dr. Mutter's operation for the Formation of a
New Cheek. The edges of the ulcer which resulted from extreme sali-
vation were first freshened, the useless teeth extracted, and four flaps
formed by incisions in the course of the dotted lines so as to permit the
approximation of the edges of the flaps. After Mutter.
Fig. 2. A three-quarter view of Dr. Mott's operation for the relief of
Anchylosis of the Jaw dependent on Cicatrization of the Mouth, with the
restoration of a part of the Cheek. 1. The cicatrix arising from an ulcer.
This was entirely excised, leaving an opening in the cheek. 2. The tongue-
shaped flap, cut to fill up the opening by being rotated upon its base.
After Mott.
Fig. 3. A front view of the operation of Dr. Pancoast for the removal
of an extensive Cancer and the formation of a new Lower Lip. The
cancer is shown as circumscribed by a curvilinear cut. A vertical incision
in the median line of the chin, extended from the curvilinear cut nearly to
the os hyoides, and another which was horizontal and parallel to the base
of the lower jaw, formed four flaps. The angles of the flaps being removed,
the upper flaps, 1, 2, were raised to the proper level, and united by the
twisted suture on the median line, when the lower flaps, 3, 4, were also
united on the median line so as to cover the front of the chin. After Pancoast.
Fig. 4. A front view of Chopart's operation for the same object. 1, 5,
3, 6. The vertical incisions. 2, 4. The horizontal cut circumscribing the
disease. 2, 4, is to be raised to the level of 1, 3. Af ter Bernard and Huette.
Fig. 5. Operation of Lallemand for closing the gap left by the excision
of a Cancer which involved the angle of the Mouth and a portion of the
Cheek and Lower Lip. 1. The remaining portion of the lip, which is to
be drawn over to the angle of the mouth at 2. A flap formed of the in-
teguments of the neck having been dissected off, is shown as being par-
tially rotated on its base, and about to be carried up to cover the deficiency.
The wound on the neck may either be approximated at its edges, or left to
heal by the second intention. After Bourgeryand Jacob.
CHEILOPLASTY.
359
off by a horizontal incision, the head was slightly flexed and the
flap drawn up to the level of the angles of the mouth, where it was
maintained by several stitches placed in the line of the vertical
incisions.
When the preservation of a portion of the mucous membrane can
be accomplished, it will add much to the natural appearance of the
new lip.
Operation of Malgaigne. — This accomplished surgeon removes
all the diseased structure either by a v incision, or by two vertical
incisions, which, starting on each side of the cancer, reach to the
chin, and are there united by a horizontal cut, as in the upper inci-
sion of the operation of Chopart.
In the V incision, in consequence of the triangular wound, it is
necessary to prolong the angle of the mouth on each side by a trans-
verse cut, and to dissect the flaps so as to give them a triangular
shape. Then, drawing them forward, and uniting their vertical
edges by sutures upon the median line, it only remains to close the
horizontal incision, in order to obtain a proper fulness for the lip.
In the two vertical incisions, the gap being square, it is necessary
to make two horizontal cuts, by which the angles of the mouth may
be elongated. Then, making another horizontal cut parallel to the
base of the jaw, detach the two square flaps thus formed, and unite
them on the vertical or central line, as well as on the horizontal
incisions, when the cheeks will be made to contribute to a lip which
contains a portion of the orbicularis, as well as the lining membrane
of the mouth. 1 •
Dr. Pancoast, in a case of extensive loss of substance from the
explosion of gunpowder, also made a new lip by the following
process: —
Pancoast's Operation. — After removing the rounded edges of
the cicatrix in a V-shaped piece, he carried two curved incisions
from a point four lines above the apex of the V (which was on a
level with the lower surface of the inferior maxilla) in the direction
of the extremities of the os hyoides. Then, freely separating the
integuments from the bone and rotating the flaps a little upwards,
he drew them inwards, and united them to each other on the middle
line by two twisted sutures, closing the incision below the chin with
1 Malgaigne, Op. Surg., p. 340, Philad. edit.
360 OPERATIVE SURGERY.
adhesive strips. 1 Other instructive cases are reported in the same
paper, which is amply illustrated by wood-cuts.
Operation op Dr. Frank Hamilton, of Buffalo. 2 — A lad, 7
years old, having lost his lower lip and corresponding portion of
the jaw from salivation, mastication became difficult, and the saliva
poured upon his chin so as to induce excoriation of the face and
neck and wet his clothing. To remedy this, Dr. Hamilton, under
the impression "that by attaching the skin directly to the perios-
teum, its displacement by cicatrization and contraction would be
prevented," operated as follows : —
First Operation. — The upper edge of the skin corresponding to
the lower lip being first abraded to the extent of a quarter of an
inch each way, from the central line, a perpendicular cut of one inch
was made from either end of this horizontal abrasion. Then start-
ing from the lower end of each perpendicular cut, an incision was
made outward and downward to the left, and outward and down-
ward to the right, to the extent of one inch and a half.
The two lateral flaps, thus formed, being next dissected from the
jaw and slid upwards, were united by sutures above the central
piece and their inferior edges also stitched to the upper and abraded
edge of the central piece, so that by leaving the central piece at-
tached to the jaw and uniting the lateral flaps above it, the new lip
thus formed would be prevented from being drawn down again by
the contraction of the wound below. This proved to some extent
successful, though the new lip in process of time shrank to such an
extent as to become insufficient, and rendered another operation
necessary in order to increase the depth of the lower lip and enable
it more effectually to retain the saliva.
Second Operation. — A single incision being made just under
the chin, was extended along the base of the jaw about three inches
from side to side, and all the integuments between this horizontal
cut and the upper edge of the lower lip being raised from the bone,
the entire mass was slid up until its lower edge corresponded with
a line just below the upper border of the jaw when the edge of the
flap was made fast to the periosteum by several points of the inter-
rupted suture, the wound below being healed by granulation. The
result was, that no disposition was shown by the flap to draw down-
1 Amcr. Journ. Med. Sciences, vol. v. New Series, p. 106.
2 South. Med. and Surg. Journ., vol. vii. p. 742; from Buffalo Journal, 1851.
GENIOPLASTY. 361
wards as the wound cicatrized, but, on the contrary, the skin from
under the chin and neck was somewhat drawn upwards.
Remarks. — This operation presents evidence of considerable in-
genuity, and was rewarded by success, as the lad obtained sufficient
lower lip to cover the gums and a part of the bodies of a set of ar-
tificial teeth.
The idea of attaching the flap to the periosteum is, I believe,
altogether a new one, and is stated by Dr. Hamilton to have ori-
ginated in his observation of the capacity of the periosteum to form
new skin, a suggestion which may be usefully remembered in many
of the plastic operations demanded occasionally by the ulcerations
which follow on excessive salivation.
§ 6. — GENIOPLASTY.
The application of the principles of plastic surgery to the resto-
ration of deficiencies in the cheeks must, like the operations already
spoken of, depend upon the peculiarities of the case. The two in-
stances hereafter stated may, therefore, suffice as illustrations of
this class of operations.
In a patient of Dr. Mott's, of New York (see Plate XXI., Fig.
2), in addition to the loss of substance in the cheek consequent on
sphacelus during an attack of typhus fever, there was also some
false anchylosis of the jaw. To remedy this, he operated as fol-
lows: —
Mott's Operation. — An incision, commencing a little within
the upper angle of the mouth, was carried around the outer margin
of the cicatrix to a little within the lower angle of the under lip, so
as to remove all the newly-formed tissues within it. Then, after
overcoming the anchylosis, the lips were brought together at the
angle of the mouth by a suture, and a portion of integument suf-
ficiently large, and of a corresponding shape to replace the portion
removed, was taken from the side of the jaw and neck (Plate XXI.,
Fig. 2). This portion, being turned into the space it was intended
to fill, left a tongue three-quarters of an inch in breadth connected
with the adjacent parts, and sufficient for all the purposes of circu-
lation. The edges being then accurately adjusted by means of the
interrupted suture and adhesive strips, and the lower wound drawn
together as much as possible by adhesive plaster, the whole was
362 OPERATIVE SURGERY.
covered with lint, a compress, and bandage. On the eighth day,
adhesion appeared to have taken place at every point, when three
of the stitches were removed, and in about one month the patient
went home cured. 1
Dieffenbach, in cases where the sides of the ulcer could be at
all approximated by drawing upon the substance of the cheek,
freshened the edges of the opening and united them by sutures ;
then, in order to obviate the danger of separation of the wound
when the sutures were withdrawn, or when the cicatrix was
stretched, he made an incision across the base of the flap at the side
where the parts were most tense, and left this wound to heal by
granulation.
Operation of Dr. Mutter, of Philadelphia. — In order to re-
lieve a shocking deformity of the face, resulting from the sloughing
consequent on profuse salivation, Dr. Mutter operated as follows :
Having first extracted the useless teeth of the upper jaw, which
would have prevented the proper adjustment of the flaps, or in-
duced their ulceration, and freshened the edges of the ulcer, he de-
tached the integuments from the side of the jaw, so as to permit
some approximation of the wound. Two incisions above and below
the ulcer were then made so as to form four flaps (Plate XXL, Fig.
1), and these were united to each other in the line of the teeth, as
far forwards as the angle of the mouth. The edges of the remain-
ing ulcer, being partly approximated by the harelip suture, were
subsequently caused to cicatrize under the use of the nitrate of
silver. The result was entirely satisfactory. 2
§ 7. — REMOVAL OF TUMORS FROM THE CHEEKS.
From disease of the buccal glands and other causes, it sometimes
becomes necessary to remove tumors from the substance of the
cheeks. No other rules need here be given, in reference to ellipti-
cal or such other incisions as the case may call for, except two of a
general kind: 1st, to make them as much as possible in the line of
the zygomatici or levatores anguli oris muscles, so as to conceal
1 Amer. Journ. Med. Sciences, vol. ix. p. 47, 1831.
2 Lecture on the Operations in Surgery, by Robert Liston, with numerous addi-
tions, by Thomas D. Mutter, M. D. Philad. edit. p. 244.
SALIVARY FISTULA. 363
the cicatrix by bringing it into the direction of the natural folds of
the cheek ; and 2d, if the tumor is far back, or towards the angle
of the jaw, to guard against injury of the duct of Steno.
§ 8. — SALIVARY FISTULA.
As the position and general anatomy of the duct of Steno have
been already given (page 348), it is only necessary at present to
mention the operations resorted to, in cases where from wound or
ulceration, this duct has been opened and the saliva flows out upon
the cheek, so as to form a salivary fistula. Various plans have
been suggested for the relief of this defect, but the object of all of
them is the same, to wit: to close the orifice on the external side
of the cheek, and keep open that upon its inside. The nearer the
external opening can be made to approach the character of a
simple incised wound, the greater will be the chance of its closure;
and the following operation, of Dr. Horner, by reducing the parts
to this condition, has, both in his hands and my own, been followed
by perfect success. In two patients on whom I have operated,
the cure was readily accomplished, the external parts healing by
the first intention.
Operation of Dr. Horner, of Philadelphia. — The patient
being seated with the head well supported by an assistant, the ope-
rator introduces a strong broad wooden spatula within the cheek of
the affected side, where it should be firmly held by an assistant,
who also supports the patient's head. The wound being then
slightly elongated by incising its sides in the line of the zygomaticus
major muscle, a round punch, like that of the saddlers, should be
placed over the fistulous orifice, care being taken to avoid the ante-
rior edge of the masseter. Then, on pressing the punch firmly
against the spatula within the mouth, a piece of nearly the entire
thickness of the cheek will be removed, and a fresh opening made
directly into the mouth, when the external wound, being accurately
closed by sutures and adhesive strips, will usually heal kindly, and
the internal opening be found to give free vent to the saliva. The
punch must have a keen edge, and the cheek be well supported in-
side, in order to obtain a clean cut (Plate XXIV., Fig. 3).
364 OPERATIVE SURGERY.
SECTION III.
DIVISION OF THE MASSETER MUSCLE FOR IMMOBILITY OF THE LOWER
JAW (FALSE anchylosis).
This disease, which has been charged with being peculiarly an
American one, owing to its having frequently ensued upon the free
salivation at one time so common in certain sections of the United
States, was first treated of as a distinct affection by Dr. Mott, of
New York. 1 The operation for its relief is especially demanded in
those cases where the anchylosis is dependent on cicatrization or
contraction of the soft parts, and was first performed by Dr. J. W.
Schmidt, of New York, Oct. 1841. 2 Subsequently, Dr. J. Murray
Carnochan, of the same city, published an account of a similar
operation performed by him in 1840; but, as his publication was
after that of Dr. Schmidt, the latter has generally received the
credit of priority. In Dr. Schmidt's case, a young lady, in conse-
quence of rigidity of one of the masseter muscles, caused by an
extensively ulcerated throat from which she suffered when a child,
had not been able for more than twelve years to open her mouth so
that the end of the little finger could be inserted. After dilatation
and similar means had failed, Dr. Schmidt operated as follows: —
Operation of Dr. Schmidt, of New York. — A narrow bistoury
being passed through the mucous membrane of the mouth imme-
diately in front of the anterior edge of the masseter muscle, on a
line with the alveolar process of the lower jaw, the integuments of
the cheek were raised from the muscle with one hand, whilst with
the other the bistoury was passed over the masseter muscles be-
tween it and the integuments, but without cutting through the
latter, when the muscle being completely divided to the bone, the
mouth was immediately opened by a lever. Considerable hemor-
rhage followed, and some extravasation into the cellular substance
of the cheek, but this soon subsided, and the case succeeded per-
fectly. To prevent the union and subsequent contraction of the
muscle to its former condition, pieces of soft wood of a wedge-
1 Mott's Velpeau's Operative Surgery, vol. iii. p. 1139.
1 Published in the Amer. Journ. of Med. Sciences, p. 516, Oct. 1842.
DIVISION OF THE MASSETER MUSCLE. 365
shape were kept in the mouth during the night, and occasionally
during the day. 1
The danger likely to ensue from inattention to the anatomical
relations of this region will be readily foreseen by every anatomist,
or may be recognized by reference to Plate XXIV., Figs. 1, 2,
where the position of the vessels and of the salivary duct is shown
after the removal of the parotid gland.
Dr. Mott's Operation. — In seventeen cases of false anchylosis
of the jaw, reported by Dr. Mott, 2 forcible dilation was practised,
after, or, in some instances, without division of the contracted tis-
sues. To overcome the contraction and expand the jaws, Dr. Mott
employed only a screw and lever, similar to that of Heister, as de-
picted in the Armamentarium Chirurgicum of Scultetus, and also in
the Surgery of John Bell. The levers, being introduced between
the teeth, are gradually expanded by turning the screw.
An instrument suggested, and frequently employed by Dr. J.
Khea Barton (Plate XXIIL, Fig. 1), will also be found to furnish an
excellent means of relieving anchylosis. Its advantages over the
lever of Heister consist in the breadth of its plates, in their being
covered by a layer of caoutchouc, and in their affording a better
basis for the teeth, in consequence of which the latter are less liable
to injury.
Bemarks. — From personal experience, and from an examination
of the recent articles published by American surgeons, 3 I am satis-
fied that this complaint is comparatively common, and also that it is
frequently very difficult to eradicate. "When the result of extended
sloughing, or when of many months' standing, the prognosis should
be very guarded, as it is not uncommon to find more or less repro-
duction of the stiffness after the dilating means are discontinued.
In more recent cases — say of six months duration — the prognosis
will be more favorable. As the immobility, even when due to the
muscles in the first instance, generally results in more or less adhe-
sion of the condyles and glenoid cavities, it should be remembered
that it is more important to preserve slight and constant motion
of the jaw, so as to favor the synovial secretion, than to rely upon
great dilatation at an interval of several days. Frictions with
anodyne liniments, or the cold douche, applied by pouring water
from a small pitcher upon the indurated region, will do much
1 Ibid., loc. cit. 2 Mott's Velpeau, he. tit. 3 Bibliography, p. 71.
3t)6 OPERATIVE SURGERY.
towards facilitating the cure, as they will promote the absorption of
effused lymph, and favor an increased circulation through the mus-
cles of the part. My experience, therefore, leads me to place more
confidence in gradual dilatation, frictions, &c, as just stated, than
on subcutaneous or other incisions, as I have found the rigidity
very apt to return to a greater or less extent, as cicatrization goes
on, in consequence of the uniting medium being less extensible
than that consequent on the division of a tendon.
CHAPTEE XI.
OPERATIONS PRACTISED WITHIN THE MOUTH.
The operations that may be required in this region are those
dependent on diseases of the tongue, tonsils, and palate.
SECTION I.
ANATOMY.
The description of the anatomical relations of the parts within
the mouth may at present be confined to such portions of that
cavity as are found within the line of the teeth, and require there-
fore but brief notice.
The Tongue, being composed in a great measure of the genio-
hyo-glossus, hyo-glossus, and lingualis muscles, which connect it
both with the os hyoides and the lower jaw, is covered by a mucous
membrane, the reflection of which to the floor of the mouth consti-
tutes the Fraenum Linguae. The general arrangement of the fibres
of the genio-hyo-glossus, and their expansion from their origin into
the bulk of the tongue, may be understood by referring to Plate
XXII., Fig. 2.
The Lingual artery is the main source of the blood supplied to
the tongue. Coming from the external carotid, this artery pene-
trates the hyo-glossus muscle just above the os hyoides, and of course
lies too deep for any operation upon this organ except its extirpa-
ANATOMY. 367
tion (Plate XXII., Fig. 2). The sublingual branch of this vessel,
being more superficial, passes forward just above the sublingual
gland, near the median line of the tongue, between the mylo-hyoid
and genio-hyo-glossus muscles, to supply the floor of the mouth and
its lining membrane. Except in an attempt to extirpate the sub-
lingual gland, it is not much exposed to injury in operations upon
this part. The ranine artery and its accompanying vein are the
continuation of the lingual artery, and advance on each side of the
median line of the tongue directly to its tip, where there is an anas-
tomosis of the vessels of each side. The ranine veins are especially
superficial, and may be seen just beneath the mucous membrane on
turning up the tip of the tongue. They can, therefore, be readily
injured, and may give rise to trouble, especially in children. The
hypo-glossal nerve is shown in Plate XXII., Fig. 2, and requires no
further reference, as it is not proposed to treat of the various
wild operations that have been recommended for the cure of stam-
mering.
The Glands of the mouth at present demanding notice are the sub-
lingual, submaxillary, and the tonsil. The Sublingual gland, being
only covered by the mucous membrane of the mouth, may be readily
seen on turning up the tip of the tongue. Its duct or ducts open
into the mouth on either side of the fraenum below the tongue.
The duct of the Submaxillary gland (Plate XXIV., Fig. 1) terminates
by a small projecting orifice on the anterior margin of the frsenum.
The obstruction of this orifice gives rise to the disease termed ranula,
and consists in an accumulation of saliva within the duct, which, by
distending the latter, or by forming cysts, creates a tumor. The
saliva also sometimes deposits sabulous matter, and gives rise to
concretions which are usually situated in the duct itself.
The Tonsil glands (Plate XXIL, Fig. 1), in a healthy condition,
are six or eight lines long, four or five wide, 1 and about three thick.
They are situated within and between the half arches of the palate,
and concur in forming the isthmus of the fauces. Immediately
beneath or outside of the tonsils, or outside of the cavity, that is,
towards the skin of the neck, lies the carotid artery, with the vessels
found between the greater cornu of the os hyoides and the angle of
the lower jaw. The proximity of these vessels should be remem-
bered by the surgeon when using a bistoury upon these glands, as
1 Horner's Anatomy, vol. i. p. 569.
368 OPERATIVE SURGERY.
there is only a thickness of about three lines of tissue between them
and the artery; and a case is reported by Bdclard, in which the in-
ternal carotid was opened in an operation upon this region. 1
The Palate is composed of two portions— the hard or bony struc-
ture, formed by the palate plates of the palate and superior maxil-
lary bones, and the soft palate, which is composed of the mucous
membrane and the muscles. The soft palate stretches across the
back of the mouth from side to side, and obliquely downwards and
backwards from the posterior margin of the hard palate. Its infe-
rior free margin presents in its centre a projection (uvula) from a
half to three-quarters of an inch long in the healthy state.
The Uvula (Plate XXII., Fig. 1) is composed of the azygos uvula?
muscle, which, arising from the posterior pointed termination of the
middle palate suture, goes down into the uvula, but the point of the
muscle stops a half inch short of its inferior extremity. The free
end of the uvula is formed of loose cellular substance covered by
mucous membrane, and in catarrhal inflammation often becomes
cedematous, swollen, and elongated, so as occasionally to require
excision ; but this excision should never be extended to the muscle,
lest it impair the voice, and give it a nasal twang, from the patient's
inability to close the orifice of the posterior nares.
From each side of the uvula proceed two crescentic doublings of
the lining membrane, called the Half Arches, and designated as
anterior and posterior. Within or beneath these folds lie the mus-
cles of the part, some of which are important in connection with the
operations on this region.
The Constrictor Isthmii Faucium is within the anterior half arch,
arises from the soft palate near the base of the uvula, and is inserted
into the side of the tongue near its root. It will close the opening
between the mouth and pharynx.
The Palato-Pharyngius is within the duplicature forming the pos-
terior half arch; it arises near the base of the uvula, and is inserted
into the sides of the pharynx, and into the posterior margin of the
thyroid cartilage. It draws the soft palate downwards, or draws
the pharynx upwards.
The Tensor Palati arises from the spinous process of the sphenoid
bone; passes downwards ; winds around the hook of the internal
pterygoid process, and is inserted into the soft palate near its mid-
1 Blandin, Anat. Topographique.
CANCER OF THE TONGUE. 369
die, and into the posterior lunated edge of the palate bone. It
spreads out, or extends the palate.
The Levator Palati arises from the point of the petrous bone, and
passes downwards to be inserted into the soft palate. It draws the
soft palate upwards. 1
In the various operations for fissure of the palate, attention to the
action of these muscles is essential to a successful result. 2
SECTION II.
OPERATIONS UPON THE TONGUE AND THROAT.
The operations practised on the tongue and throat consist in such
as are required for the relief of cancer, ranula, or hypertrophy in
the tongue, together with those upon the uvula and tonsils.
§ 1. — CANCER OF THE TONGUE.
When the development of cancer in the tongue is of a limited
extent, and shows itself as a circumscribed tumor, its removal may
be accomplished either by the ligature or by excision.
Preliminary Measures. — In order to remove a cancerous tumor,
or before attempting any operation upon the tongue, the surgeon
will find it necessary to obtain entire control of the member, by in-
serting into its tip a tenaculum, a needle and ligature, or a pair of
hooked forceps; but the former is preferable, both on account of its
simplicity and efficiency. In order to employ it, direct the patient
to protrude the tongue, and spear the tip of the organ by rapidly
passing the point of the tenaculum through its structure, when its
motions may be perfectly controlled without creating any very
great suffering, and the hand of the assistant holding the instru-
ment will then have this unruly member entirely in its power.
Ligatures, either of silk or wire, may be resorted to for the
removal of cancerous tumors when the disease is slight. When the
silk ligature is employed, the base of the tumor should be trans-
fixed by a needle armed with a double ligature, and then, on dividing
1 Horner's Anat., vol. i. p. 490, eighth edition. 2 See Staphyloraphy.
24
370 OPERATIVE SURGERY.
PLATE XXII.
OPERATIONS PRACTISED ON THE TONGUE AND TONSILS.
Fig. 1. A front view of the anatomical relations of the parts about the
Fauces, as shown with the Mouth widely opened. 1. The dorsum of the
tongue as depressed within the teeth. 2, 3. The tonsils in sitd. 4. The
uvula. 5. The anterior half arch. 6. The posterior half arch, with the
tonsil between it and 5. 7. The soft palate. After Bernard and Huette.
Fig. 2. A side view of a vertical section of the Mouth and Tongue,
showing the anatomical relations of the Vessels and Nerves of the Tongue.
1. The lingual artery. 2. Its sublingual branch. The veins accompany
the arteries. 3. The hypoglossal nerve. 4. The ranine vessels as seen
near the tip Of the tongue. After Bernard and Huette.
Fig. 3. A front view of the Removal of the end of the Tongue as prac-
tised either for Cancer or Hypertrophy. 1, 2, 3. The lines of the V-shaped
incision. 4. A pair of tumor-shaped forceps (Plate I., Fig. 19) holding the
portion to be extirpated, and controlling the tongue until the vessels are
ligated. The incision should, therefore, not be carried entirely to 3, until
the hemorrhage is checked and the flaps partially united by the application
Of the first SUture. After Bernard and Huette.
Fig. 4. The operation of excising the tongue as shown in Fig. 3. 1.
Left hand grasping the flap of the right side. 2. The forceps holding the
tip. 3. The right hand of the Surgeon. After Bourgery and Jacob.
Fig. 5. The preceding operation as completed. 1, 2. The sutures ap-
proximating the two flaps. After Bernard and Huette.
Fig. 6. A three-quarter view of a Hypertrophied Tongue (Lingua Yi-
tula), as it existed in Dr. Harris's patient prior to the operation.
After Harris.
Fig. T. A vertical section of the Mouth and Pharynx, to show the
excision of the Tonsil by means of the probe-pointed. curved bistoury and
tumor-forceps. 1. The forceps holding the gland. 2. The bistoury in
the act of excising it. Modified from Bernard and Huette.
Fig. 8. A similar view of the parts in the Throat, showing the ampu-
tation of the Tonsil by Physick's instrument. 1. The right tonsil, as
excised and about to be removed in the instrument. 2. The Tonsilitome
of Phvsick. Modified from Bernard and Huette.
-£> - *V
HYPERTROPHY OF THE TONGUE. 371
this at its loop, each portion of the tumor may be strangulated by
tying the ends firmly around its base. As the tissue to be con-
stricted is extremely dense, it is requisite that the ligature should
be drawn very firmly, in order perfectly to strangulate the portion
included in the loop.
The Double Canula and Wire Ligature. — When the wire
ligature is employed, the double canula of Levret (Plate IV., Fig.
2) should be prepared as directed for polypus of the nose; the
motion of the tongue be perfectly controlled by the means just men-
tioned; a superficial circular incision made around the base of the
tumor; a tenaculum passed through the diseased structure so as to
elevate it from that portion of the organ in which it is deposited,
and then the loop of the wire passed over the tenaculum and carried
around the tumor in the incision first made. The wire being then
drawn as firmly as possible, should be fastened to the wing of the
canula, and the latter left wrapped with linen or tinfoil, protruding
at the angle of the mouth nearest to it until sloughing occurs, when
the instrument may be removed.
Extirpation. — Excision of these tumors may be accomplished
in this as in other cases, by elliptical incisions and dissection, the
anterior cuts being made first, in order to prevent the hemorrhage
from impairing vision. Subsequently, the wound should be closed
by one or more stitches of the interrupted suture.
In more extended cases of disease, amputation or excision of the
end of the tongue by a V-shaped incision (Plate XXII., Figs. 3, 4),
as mentioned under Hypertrophy, may be required.
§ 2. — HYPERTROPHY OF THE TONGUE.
Under the name of Lingua Vitula, authors have described an
enlargement of the body of the tongue, which sometimes has been
so great as to require the excision of the enlarged portion in order
to enable the patient to retract the tongue within the mouth. The
operation of Dr. Thomas Harris, of Philadelphia, in 1830, which was
the first performed in the United States, was of a marked character. 1
His second operation, in May, 1835, in which I assisted him, was of
a similar character, and sufficiently illustrates the ordinary pro-
ceeding in such cases.
1 See Bibliography, p. 76.
372 OPERATIVE SURGERY.
Amputation of the Tongue, by Dr. Harris.— The patient, aged
nineteen, had the tongue enlarged at birth. A short time previous
to the operation, it projected beyond the upper incisors three inches;
its circumference was six inches, and its vertical thickness one inch
and a half (Plate XXII., Fig. 6), and filled up the jaws so completely
that it was necessary to have his food cut into small pieces and in-
troduced at the side of the mouth.
Operation. — The tongue being elevated, a strong ligature was
i passed through its tip, so as to control its movements. The under
surface was then dissected from the floor of the mouth about three-
fourths of an inch behind the anterior part of the jaw, and a strong
straight bistoury introduced into the organ at the point where the
dissection terminated, whence it was pushed through between the
median line and the left ranine artery, and being drawn forward
and laterally, was made to cut a flap, which terminated near the first
bicuspid tooth. The left ranine artery being then secured with a
ligature, the bistoury was again introduced in a corresponding posi-
tion on the right side, and the opposite or right flap made in a
similar manner. The artery of this side being now secured, and
the central portion, or space intervening, divided by strong scissors,
the incisions or flaps resembled the letter V, and being approximated
by three interrupted sutures, made a pointed well-formed tongue of
the ordinary length. A year subsequently, the patient articulated
distinctly, and was relieved of all deformit}'. 1
Having had a favorable opportunity of witnessing this operation,
I could not but notice the great advantage possessed by the opera-
tor from the use of the ligature in the tongue in controlling the
motions of this organ; and as but one half of the structure was
incised at a time, the hemorrhage was readily controlled by the
immediate application of the ligature to the artery. The flaps were
then accurately adjusted by sutures without any difficulty.
In a previous case, June, 1829, the same surgeon applied a liga-
ture to the enlarged portion, in order to cause it to slough off, but
the irritation was so great that he was subsequently obliged to am-
putate the end of the tongue with a catlin. In this patient, the
tongue protruded beyond the teeth four inches ; its circumference
was six inches and three-fourths, and its vertical thickness one inch
and three-fourths. 2
1 Am. Journ. Med. Sciences, vol. xx. p. 16. » Ibid., vol. vii. p. 17.
EXCISION OF THE UVULA. 373
In a case, also congenital, operated on by Dr. H. S. Newman, of
Pennsylvania, the enlargement was very great, the portion ampu-
tated measuring in length two inches and three-fourths, circum-
ference seven inches and a half, thickness one inch and a half.' A
reference to the Bibliographical Index, p. 77, will also show the
record of the operations of Drs. Warren, of Boston, Mussey, of
Cincinnati, Wells, of Columbia, Hayward, of Boston, and Delaney,
of the Navy, for the same complaint.
The operations for the relief of tongue-tie, and also that for
ranula, will be found among those of minor surgery. 2
§ 3. — EXCISION OF THE UVULA.
When, in consequence of chronic inflammation, the mucous mem-
brane of the uvula becomes infiltrated so as to resist the action of
astringents, or when it and the azygos uvulae muscle become re-
laxed, the end of the uvula is apt to fall upon the edge of the glottis,
and produce a cough and irritation of the throat, accompanied by
profuse expectoration, and such other natural symptoms of phthisis
pulmonalis as have been mistaken for those of this complaint. The
effect of this state of the parts, and the mode of relief, were early
suggested by the late Dr. Physick, of Philadelphia, 3 who also reported
a special instrument for the amputation of the elongated portion.
Various other surgeons have since then proposed instruments which
they deemed advantageous, and calculated to accomplish their object ;
but it will be found that a pair of dressing forceps to seize the point
of the velum pendulum, and scissors or a bistoury to excise it, are
all that are necessary.
Ordinary Operation. — Seize the- end of the uvula by the forceps
held in the left hand, depressing the tongue with the joint of the
instrument, or by a spoon in the hands of an assistant. Then, with
a pair of scissors hooked at one end like those in Plate XXVI., Fig.
1, or curved on the flat, and held in the right hand, cut entirely
through the elongated part, removing the piece in the grasp of the
forceps. If the mucous membrane is not cut entirely through at
the first clip, or if it escapes from the grasp of the forceps, the frag-
1 Med. Recorder, vol. vii. p. 541. 2 See Smith's Minor Surgery, 3d edition,
3 Am. Journ. Med. Sciences, vol. i. p. 262, 1827.
374 OPERATIVE SURGERY.
merit will be apt to fall into the glottis and induce such violent-
coughing as will render its subsequent excision very difficult. Not
more than three-eighths of an inch should be excised, and it is of
great consequence to avoid amputating the muscle, as this will mate-
rially affect the voice, as before mentioned, and cause the individual
to speak in a nasal tone. All that is essential in a primary opera-
tion is to cut off the glove-like end of the mucous membrane, and
thus give vent to the serum that has elongated it. The subsequent
cicatrization will generally accomplish the cure. If it does not,
the probability is that the apparent elongation of the uvula will be
due to a relaxed condition of the soft palate, and be relieved by
stimulating applications, such as painting the parts occasionally
with a strong solution of the nitrate of silver, or with the tincture
of iodine or tincture of the chloride of iron.
After-Treatment. — Nothing more is requisite after this opera-
tion, than to gargle the throat several times a day with cold water,
and to guard against the use of hot, or highly seasoned, or salt food.
Should there be any hemorrhage of consequence, touching the end
of the stump with the nitrate of silver will generally arrest it.
§ 4. — EXCISION OF THE TONSILS.
Chronic inflammation of the tonsils, or repeated attacks of quinsy,
sometimes cause such effusions of lymph into the parenchymatous
structure of these glands as results in induration and permanent
enlargement, or in the condition sometimes, though improperly,
designated as scirrhus. The continuance of this enlargement being
a constant source of irritation, such patients are liable to inflamma-
tion of the throat on the slightest change of temperature.
To relieve this sensibility, after the failure of other means, an
operation for their removal may become necessary.
Operation of Dr. Physick. — In order to accomplish this object
without any risk of hemorrhage, Dr. Physick proposed, and prac-
tised for some years, the removal of these glands by sloughing,
induced by strangulating them with the double canula and wire
ligature before referred to. 1 But, in consequence of the pain and
inflammation which sometimes ensued, this operation has justly
1 See Polypi in the Nostril, p. 345.
EXCISION OF THE TONSILS. 375
been supplanted by that of excision. Various instruments have
been recommended by different surgeons for this purpose, and for
a list of those suggested by surgeons in the United States the reader
is referred to the Bibliographical Index, at the commencement of
the volume. 1 At present, one of two instruments is most fre-
quently resorted to in this country, viz., that of Dr. Physick,
slightly modified by Schiveley (Plate XXYL, Fig. 3), and that of
Dr. Fahnestock.
The instrument of Dr. Physick consists of a ring, which sur-
rounds the part to be excised, and of a triangular-shaped knife,
which, sliding in the ring, guillotines the gland.
Dr. Fahnestock's instrument is also formed of a ring, but his
knife is of a circular shape, and excises the tonsil by drawing it
towards the operator. This instrument has justly been objected to,
by many who have employed it, from the difficulty of giving a
good edge to a circular blade, and also from its tendency to cut by
pulling upon the gland rather than by dividing it with the clean
incision of a knife. That of Dr. Physick, as modified by Schiveley,
having none of these defects, and having its cutting edge of such a
shape as will enable the surgeon to preserve or renew it himself, is
preferred by others, and has much to recommend it. M. Velpeau
prefers the instrument of Fahnestock, but has modified it to some
extent ; and I have lately seen a further modification by Charriere,
in which the knife is only half a ring, and made to cut like a curved
bistoury. This is, however, nothing new, a similarly-shaped knife
having been suggested and used by Drs. Eogers and Cox, of New
York, nearly twenty years since. 2
Physick's Operation of Excision. — The patient being seated
before a strong light, the head supported against the breast of an
assistant, and the thumb of the latter made to press on the external
parts just behind the angle of the jaw, so as to render the tonsil
prominent in the throat, and force it from between the half arches,
the surgeon should introduce the instrument flat upon the tongue,
pass it rapidly back to the fauces, turn it on its side, so as to place
the tonsil in its ring, transfix it with the needle attached to the
instrument, and, pushing the knife backwards, shave off all the
portion included in the ring by a movement similar to that of a
guillotine. Then removing the instrument, the excised portion will
1 See Bibliography, p. 78. 2 Ibid.
376 OPERATIVE SURGERY.
be brought out with it in less time than it takes to describe the
steps of the operation (Plate XXII., Fig. 8).
Should this instrument not be at hand, a probe-pointed bistoury
and dressing forceps may be made to answer by a skilful manipu-
lator (Plate XXII., Fig. 7), but the proximity of the carotid artery
to the outer wall of the pharynx at the seat of the tonsil, should
induce the surgeon to be cautious, lest he open it by prolonging
his incision to too great a depth.
After-Treatment. — The only after-treatment that is requisite
is that referred to in excision of the uvula.
Remarks. — The simplicity of the operation of amputating the
tonsil, as performed by the Tonsilitome, is such that it is difficult,
at the present time, to realize the anxiety and discussions of the
surgeons of the period when amputation of the tonsil was first sug-
gested. The fear of hemorrhage, which was so generally entertained
at that period, is now seldom noticed, and out of very many cases
upon which I have operated, I can only recall one in which there
was sufficient bleeding to demand attention, and this yielded readily
to the application of a strong solution of the nitrate of silver. When
a tonsil has been indurated for many months, the effused lymph
will cause such a constriction of the bloodvessels in the structure
of the gland as will diminish their caliber, the limited space in
which the tonsil is placed, not permitting any marked distension
of the structure, except in the line of the thickening of the gland.
It may, however, prove useful to state that under no circumstances
is it safe to attempt the excision of a portion of the tonsil, when
its structure is acutely inflamed, as the hemorrhage will then be
very free.
CHAPTER XII.
RESECTION OF THE BONES OF THE FACE.
The sawing and removal of a portion of any bone having long
been designated by surgeons as a Resection, and being also gene-
rally understood to mean the cutting or paring off of any part, 1 it
1 Webster's Dictionary.
ANATOMY. 377
does not seem necessary to change the word Eesection to that of
Exsection, as has lately been suggested, 1 under the erroneous idea
that the term resection means the repetition of a section. As the
old nomenclature is entirely correct, the introduction of a new term
has nothing to recommend it, and in the subsequent remarks on
the operations on the bones, the word "Eesection" will be employed,
as it has heretofore been almost universally used, to wit, to desig-
nate the section of any portion of a bone, whether performed on
the first or any subsequent occasion.
SECTION I.
ANATOMY.
The Superior Maxillary bone articulates with the frontal, nasal,
and unguiform bones; in front with the os frontis and nasal by its
nasal process, by means of a firm regular suture; with the ungui-
form and ethmoid in the orbit of the eye by simple apposition, and
with the malar bone at its anterior external angle by a firm suture.
To the pterygoid process of the sphenoid bone at its posterior infe-
rior portion ; to its fellow of the opposite side ; to the vomer in the
middle line of the mouth, and to the palate bones in the same line
posteriori}' - , it is also joined by more or less close adhesions.
The Inferior Maxilla forms the lower outline of the face extend-
ing entirely around it from ear to ear. It articulates with the
glenoid cavity of the temporal bone just in advance of the external
meatus of the ear by means of its condyloid process. This process
is a transverse cylindrical ridge directed inwards and slightly back-
wards, and springs from the ramus of the jaw by a narrow neck.
The coronoid process is seated in advance of it, and has the temporal
muscle inserted into its point. It is important to notice that both
processes are apt to be much enlarged by the tumors or malignant
deposits, which sometimes require the resection of the jaw.
The Masseter Muscle, arising from the parts about the zygoma, is
inserted into the base of the jaw at its angle. The Muscles forming
the floor of the mouth are also attached along the base of the jaw
on the inner side of the bone, and it is by this attachment that the
tongue mainly maintains its position in advance of the glottis.
1 Mott's Velpeau, by Townsend.
378 OPERATIVE SURGERY.
PLATE XXIII.
INSTRUMENTS EMPLOYED ON THE JAWS AND EAR.
Fig. 1. A three-quarter view of Barton's Dilator for expanding the
Jaws, in eases of False Anchylosis. Sohivetey'a Pattern.
Fig. 2. A view of the Dilator of Jno. Bell, of England. The screw
causes the blades to separate. Le '
Fig. 3. A strong Scalpel, with a Raspatory at one end of the handle,
applicable to all bone operations. Schiveley's Pattern.
Figs. 4, 5. Strong double-edged curved Scalpels for the same purpose.
Schiveley's Pattern.
Figs. 6, T. Strong Knives or Scrapers for excising Carious or other
diseased Bones. Charriere's Pattern.
Fig. 8. A pair of Hawk-bill Scissors, useful in dividing the middle
palate suture in Resection of the Upper Jaw. The probe-pointed end is
to be passed into the nostril and the other blade made to cut from the
mouth upwards. This instrument is similar to that used by gardeners for
lopping trees, and is the best kind of bone-nippers I ever employed.
Schiveley's Pattern.
Fig. 9. Horner's Triangular Yertical-Bladed Knife for dividing the
transverse portion of the palate in Resection of the Upper Jaw.
Schiveley's Pattern.
Fig. 10. Itard's Ear Speculum. After Bernard and Huette.
Fig. 11. Bonafond's Ear Speculum. "
Fig. 12. Itard's Catheter for the Eustachian Tube. "
Fig. 13. Blanchet's
Fig. 14. Dupuytren's Forceps for Aural Polypi. "
Fig. 15. Fabrizj's Forceps for the removal of
Foreign Bodies from the Ear. "
Fig. 16. A Curette for the same purpose. "
Fig. IT. Horner's Knife for perforating. the Membrana Tympani.
Schiveley's Pattern.
Figs. 18, 19. Deleau's Instrument for perforating the Tympanum. In
one the perforator is concealed, in the other protruded from its sheath.
Charriere's Pattern.
Fig. 20. Homer's Syringe for washing out either the external or middle
Ear either with air or water. Schiveley's Pattern.
Fig. 21. The Nozzle of Fig. 20 passed through a cork, so as to plug
up the external meatus when injecting the middle ear. From the instrument.
Fig. 22. A Caoutchouc Bottle for washing out the Ear.
Charriere's Pattern.
Fig. 23. Horner's Portable Air-Chamber for Injecting the Ear. 1.
The air-pump. 2. The tin chamber. 3. A cock which keeps the air in
the chamber when charged. The opening of this tube being applied to the
catheter and the cock turned, the current of air will pass, as regulated by
the COCk. From the Instrument.
FiS 18
RESECTION OF THE UPPER JAW BONE. 379
When these attachments are divided, the tongue may be drawn in
upon the glottis, and induce suffocation unless artificial means are
employed to prevent it, though it is not always the case, the con-
nection of the sterno-hyoid muscles with the hyoid bone having
a tendency to counteract the action of the styloid muscles, which
are those that mainly induce it.* The Carotid artery, in its con-
nections with the parotid gland, is found near the angle of the jaw,
but, by drawing the bone well forwards and downwards, this artery
will be separated to some extent from the bone, in consequence
of the posterior adhesions of the parotid.
SECTION II.
OPERATIONS UPON THE JAW BONES.
§ 1. — RESECTION OF THE UPPER JAW BONE.
The development in the bones of the face of tumors of a malig-
nant character, and their encroachment on the surrounding struc-
tures, has sometimes created such a condition as has rendered it
desirable to remove either a portion, or the entire structure of the
bones which constitute the basis of this region. As the jaw bones
are generally deemed to be essential to speech as well as mastica-
tion, it would appear, at first sight, as if their removal would neces-
sarily impair the nutrition, and also the usefulness of the patient,
whilst their close proximity to large bloodvessels and important
nerves, indicates the necessity of great caution in any extended
operations that might be practised upon them. Such appears to
have been the views formerly entertained by surgeons, respecting
the practicability of resorting to resections of these bones entire ;
and we accordingly find that the earlier operations were either of
a limited character, or only performed after every possible precau-
tion had been taken to guard against hemorrhage, either by pre-
paring cauterizing irons, or by ligating the main trunk of the
carotids previous to the operation. The condition of patients who
had suffered from extensive gunshot wounds of this region, having
shown, however, that a much greater amount of the face could be
removed without loss of life than had been supposed, surgeons
gradually extended their efforts to relieve the diseases of these
380 OPERATIVE SURGERY.
parts until they have at last succeeded in removing the entire
upper jaw of each side, and taken away all the lower jaw from its
articulations forward.
In reviewing the records of these operations, we find that Acolu-
thus, a surgeon of Breslau, first removed a portion of the upper
jaw for a tumor, he having operated as early as 1693; that Jourdan
also removed a part of the antrum Highmorianum for the relief of
a tumor in May 1768, and that Dupuytren resected a considerable
portion of the alveolar cavities of the bone in 1819. These opera-
tions, though among the earliest of those recorded, did not reach
the extent of a resection of either the entire body, or even half of
the bone ; and it may, therefore, be justly said that the most exten-
sive and daring resection of either of the bones of the jaws were
first performed by American surgeons; that of Dr. Jameson, of
Baltimore, upon the upper jaw, having been executed in 1820,' and
that of Dr. Deaderick, of Kentucky, 2 upon the lower jaw, per-
formed in 1810.
One of these operations (Deaderick's) was also performed nearly
ten years prior to the operation of Dupuytren, whilst the other
(Jameson's) was so near the same period as to leave no time for any
communication of the event to this country. I have, therefore,
no hesitation in claiming for American surgeons the credit of
having been the first to illustrate the feasibility of these extensive
resections.
The first resection practised upon the bones constituting the
upper jaw, was performed in the United States for the removal
of a tumor from the antrum by Dr. Horatio G. Jameson, in
November, 1820. 3 From an inspection of the drawing which
accompanied this case, as well as from its history, it is evident that
this resection embraced nearly the entire body of one superior
maxilla, although the roof of the antrum, or floor of the orbit,
which was not diseased, was allowed to remain.
The operation of resecting the superior maxillary bone of one
side having been thus commenced, the resection was soon after
(1824) carried yet further by Dr. David L. Kogers, of New York,
who successfully removed nearly the entire upper jaw, that is,
both superior maxilla? as far back as the posterior external por-
tion adjacent to the pterygoid processes. 1 Mr. Lizars, who was the
1 Am. Med. Record, vol. iv. p. 222, 1820. * Ibid., vol. vi. p. 51 G, 1823.
3 Ibid., vol. iv. p. 222, 1820. « Bibliography, p. 70.
RESECTION OF THE UPPER JAW BONE. 381
earliest of the British surgeons that resorted to this resection, did
not operate until 1827, and Gensoul, of France, whose subsequent
proceedings have so intimately associated his name with the opera-
tion, did not attempt it until about the same year. Since 1827, the
operation has been very frequently performed in the United States
— Dr. A. H. Stevens, of New York, in 1840, having successfully
extirpated the entire superior maxillary and malar bones with
portions of the ethmoid and sphenoid of one side ; Drs. K. D. Mus-
sey, of Cincinnati, and John C. Warren, of Boston, having also suc-
cessfully removed the upper jaw in 1842, and Gross, of Kentucky,
doing the same in 1843. A reference to the Bibliography 1 will
also show that since this period, many other American surgeons
have been equally successful; so that this once doubtful operation,
may be now considered as permanently established. The result
of the operation, as shown by an analysis of many of those per-
formed in Europe since 1820, also indicates that an equally suc-
cessful result has been obtained elsewhere, Eied 2 (Die Eesectionem
der Knochen) having collected thirty-five cases, in twenty-four of
which the patients were reported as cured — meaning, probably,
cured as to the operation, though not preserved from a return of
the disease when the tumor was malignant.
As characteristic of the method usually pursued in this opera-
tion, the following one, performed by Dr. Warren, may be first re-
ferred to: —
Operation of Dr. Warren.— The patient being seated with
his head well supported, an incision was made through the cheek
down to the bone, from the middle of the external edge of the left
orbit, to the left angle of the mouth, and was followed by a copious
gush of blood. The internal or nasal flap being then quickly dis-
sected forwards to the middle of the nose, the attachment of the
cartilage of the left alas of the nose was cut off, thus freeing the
eyeball from the inferior part of the orbit, by dividing the inferior
oblique muscle, the fascia of the eye, and the periosteum. The outer
or lower flap was next rapidly dissected from the os mala? and supe-
rior maxilla, and around the latter bone as far as its union with the
pterygoid process of the sphenoid ; but the uniting space was not
penetrated at this time, on account of the large pterygoid branch of
the internal maxillary, which it would have been difficult to secure
at this stage of the operation.
1 Bibliography, p. 70. « Med. Examiner, vol. ix. p. 595.
S82 OPERATIVE SURGERY.
PLATE XXIV.
A VIEW OF THE ANATOMY OF THE SIDE OF THE FACE, AND OF SOME
OF THE OPERATIONS PRACTISED ON IT.
Fig. 1. A side view of the Anatomy of the Face after the removal of
the integuments. 1. The shape and position of the parotid gland. 2.
The duct of Steno. 3. The sublingual gland. 4. The facial artery, at
the point where it passes on to the face. 5. The facial vein. 6. The
sterno-cleido-mastoid muscle. 7. The external jugular vein. 8. The
zygomatic muscle. 9. Branches of the portio dura nerve emerging from
the upper edge of the parotid; other branches are seen on the face.
After Bernard and Huette.
Fig. 2. The same Section after the removal of the Parotid Gland. 1.
The portio dura nerve at its exit from the stylo-mastoid foramen. 2.
The duct of Steno divided transversely. 3. The external carotid artery
when freed from the parotid. 4. The temporal artery. 5. The facial
artery after removal of the sublingual gland. 6. The sterno-cleido mus-
cle. 7. Main trunk of the external jugular vein. After Bernard and Huette.
Fig. 3. A three-quarter view of Horner's operation for the cure of Sa-
livary Fistula. A wooden spatula supports the inside of the cheek ; a
slight longitudinal incision is made at the external fistulous orifice, and
the hand of the surgeon is seen pressing the punch against the spatula so
as to cut out a piece through the cheek. The external incision, being
closed by a point of a suture, heals usually by the first intention, leaving
the orifice, made by the punch, open in the mouth.
Drawn from Nature.
Fig. 4. A view of the operation of Resection of the Upper Jaw, as
practised by the incision of Dr. Warren. 1, 2, 3. The flaps everted, and
turned over the nose and eye so as to expose the bone. The left hand of
the surgeon is holding, 4, the bone at the moment of disarticulation by the
knife, 5, which is working at the pterygo-maxillary fissure. Velpeau's
operation is nearly the same as that of Dr. Warren.
After Bernard and Huette.
Fig. 5. Represents the completion of the operation, the union of the
wound by the twisted suture, and the line of the cicatrix, which extends
from the malar bone to the mouth near, but not at the angle.
After Bernard and Huette.
Fig. 6. A view of the termination of Gensoul's operation, showing the
lines of his incision. 1, 2. The first incision across the tumor. 3 4
The second incision. 1, 5. The third incision, forming flaps which are
to be turned up and down upon the face. The sutures are seen as placed
at the termination of the operation. After Gensoui.
tm
RESECTION OF THE UPPER JAW BONE. 383
The two flaps being separated, the anterior extremity of the
spheno-maxillary fissure was perforated, and the cutting forceps
applied to the broadest part of the os malae directly opposite to the
perforation, by which it was smoothly divided in a few seconds.
The same instrument was then applied at the internal angle of
the eye in an oblique direction from the lower edge of the orbit, to
the lower termination of the os nasi, and the bone divided without
difficulty.
In the mean time, the blood flowed in torrents ; one large artery
required immediate ligature, but the bleeding of the others was
controlled by compression of the carotid artery. The mouth of the
patient filling with blood, frequent pauses were required to afford
him an opportunity of ejecting it, and occasionally he was recruited
with a little wine.
The most difficult part of the operation remained, that of dividing
the sound from the diseased parts within the mouth, and separating
the maxillary from the sphenoid and palate bones without injuring
the latter, so as to leave the patient the whole of the soft palate, with
the palatine plate of the os palati to support it.
In order to accomplish this without dissection, an incision was
made through the mucous membrane of the hard palate, beginning
at the edge of the palatine plate of the os palati, and extending
forwards to the front edge of the jaw, and then upwards across the
alveoli into the bone. To facilitate this incision, the central incisor
within the left side was extracted so as to break the anterior part of
the alveolus. Then, by a single stroke of the cutting forceps, the
upper maxillary was separated from its fellow, and its palate plate
cut through as far as its junction with the os palati. In order to
separate the palatine plates of the maxillary and palate bones, the
forefinger of the left hand was passed into .the mouth to the last
molar tooth, and its pulp turned forwards to receive and support
the cutting instruments, the flow of blood preventing anything
being seen. A strong pointed knife was then stuck through the
hard palate at the union of the maxillary and palate bones, so as to
separate them, and also free the maxillary from the pterygoid pro-
cess of the sphenoid, thus accomplishing the disunion of all the
bones concerned.
Finally, the knife was passed externally behind the upper maxil-
lary bone into the space between this and the pterygoid process, and
seizing the bone with the left hand by its orbitar and alveolar por-
384 OPERATIVE SURGERY.
tions, it was, by a gradual movement, started from its situation (Plate
XXIV., Fig. 4), and, aided by a few touches of the knife, freed from
its remaining periosteal attachments. The hemorrhage was arrested
by ligatures and lint. Eight weeks afterwards, the patient went
home, and three months from that time continued well. 1
Dr. William E. Horner, in a case of scirrhus of the antrum,
succeeded in removing the whole of the upper jaw without any
external incision, thus saving the patient the scar in the face. The
removal of a considerable portion of the same bone was also suc-
cessfully performed by Dr. A. H. Stevens, of New York, in 1823,
and published in the New York Journal of Medicine and Surgery for
1849. The publication of the case having been delayed for several
years, from motives of delicacy to the patient, who was widely
known, Dr. Stevens has not received that general credit to which
his ingenuity entitled him. Dr. Horner was ignorant of Dr. Ste-
vens's success at the time of his operation.
Kemoval of the Superior Maxillary Bone without any
external Incision in the Cheek. — Dr. Horner having deter-
mined to avoid cutting through the cheek, as commonly practised,
the patient was seated in a chair, with his head well supported, and
partially etherized. The assistant, supporting the patient's head,
then raised the angle of the mouth on the left side, and held it
widely open, whilst the upper lip and cheek were dissected from
the superior maxilla as far back as possible, in a line parallel with
the superior margin of the buccinator muscle. The two incisor
teeth on the left side being then drawn, the corresponding alveoli
were cut through in the middle line by a narrow saw (Plate V., Fig.
7), which worked its way from the mouth into the left nostril ; then
a pair of strong hawk-bill scissors (Plate XXIII., Fig. 8), such as are
used by gardeners for lopping off twigs, took out the two vacated
alveoli at a clip.
A thin, flat, well-tempered knife, with a strong round handle
(Plate XXIII., Fig. 5), was now struck through the roof of the mouth
into the nose, at the junction of the palatine processes of the palate
and superior maxillary bones (posterior middle palate suture), so as
to cut forwards and separate the maxillary bones from each other
in the middle. AVhen the narrow saw was again used to cut
through the root of the nasal process of the maxillary bone, and
' Boston Med. and Surg. Journ., vol. xxvi. p. 9, 1842.
RESECTION OF THE UPPER JAW BONE. 385
strong scissors, curved on the flat, made to cut through the orbitar
plate at its margin, the incision being carried back to the pterygoid
process of the sphenoid, around and below the malar bone.
The base of the soft palate being then detached by a short trian-
gular knife (Plate XXIII., Fig. 9), curved on 'the flat, so as to leave
the soft palate attached to the palate bone, a few touches of the
knife freed the remaining attachments.
The pterygoid process, malar bone, and the orbitar plate of the
upper maxillary were, however, not disturbed, but left. The tumor,
besides its bony connection, was also attached to the posterior part
of the cheek, and to the external pterygoid muscle. The gouge and
scissors, however, sufficed to remove every part that could be detected.
The bleeding was profuse, especially from what was believed to
be the posterior palatine artery ; but the vessel was readily secured
by means of a ligature and Physick's needle; and a few other liga-
tures, with charpie, arrested the remainder of the hemorrhage. The
drawing (Plate XXV., Fig. 1) shows the appearance of the mouth,
immediately after the removal of the bone, though representing it
on the right instead of the left side of the face, in consequence of
its being daguerreotyped, this peculiarity having been overlooked
by the engraver. The amount of the jaw which was removed in
this operation is accurately shown in Plate XXV., Fig. 2.
The additional time required for this mode of operating is pro-
bably fifteen or twenty minutes; but it saves the patient a scar for
life. 1
Three years afterwards, the patient presented no appearance of
the return of the tumor; and his daguerreotype (Plate XXV., Fig.
3) shows the small amount of deformity. I have recently seen
this gentleman, and he is now 2 engaged in the study of medicine,
and in the enjoyment of excellent health.
Dr. Stevens, of New York, in August, 1823, extirpated a fungus
from the antrum maxillare, and removed a considerable portion of
the bone, also, without any external incision.
Operation of Dr. Stevens, of New York. — The second incisor
and the last molar tooth but one, being first extracted, the upper lip
was dissected off from the jaw as high as the infra-orbitar foramen.
The bone being then bored through by means of a trocar, which was
carried backwards and downwards till it perforated the palatine
« Med. Examiner, No. 1, p. 16, 1850. 2 1854.
25
386 OPERATIVE SURGERY.
membrane near the junction of the left os palati with the palatine
process of the left superior maxilla, the palatine membrane was
incised from this point to the external edge of the first left incisor
tooth. The palatine process of the superior maxilla was next
divided by a saw, withits teeth directed downwards, passed through
the route made by the trocar; and the bone, both above and below,
between the socket of the last molar tooth and the perforations of
the trocar, was also divided by a fine flexible saw, seven inches
long, made of watch-spring, and having teeth only in its middle for
the extent of three inches, the division being made in the direction
of a curved line, which extended from the point where the trocar
first entered to the alveolar cavity of the molar tooth extracted.
No bad symptom followed, and in six months the opening in the
antrum was completely closed.
The patient, seven years subsequently, was in perfect health. 1
Dr. Mott, in an operation for a large polypus of the nose, was
compelled to make a partial section of the upper jaw, by an incision
through the integuments from below the internal canthus, down the
side of the nose, and through the upper lip about three lines from
the angle of the mouth. Then, dissecting back the two flaps thus
made, he divided the necessary portion of the bone with a saw. 2
Eemarks. — It will be found to be a matter of some consequence,
in these resections of the upper jaw, to leave the os unguis and the
superior extremity of the nasal process of the superior maxillary
bone untouched, in order to preserve the lachrymal sac from injury.
"When attention is not given to the preservation of this sac and its
duct, the patient will be liable to a constant cedematous condition of
the lower lid, and suffer also from stillicidium lachrymae. If the
orbitar plate can also be left, it will diminish the deformity.
In tumors requiring the entire amputation of the jaw, the incision
of Dr. Mott will be found to expose the bone freely, and may be
advantageously resorted to; and in the case of a very large tumor,
whose removal would be impracticable by the plan of Dr. Horner,
this incision would probably open the parts sufficiently, and yet
create a scar that would hardly be noticed. 3
In a valuable paper by Dr. Gross, of Louisville, 4 will be found
i Velpeau's Surgical Anatomy. Appendix, by John W. Sterling, M. D., vol. ii. p.
518, New York, 1830.
2 Velpeau's Surgery, by Mott, p. 907. 3 See Bibliography, p. 70.
* Western Journ. Med. and Surg., vol. x. 3d series, p. 185. On Excision of the
Superior Maxillary Bone, illustrated by Seven Cases.
RESECTION OF THE UPPER JAW BONE. 387
some practical remarks on various points connected with this ope-
ration, which may now be advantageously referred to in connection
with the different methods of operating.
Position of the Patient. — Dr. Gross prefers that the patient
should be placed in the recumbent position, with a broad and rather
thin pillow under the head and shoulders, and with the face inclined
to the sound side.
Anaesthesia. — Anaesthetics he considers decidedly useful, and
has seen no reason for apprehension in consequence of the flow of
blood into the mouth when employing them in operations upon
this region. He also expresses his satisfaction with their use in
every kind of operations upon the mouth that has come under his
observation, especially when, as in resections of the jaw, proper
care is taken to compress the vessels as soon as they are divided.
Hemorrhage. — In no instance, either in the upper or lower jaw,
has he found it necessary to secure the carotid artery, or even com-
press it, the chief danger being from the subcutaneous arteries
rather than from the larger trunks. In operating for resection
of the bones of the face, he rarely stops to tie a vessel, as expe-
rience has taught him that there is, in general, no necessity for
this course. The deep-seated arteries have seldom bled much when
care has been taken to keep beyond the limits of the diseased struc-
ture; but, if this precaution is neglected, the hemorrhage may be
copious. The oozing after the resection of the bone has also gene-
rally ceased by exposure to the air, or by compression of the bleed-
ing surface with lint wet with strong alum-water.
Incisions. — The extent and number of the incisions through the
soft parts requisite for the removal of tumors of the jaws, must
necessarily vary, but when the morbid growth is comparatively
limited, or seated anteriorly, Dr. Gross is of the opinion that exter-
nal incisions may be dispensed with. In other cases, he prefers one
long curvilinear incision, with its convexity downwards, so made
that it may extend across the most prominent part of the tumor,
from the angle of the mouth to the zygomatic process of the malar
bone, and terminate within a few lines of the external angle of the
eye. Generally he has found this incision sufficient to expose the
disease when the two flaps are dissected off; but, if not, it may
easily be increased by a horizontal cut along the inferior edge of
the orbit.
Division of the Bone. — In dividing the bony structure, Dr.
388 OPERATIVE SURGERY.
Gross generally employs a saw, three inches long, eight lines wide,
a little rounded off at the end, with sharp, wide-set teeth, and a stout
handle, as he deems it preferable to the bone-nippers; he also pre-
fers the use of the chisel, lenticular and bone scalpel to any other
instruments that have been suggested for cutting away smaller por-
tions of the bone. The following case is cited as characteristic of
his method of operating: —
Operation of Dr. Gross, of Louisville. — The canine and the
last molar tooth being extracted, the patient was placed upon a table,
with her head resting on a pillow, and fully etherized. An incision
being then made over the most prominent portion of the tumor,
from the angle of the mouth to within a short distance of the ex-
ternal canthus of the eye, in a slightly curvilinear direction, and with
the convexity downwards, the flaps were dissected off, and the saw
applied to the anterior and lateral part of the jaw, from whence it
was carried obliquely backwards through the raph£, to a little beyond
the juncture of the maxilla with the palate bone (transverse palate
suture). The nasal process of the superior maxilla being next
divided with the saw and nippers, nearly on a level with the edge
of the orbit, the malar process, and part of the horizontal plate
of the palate bone, were cut through, when, having thus severed
the most, important bony connections, the tumor was wrenched
from its bed with the hand and chisel, and the bottom and side of
the chasm cleared of everything that had the slightest appearance
of disease. The oozing of the blood, which was free, having soon
ceased spontaneously, the cavity was filled with lint wet with alum-
water, and the wound closed by fine harelip sutures. No arteries,
except a small muscular branch, required the ligature. On the
fourth day, the sutures were removed, and the external wound
found to be healed by the first intention. The lint from inside the
mouth being removed as soon as suppuration began, was replaced
daily for a week, when it was discontinued. The chloride of lime
in solution was also freely used as a detergent with great comfort,
and the face was ultimately but slightly disfigured. 1
1 Western Journ. Med. and Surg., vol. x. 3d series, p. 213.
RESECTION OF BOTH SUPERIOR MAXILLAE. 339
§ 2. — RESECTION OF BOTH SUPERIOR MAXILLA.
Eesection of both superior maxillary bones, which was first at-
tempted by Dr. David L. Rogers, of New York, 1 in 1824, was re-
peated by Heyfelder, in 1844, and again in January, 1850, both
operations succeeding, though the disease had reappeared in one
case at the last account. It has also been lately performed, unsuc-
cessfully, by Maisonneuve, of Paris, on a man sixty-nine years of
age, who suffered from cancer of these bones, and, successfully,
upon a young girl affected with necrosis from the vapor of phos-
phorus, or as one account says polypus. The first case was operated
on as follows: —
Maisonneuve's Operation for Resection of both Superior
Maxillae. — A vertical incision being made in the middle line, so as
to divide the nose from its root, and terminate in the upper lip, a
transverse incision was made from the internal angle of the right
to that of the left eye, leaving two large quadrilateral flaps, which
were dissected along the edges of the orbit to the external angle on
each side. These flaps being inverted, the disease was exposed.
One end of a chain-saw being then passed by its needle through
the spheno-maxillary fissure, and the other through the root of the
nose, so as to traverse the os unguis of each side, the bones were
detached laterally and superiorly, the velum palati freed trans-
versely and posteriorly by a bistoury, and the entire mass of the
bones detached by the help of Liston's forceps. 2
Heyfelder's Operation. 3 — Both the superior maxillae being
involved in a malignant tumor, an operation for their removal was
performed as follows : — i
The patient being seated in a chair, with his head supported
against the breast of an assistant, an incision was made on each side
of the face, from the external angle of the eye to the labial commis-
sure, and the included parts reflected upwards towards the internal
angles of the eyes, the nasal bones, and also towards the forehead,
until the infra-orbital ridge was exposed. The chain-saw of Jeffrey
being then passed through the spheno-maxillary fissures, the malar
' See Bibliography, art. Upper Jaw, p. 69 ; also Velpeau, Med. Operat., torn. ii. p.
628.
2 New York Journ., vol. v. N. S. from Med. Gaz.
3 Med. Examiner, vol. ix. N. S. p. 595, from Rev. Med.-Chir., Paris.
390 OPERATIVE SURGERY.
bones were divided, the maxillae separated from the ossa nasi, and
the vomer and the thinner bones cut with strong scissors, when
the application of the chisel to the upper part of the tumor was suffi-
cient to effect its separation by the employment of slight force.
Yery little blood was lost, torsion and compression sufficing to
arrest the hemorrhage. Two hours afterwards, the edges of the
wounds, from the angles of the eyes to the corners of the mouth,
being united by twenty-six points of the interrupted suture, cold
lotions were applied; there was no reaction or swelling, and the
patient could swallow water and broth. Four days subsequently,
the wounds had nearly healed by the first intention, and in six
weeks the patient was exhibited to the Medical Society of Erlachen.
At this time there was no deformity of the features; a fissure, thir-
teen lines long and three lines wide, was seen along the median line
in his mouth; the soft palate and uvula were in their natural place;
deglutition was free; the nose had resumed its usual form and direc-
tion, and the face, which, before the operation, was like that of a
monkey, again possessed a human expression; a firm and solid
tissue replaced the extirpated parts.
Kemarks. — In resection of the upper jaw, as in all other surgical
operations, the circumstances of the case exert so great an influence
on the decision of the means to be employed, that an estimate of
their value must necessarily be only an approximation. Where the
tumor will permit it, there is, however, no question that the opera-
tion of Dr. Horner, for the removal of the bone without an external
incision, is the best for the patient, as it preserves the functions of
the portio-dura nerve, saves him a most unsightly scar, and, when
the cheek can be freely dissected off from the surface of the tumor,
exposes the part with considerable freedom. But if the develop-
ment of the disease requires a more free opening of the integu-
ments, in order to afford space for acting in the various steps of the
disarticulation, then the simple curved incision from the outside of
the malar bone to near the angle of the mouth, so as to avoid the
main trunk of the portio dura, as practised by Drs. Warren and
Mussey, and subsequently by Velpeau, or the vertical cut of Dr.
Mott, will probably answer better; but it is always advisable to
make these incisions terminate near and not precisely at the ano-le
of the lips, as the cicatrix, from its stiffness, is then less apt to
interfere with the expansion or contraction of the mouth, and
consequently with the expression of the face when the patient
is engaged in conversation. In all external incisions, and espe-
RESECTION OF BOTH SUPERIOR MAXILLAE. 391
daily those near the masseter muscle, the operator should bear in
mind the position of the duct of Steno, and so arrange his incisions
and dissections as to leave it uninjured in the lower flap of the
integuments. Whenever the disease has not encroached upon the
orbit, it is also desirable to leave the orbitar plate for the support
of the eyeball. But as this can seldom be told unless by opening
the front of the antrum and removing the mass of the tumor, at
the commencement of the operation, the proceeding will, in many
cases, prove dangerous from the hemorrhage that it will induce.
Statistics of Resection of the Upper Jaw. — Resection of the
superior maxilla has been twice performed by Dr. Jno. C. Warren;
one patient being cured, and the other lost; the same surgeon has
also performed partial resection many times with perfect success. 1
By a reference to the Bibliographical Index, p. 69, it will also be
seen that the cases as reported by Drs. Jameson, Rogers, Warren,
Mussey, Stevens, Mott, Eve, Horner, Gross, and other American
surgeons, have often been followed by a successful result. From
an analysis of these cases, we have the following facts : —
Of eighteen cases reported, ten were cured and eight died, or
nearly three-fourths were cured, that is, the patients were doing
well at periods varying from six weeks to five years after the ope-
ration. But, to prevent misapprehension in relation to the effects
of this operation upon the disease, I would state that several of
those above reported as cured, are so referred to by the operators
solely in connection with the results of the operation, some of them
being expressly mentioned as dying subsequently of the disease.
In prognosticating the result of the operation, it should therefore
be remembered that, though its happy termination is more marked
than that of other great operations (nearly three-fourths recovering),
yet the tendency to ultimate death from the disease is but slightly
diminished by removing it from the point in which it was first
apparent. According to the experience of Dr. Gross, 1 it may be
anticipated that in every instance of encephaloid tumor the disease
will return, no matter how thoroughly the abnormal structure has
been extirpated, but that in the fibrous or other non-malignant tu-
mors there is no reason to apprehend a relapse. The results of Mr.
Ried's examination of the history of this operation also shows that
out of thirty-five cases treated in Europe, there were twenty-four
cured.
1 Manuscript of Dr. Warren. 2 West. Journ. Med. and Surg., vol. i. 3d series.
392 OPERATIVE SURGERY.
PLATE XXV.
RESECTIONS OF THE UPPER AND LOWER JAW.
Fig. 1. A view of the inside of the Mouth immediately after the removal
of the left superior maxillary, as performed by Horner, without any ex-
ternal incision in the cheek. The soft palate is shown as preserved, but
the engraving has reversed the side from which the bone was taken, making
it appear as if performed on the right side. After Nature.
Fig. 2. A side view of the portion of bone removed
from the mouth. " "
Fig. 3. A likeness of the patient three years after the
operation. " "
Fig. 4. An outline of a Skull, showing the relative size and position
o'f the Tumor in Dr. Barton's patient. After Barton.
Fig. 5. An outline of an Inferior Maxilla, showing the
line of incision in the Jaw. " "
Fig. 6. A front view of Barton's operation for Resection of the Lower
Jaw without destroying its base, thus preserving the outline of the Face.
In the original operation, the lower lip was divided vertically at its left
angle, but this has not been done in the drawing, in consequence of its
not being universally necessary. "When the tumor permits it, the simple
horizontal cut in the integuments, as shown in the figure, brings the cica-
trix under the chin, where it is hardly perceptible. After Nature.
Fig. 1. A side view of Lisfranc's operation for Resection and Disar-
ticulation of half of the Lower Jaw, at the moment of removal, the jaw
being everted and drawn forwards and downwards in order to avoid any
injury to the artery at this point. After Bernard and Huette.
Fig. 8. A front view of the Resection of the Chin or middle portion of
the Inferior Maxilla, as practised by Dupuytren. A vertical incision in
the median line of the chin enables the operator to turn back two flaps,
1, 2, and expose the bone, which may then be readily divided by Hey's
saw, if it is desirable to cut from before backwards, or by the chain saw
passed around the bone and made to cut from behind forwards. The lat-
ter is preferable, in most instances. After Bernard and iiuctte-
<£
__
RESECTION OF THE INFERIOR MAXILLA. 393
§ 3. — RESECTION OF THE INFERIOR MAXILLA.
The Inferior Maxilla may be resected either partially or entire,
the former having been performed by Dr. W. H. Deaderick, of
Rogersville (now of Athens), Tennessee, in Feb. 1810, and subse-
quently by Dr. Mott, of New York, in 1821, and the latter having
been successfully performed by Dr. George McClellan, of Phila-
delphia, who, in 1823, 1 removed all the bone, anterior to its angles,
and was the first surgeon who attempted so extended a resection
of this portion of the face. Walther, of Bonn, and Grasfe, of Ber-
lin, have since then resected and also disarticulated the entire bone,
and Dr. Carnochan, of New York, has lately repeated the operation
in order to relieve a patient who was suffering from an extensive
necrosis. Professor Ackley, of Cleveland, Ohio, is also reported 2 to
have succeeded, in July, 1850, in removing the bone entire^ in a case
of osteo-sarcoma, the patient being alive and in good health two years
subsequently. The partial resection of the jaw has now been so
often accomplished as to render it difficult to register all the cases. 3
Whether the evils resulting from the loss of the entire lower jaw
bone are not such as will forbid its repetition, is at present a ques-
tion that experience has not settled. They should, however, be
deliberately considered by every surgeon before attempting the
operation, the difficulties of accomplishing the operation not being
so great as the evils likely to ensue to the patient on its completion.
I. RESECTION OF ONE SIDE OF THE INFERIOR MAXILLA.
Operation of Dr. Deaderick. — An incision was commenced
under the zygomatic process, and continued over the tumor (which
almost entirely enveloped the left portion of the jaw, and occupied
nearly the whole mouth) in the direction of the bone, to nearly an
inch beyond the centre of the chin. A second incision was then
begun about midway and at right angles with the first, extending
a short distance down the neck. The integuments being now sepa-
rated from their connection with the tumor, and the jaw sawed
» Am. Med. Review, vol. ii. p. 153, 1825. Also, Cooper's First Lines, p. 16, edited
by Samuel McClellan, Philadelphia, 1830.
2 N. Y. Journ. Med., vol. x. N. S. p. 288, 1853. Also Dr. S. S. Purple, in MS.
a See Bibliography — article Lower Jaw, p. 72.
394 OPERATIVE SURGERY.
through near its angle, as well as at the centre of the chin, there
was no difficulty in freeing it from its other attachments. The
wound was then closed in the usual manner, and the boy had a
speedy and happy recovery. Thirteen years subsequently, there
was no connecting medium between the ends of the divided bone. 1
The description of the tumor shows it to have been osteo-sarcoma.
Remarks. — As the account of this operation was not published
by Dr. Deaderick until nearly one year after Dr.Mott's operation, 2 and
as the latter surgeon had performed his operation before he heard
of that of Dr. Deaderick, the credit of priority has been strongly
urged, and by many accorded to the latter gentleman. But, as the
case of Dr. Deaderick, though not published until 1823, contains
the evidence of those who know it to have been performed in 1810,
justice would seem to demand that Dr. Deaderick should obtain the
renown which has been so frequently attached to those who only
followed in his footsteps, especially as claims to the credit of ori-
ginating the operation have been advanced in Europe both by the
English and French surgeons. The decision of the priority of the
operation of Deaderick is now generally received in the United
States as correct, though there are yet some European surgeons
who assign the credit of the first operation to Dupuytren in 1812.
It is, however, but just to state, in connection with the varying
claims of Drs. Mott and Deaderick to the originality of their
operations, that the operation of Dr. Deaderick was a resection of
a portion of the jaw, the ramus of the same side being left, whilst
that of Dr. Mott was the resection of the entire half of the bone,
and necessitated a disarticulation at the temporo-maxillary joint.
Though the credit of the first resection of this bone therefore be-
longs to Dr. Deaderick, Dr. Mott was certainly the first American
or European surgeon who whilst resecting also disarticulated half
of the lower jaw.
In the early operations performed by Dr. Mott, it was deemed
essential to success to ligate the carotid artery a few days prior to
removing the bone; but many cases, since operated on by others,
as well as that of Dr. Deaderick, have proved that this step is only
a complication of the proceeding; it is therefore now seldom re-
sorted to.
1 Amer. Med. Recorder, vol. vi. p. 516. Philadelphia, 1823.
2 Bibliography, p. 72.
PARTIAL RESECTION OF THE INFERIOR MAXILLA. 395
. Dr. Wm. Gibson, in a late operation before the medical class of
the University of Pennsylvania (Jan. 1851), removed the entire
half of the jaw, Avithout tying any vessels of consequence; and if
the bone is drawn well forwards previous to attempting its disar-
ticulation, and the knife is made to shave off the soft parts close to
the angle and ascending ramus of the jaw, it will be found that
there is really very little risk of injuring this vessel, as the artery,
by remaining in situ, is removed several lines from the dissections
required for the disarticulation of the bone.
Ordinary Operation for Eesection and Disarticulation
of half of the Jaw. — The patient being seated on a chair, so
that his feet will not touch the ground and enable him to tilt
himself backwards, and having his head supported by an assist-
ant, make a horizontal incision over the tumor, from the angle
to the symphysis, along the base of the inferior maxilla. A ver-
tical cut over the symphysis from the lip to the end of the first
incision will then free the flaps, which should be dissected back
from the tumor, one being turned up on the cheek, and the other
downwards aud backwards. After sawing through the bone at the
symphysis from without inward, shave off with a strong good scal-
pel all the soft parts on the inside, as far as the angle of the bone,
then, drawing the bone outwards and forwards, use it as a lever
(Plate XXV., Fig. 7); and, whilst its upper attachments are upon
the stretch, insert behind the coronoid process, and just below the
zygomatic arch, a bistoury, so as to detach the temporal muscle
from its insertion. At the same time, whilst depressing the bone
so as to dislocate the condyloid process, draw it forcibly forwards
so as to remove it from the artery, and divide the capsular ligament
and pterygoid muscles, which will generally free the jaw entirely,
when the wound may be closed with a few stitches and adhesive
plaster.
Kemoval of the Middle of the Bone. — The patient being
arranged as before, seize one angle of the mouth with the left
hand, while an assistant does the same with the other, and, whilst
drawing the lip tense, divide it immediately in its middle by a
single vertical incision. The two flaps being then shaved off' from
the bone to the desired extent, let them be held by the aids, whilst
the teeth at the points of division are extracted, when the bone may
be cut through, either by Hey's or the chain saw, the latter cutting
from behind forwards, after being passed around the jaw by means
396 OPERATIVE SURGERY.
of a needle. If it is desirable to divide the bone from before back-
wards, a saw similar to that of Hey must be employed. (Plate
XXV., Fig. 8.)
The point of the tongue being now held, either by a ligature
introduced through it, or by means of a tenaculum, so as to prevent
its being drawn back upon the pharynx, shave off the muscular
attachments from the inside of the bone, and close the wound by
sutures.
Should the portion of bone to be removed be the entire chin, it
will perhaps be necessary to attach the tongue to the side of the
cheek for a few days, by means of a suture, in order to prevent its
retraction upon the glottis, lest this should induce suffocation.
Barton's Operation for Removal of Half the Jaw, by a
longitudinal section, without destroying the base of the bone, so
as to preserve the line of the face. — The patient had a tumor (epulis),
which had taken entire possession of the mouth, forcing the tongue
into the pharynx, and stretching the jaws widely apart. It also rose
up outside the superior maxillary bone (Plate XXA r ., Fig. 6), pro-
truding the lips, cheek, and neck on the left side.
Operation. — An incision, which commenced over the left angle
of the lower jaw, being carried on a line with the under edge of the
base around to near the edge of the masseter on the opposite side,
through the integuments and muscles of the cheek and lip, so as
to open the cavity of the mouth, the under lip was cut through
vertically towards the left commissure of the mouth, so as to
meet the first incision at a right angle, when the tumor, being thus
exposed, was found to be adherent to the anterior and posterior
surfaces of the bone. These adhesions being detached from the
anterior face of the bone as high up as it was sound (Plate XXV.,
Fig. 6), the bone was cut through longitudinally with a small nar-
row saw from without inwards, in a line parallel to the base of the
jaw, and just below the maxillary canal, this section being extended
as far back as the roots of the last molar tooth on the left, and the
second molar on the right side. A vertical cut being then made
through the alveoli between these teeth, so as to meet at a right
angle the horizontal division of the bone (Plate XXV., Fig. 5), the
portion thus insulated was found to contain the diseased mass, so
that, after separating the attachments of the soft parts, the operator
was enabled to take it away entire (Plate XXV., Fig. 6), leavino-
RESECTION OF THE INFERIOR MAXILLA ENTIRE, OR NEARLY SO. 397
the base of the bone in a healthy state, except at one point on the
surface, which was readily taken off with the nippers. No blood-
vessels required the ligature except the left facial and right coro-
nary arteries. The flap being replaced, the vertical cut through
the lip was closed by the harelip suture, and the remainder of the
wound united by the interrupted suture and adhesive plaster. In
a month, the patient was well; the contour of the face was preserved,
and he was able to masticate his food with the three remaining
molars and their antagonists of the upper jaw. 1
Resection of a Portion of the Lower Jaw, and Extirpation
of the Inferior Maxillary Nerve, for the Cure of Neural-
gia. — Operation of Dr. J. M. Warren, of Boston.— An incision
being made from the sigmoid cavity of the temporal bone down to
the edge of the jaw, the parotid gland was raised and turned to the
outside, when the lower portion of the masseter muscle was dissected
up and a portion of the ramus removed by means of the trephine
and chisel. The nerve being thus fully exposed, about half an inch
of its main trunk was excised. The inferior maxillary artery was
cut and tied, and there was also a slight discharge of saliva through
the wound, from interference with the parotid.
IT. resection of the inferior maxilla entire, or nearly so.
Resection of the Inferior Maxilla, nearly entire. — Ope-
ration of Dr. Geo. McClellan, of Philadelphia. 2 — The entire
substance of the lower jaw, in front of its angles, being affected with
osteo-sarcoma, and the tumor having extended in all directions, and
pushed the tongue back into the pharynx, so as to impede degluti-
tion and respiration, Dr. McClellan operated as follows : —
Operation. — Making an incision through the integuments, from
the left commissure of the lips obliquely downwards and backwards,
he carried it over the anterior edge of the sterno-cleido-mastoid
muscle, so as to command the internal carotid artery, if necessary.
Having ascertained that the artery need not be touched, he next
exposed the tumor by dissecting up the integuments, and, paying
no attention to the small vessels, at once secured the facial artery,
when the bleeding immediately ceased. After dissecting up the
1 Am. Journ. of Med. Sciences, vol. vii. p. 331, 1831.
2 Cooper's First Lines, edited by Sum. McClellan, p. 1G, Phila. 1850.
398 OPERATIVE SURGERY.
insertions of the masseter a little way behind the tumor, he divided
the bone on each side with a metacarpal saw, turned the tumor out
of the mouth, and dissected from the under surface of the tongue
such portions of the submaxillary glands as were sound, when the
remainder, and especially a portion of the left submaxillary, were
removed with the tumor. Only three small arterial twigs required
a ligature, and the wound was closed by sutures and adhesive plas-
ter, the large cavity under the tongue being rilled with lint to
support the skin. This patient recovered and lived some months
subsequently, and the preparation is now the property of his son,
Dr. J. II. B. McClellan, of Philadelphia, who has deposited it in the
Museum of Pennsylvania College, Philadelphia.
Eemarks. — This operation was a very bold and successful one,
but appears to have been generally overlooked by the profession,
though its performance at so early a date should have given it a
prominent position, especially as no surgeon had then attempted
as extended a resection.
Eesection of the Inferior Maxilla entire. — Operation of
Dr. J. M. Carnochan, of New York. — A patient in the Emi-
grants' Hospital having long suffered from a necrosis, which had
loosened the teeth in the lower jaw, partially denuded the alveolar
ridge, and caused great suffering and depression, it was decided to
remove the inferior maxilla. The patient being seated, an incision
was first made commencing opposite the left condyle; then passing
downwards to the angle of the jaw, about two lines in front of the
posterior border of the ramus, it was extended along the base of the
jaw, and made to terminate by a slight curve on the mesial line,
half an inch below the free margin of the lower lip. The flaps being
dissected offj the bone was laid bare, and the tissues forming the
floor of the mouth separated from their attachments, from the mesial
line back as far as the angle of the jaw. The attachments of the
buccinator being next divided, and the facial and sublingual arteries
tied, the bone was found to be partially separated at the symphysis,
and completely necrosed from this point to the inferior portions
of the ramus, the latter being also diseased. A double ligature
having now been passed through the anterior part of the tongue,
and intrusted to an assistant in order to prevent its falling back
upon the orifice of the larynx, the bone was broken at the sym-
physis and at the angle, and this portion readily removed ; when,
by pulling on the ramus, it was disarticulated and removed, after
RESECTION OF THE INFERIOR MAXILLA ENTIRE, OR NEARLY SO. 399
being freed from the soft tissues by the use of the knife and blunt-
pointed scissors, without any injury to the internal maxillary
artery. The same incision and dissection being practised on the
opposite side, the bone was disarticulated in a similar manner at
this joint, also without injury to the bloodvessels, and the amount
of blood lost was inconsiderable. Union of the wound occurred in
forty-eight hours, and the patient afterwards recovered, articulation
being sufficiently distinct to render words intelligible, whilst his
food was broken up by the pressure of the tongue against the roof
of the mouth.
Remarks. — Although so important a portion of the general out-
line of the face and of the organs of mastication is necessarily re-
moved in the resection of the lower jaw, the deformity which results
from the operation is by no means such as might be anticipated.
In the case of a gentleman, formerly an Interne of Lisfranc's at the
hospital of La Pitid, and whom I saw in Paris in 1839, the deficiency
was admirably concealed by his whiskers; and in the modification
proposed by Dr. Barton, of Philadelphia, where a rim of the base
of the jaw was left, it is very slight. In all cases, where the amount
of the disorder will permit it, Dr. Barton's method of operating
will be found to be the most advantageous ; but it is essential to a
successful result that as much as possible of the base of the bone
below the orifice of the nutritious artery be preserved in order to
obviate the risks of necrosis from the want of circulation.
In reviewing the various methods of operating, it is, therefore,
apparent that, as the object of all is the same, the modifications will
be chiefly such as are demanded by the peculiarities of the case.
There are, however, certain general* points connected with all of
them, which it is desirable should be remembered in every similar
operation, and which, as they have been sanctioned by the extended
experience of Dr. Gross, I shall refer to by condensing the substance
of another of his papers. 1 After referring to the dangers as well
as inutility of previously ligating the carotid, in this resection, Dr.
Gross gives the following general rules : —
1st. Always keep in close contact with the morbid structures,
but not so close as to leave any portion of them behind ; this saves
hemorrhage.
1 "On Excision of the Inferior Maxillary Bone, illustrated by five Cases :" Western
Journ. Med. and Surg., vol. x. 3d series, p. 277.
400 OPERATIVE SURGERY.
2d. Work with the handle of the knife as much as possible, instead
of the edge and point, especially in detaching the soft parts from the
bone, saving the periosteum, if possible.
3d. Make the external incisions so as to conceal the unsightly
cicatrix, and without, if possible, removing any of the integument.
4th. If the disarticulation is very difficult, make a horizontal
incision just below the zygomatic arch, avoiding the duct of Steno.
oth. In removing the jaw, saw the bone first anterior to the
tumor, and thus obtain the benefit of the leverage, and facilitate the
division of the soft parts.
6th. In liberating the coronoid or condyloid processes, which,
from their being expanded and diseased, is often very difficult, use
a knife which is slightly curved on the flat of the blade, three and
a quarter inches long, three-eighths wide, and about one line and a
half thick, the end of which terminates in a convex edge, bevelled
off" in front and behind, and set in a stout rough handle, four inches
long. This instrument acts as a lever as well as a knife.
Statistics. — When we remember the character and extent of the
parts involved in this operation, it must be admitted that the suc-
cess attending resection of the lower jaw, and the relief afforded by
it from a painful and loathsome complaint, is such as is highly
creditable to the surgery of the nineteenth century.
Out of about one hundred and sixty cases collected from various
sources by Velpeau, there have only been forty deaths, or one-fourth
of the whole number operated on, a success which is very great when
compared with the serious character of the operation. 1 By refer-
ring to the Bibliographical Index, p. 72, it will also be seen that
the operation is one which nas been frequently resorted to by
American surgeons, the whole number of resections of this jaw
there referred to, and doubtless reported as those of special interest,
being forty-two. As many others have been performed within my
knowledge, which have not been reported, the whole number of
cases operated on, including those reported by Velpeau, now
amounts to more than two hundred.
1 Velpeau, M6d. Operatoire, vol. ii. p. C20.
STAPHYLOKAPHY. 401
SECTION III,
OPERATIONS ON THE PALATE.
The occurrence of a fissure, either in the hard or soft palate, or
in both, is most frequently the result of a congenital defect, and
often coexistent with a similar fissure in the alveolar processes of
the upper jaw as well as in the lip, as was mentioned when treating
of the operation for harelip. In consequence of the effect of this
fissure upon the tone of the voice, as well as upon the enunciation
of words, it becomes desirable to attempt its closure by uniting the
two halves, or by performing a plastic operation at as early a period
as will be permitted by the patient, or rather so soon as the indi-
vidual is willing and able to assist the operator in the efforts required
for its execution. If the case is seen during infancy, the cure of
the harelip will often diminish the size of the fissure in the palate,
or materially aid the subsequent operation ; but if both harelip and
fissure of the palate are present in an adult, the operation must first
be performed upon the lip, and then, if necessary, repeated upon
the palate, the operation of staphyloraphy or union of the fissure
of the palate being very much the same iu principle as well as
means of treatment with that resorted to for the relief of harelip.
§ 1. — STAPHYLORAPHY.
The operation of refreshing the edges of a fissure in the palate
and then uniting them by a suture, was suggested by a French
dentist, Le Monier, in 1764, and termed Staphyloraphy (<jra$v^, the
palate, and pa<j»?, suture). After being for a time forgotten, it was
revived by Graefe, of Berlin, in 1817, but methodized and first pub-
lished with the rules for its performance by Roux, of Paris, about
1819. In 1820, a nearly similar operation was invented and exe-
cuted by Dr. John C. Warren, of Boston, he being at the time
ignorant of the views or operations of the other surgeons. In
many respects, the steps proposed by Drs. Warren and Roux cor-
responded, though the means suggested by Dr. Warren were the
simplest. The operation of the latter being, however, generally
26
402 OPERATIVE SURGERY.
PLATE XXVI.
A VIEW OF THE INSTRUMENTS EMPLOYED IN OPERATIONS UPON THE
THROAT, AND ESPECIALLY IN STAPHYLORAPHY.
Fig. 1. Scissors for Excising the Uvula.
Scbiveley's pattern. Drawn from the Instrument.
Fig. 2. Gibson's Glosso-catochus, or Spatula, to depress the Tongue.
Schiveley's pattern. Drawn from the Instrument.
Fig. 3. Schiveley's modification of Physick's Tonsilitome for excising
the Tonsil Gland. The ring surrounds the tonsil, the needle transfixes it,
and the angular knife shaves it off. Schiveley's pattern. Drawn from the Instrument.
Fig. 4. A long-handled double-edged Scalpel, for freshening the edges
of the fissure in the operation of Staphyloraphy.
Schiveley's pattern. Drawn from the Instrument.
Fig. 5. Curved Scissors, with long handles for the same purpose.
Schiveley's pattern. Drawn from the Instrument.
Fig. 6. Physick's Forceps, with long handles, and holding a small needle
of the proper curve, to facilitate its passage through the side of the Uvula.
This curve may be readily given to the ordinary curved needle, simply by
pressure and gentle heat. The catch on the handle of the forceps enables
the operator to free the needle in a moment, after transfixing the part, and
again to seize its point with the same instrument, so as to draw it through
the Opposite side Of the fissure. Schiveley's pattern.
Fig. *7. Gibson's Forceps for inserting the ligatures in Staphyloraphy,
at the moment when the needle is passed through the palate.
Schiveley's pattern.
Fig. 8. The same instrument drawing the ligature into its position.
Schiveley's pattern.
Figs. 9, 10. Needles of different sizes, as adapted to Gibson's Forceps.
The shoulder near the spear point facilitates the grasp of the forceps, which
close around it in consequence of a little split in the top of the first up-
right portion. Schiveley's pattern.
STAPHYLORAPHY. 403
regarded as the basis of the various modifications that have since
perfected the proceeding, his plan may be first referred to.
Operation of M. Roux, of Paris. — Four different objects,
which are to be attained in four different stages of the operation,
have been laid down by M. Koux as likely to facilitate the sur-
geon's manipulation, and the success of the means employed.
1st. The paring off the edges of the fissure.
2d. The introduction of the ligatures at equal distances through
its margins.
3d. The knotting of the ligatures and the approximation of the
freshened sides of the fissure.
4th. The relief of any tension in the parts consequent on the
suture.
Instruments. — The instruments proposed by M. Roux for ac-
complishing these objects are sufficiently complicated, consisting of
three silk ligatures, made of two or three strands, and waxed; of
six small-curved but flat needles, each end of the three ligatures
receiving one needle; of a porte-aiguille or needle-holder; of dress-
ing forceps ; and of a probe-pointed bistoury, and curved scissors.
Operation. — The patient being seated before a strong light, with
the head thrown back and supported against the chest of an assist-
ant, the mouth is to be kept widely opened by means of a cork
placed between the molar teeth. The surgeon, being placed in front,
then seizes, with the forceps held in his left hand, the right lip of
the fissure; and, with his right hand armed with the needle-holder,
introduces the point of the needle from before backwards behind
the uvula, in order to traverse the flap from behind forwards (Plate
XXVII., Fig. 1) at three or four lines from the free edge of the
fissure. The needle, being now thrust in as far as its head, is then
to be freed from the needle-holder, and seized at its point by forceps,
which draw it and the ligature through into the mouth. After
resting a few seconds, the same manoeuvre is practised on the left
half of the fissure with the other needle of the same ligature, the
two ends of which are thus brought out into the mouth. In pass-
ing three ligatures, the operator should commence by the lowest,
then pass the highest, and, lastly, apply the third in the middle of
the fissure. Plate XXVII., Fig. 1, shows the ligatures as the last is
being passed through the right side of the fissure.
The extremities of the ligatures, 3, 3, 4, 4, 5, 5, being brought
404 OPERATIVE SURGERY.
outside the mouth, and their loop or central portion depressed to-
wards the pharynx, the surgeon proceeds to
Freshen the Edges of the Fissure. — To accomplish this
(Plate XXVII., Fig. 2), he should seize the lower end of the left
margin with the forceps, 1, held in the left hand, and cut off the
edge from behind forwards with the probe-pointed bistoury, 2, or
curved scissors (Plate XXVL, Fig. 5), held in the right hand, cutting
from below upwards, and prolonging the incision a little beyond
the centre or angle of union of the two sides of the fissure. The
other margin is then to be incised in the same manner by cutting
a little beyond the angle of union, in order to free the flap.
In order to tie the ligatures, M. Koux commences by knotting
the middle ligature (Plate XXVII., Fig. 1) with the fingers, and,
after making a simple knot, confides it to an assistant, who holds
with a serre-nceud (knot-tier), whilst he ties the second and then the
first ligature, drawing them tighter than is necessary to approach
the edges of the wound, in order to prevent any separation. This
being completed, the ends of the ligatures are then cut close to the
knots, and the patient kept from eating, drinking, or speaking
during two or three days ; the ligatures being removed on the third
or fourth day, and the lowest ligature being left twenty-four hours
longer than the others.
It is essential that the ligatures be placed at equal distances ;
that the points of each one be on the same level, and that they be
at a proper and equal distance from the free edge of the fissure. 1
If, on knotting the ligatures, the strain upon the parts seemed to be
too great, or such as might excite an apprehension of their tearing
out, Roux made an incision in the sides of the soft palate (Plate
XXVII., Fig. 5), and allowed these wounds to heal by granulations.
Operation of Dr. Jno. C. Warren.— In the case of a young
girl, aged seventeen years, who from birth had suffered from a cleft
on the left side of the uvula, extending as far as the ossa palati,
where the fleshy membrane was so thin as to be transparent, the
operation of staphyloraphy was performed by Dr. Jno. C. Warren,
of Boston, as follows: —
" The patient being well supported and secured, a piece of wood
an inch wide, a little curved at the end, and with a handle to be held
by an assistant, was placed between the molar teeth on one side, to
1 Bernard and Iluette, p. 207. Paris, 1850.
STAPHYLORAPHY. 405
keep the mouth open. A sharp-pointed curved bistoury was then
thrust through the top of the palate, above the angle of the fissure,
and carried down on one edge of the cleft to its extremity (Plate
XXVII., Fig. 3); and the same was done on the opposite side, so as
to cut out a piece in the form of a letter V, including about a line
from each edge. Next, a hook, or curved needle, fastened in a han-
dle, with an eye on its extremity, and a movable point armed with
a triple thread of strong silk, was passed doubled into the mouth
through the fissure and behind the palate, and the latter pierced by
it at one-third the length of the fissure from the upper angle of the
wound, so as to include about three lines of the edge of the soft
palate. The eye with the ligature, being seen, was seized by a
common hook and drawn out. The eyed hook was then drawn
back, turned behind the palate, and the other edge transfixed in a
similar manner. A second and a third stitch were now passed in
the same way, the third being as near as possible to the lower end
of the fissure. Then, seizing the upper ligature with the fingers,
the knot was tied without using a serre-nceud, and placed on one
side of the wound in order to prevent its pressing on the fissure ;
the others being tied in a like manner, and the fissure closed. The
patient was exhausted by the operation, but soon revived ; remained
twenty-four hours without speaking or taking a drop of liquid into
her mouth, then used a little water. In seven days, the stitches
were removed, and she left the hospital a day or two after. Two
years subsequently she swallowed perfectly and spoke well. 1
In 1826, a similar operation was successfully performed on a boy
set. eleven. The cure was perfect. 2
Kemarks on the American Operations. — The first of these
operations is stated by Dr. Warren to have been original with him-
self, as he was not at that time acquainted with the operations per-
formed in Europe. From the simplicity of the instruments em-
ployed, and the freshening of the edges from above downwards, his
method has advantages over that of M. Eoux, from the fact that
the incision of the soft tissues is facilitated by the traction, whilst
the flap, being left adherent above until the completion of the oppo-
site edge, is less likely to cause irritation about the fauces. That
1 Amer. Journ. of Med. Sciences, vol. iii. p. 1, 1821 ; and MS Records of Mass.
Hospital.
» Amer. Journ. of Med. Sciences, vol. iii. p. 1, 1828.
406 OPERATIVE SURGERY.
PLATE XXVII.
A FRONT VIEW OF THE OPERATION OF STAPHYLORAPHT.
Fig. 1. The operation as practised by Roux. 1. The needle-holder
(porte-aiguille), in the act of carrying the last ligature through the right
side of the fissure. 2. Dressing forceps holding this margin. 3. The
first ligature as placed, the ends being brought out the angles of the
mouth, and the loop being loose behind the palate. 4. The second liga-
ture as introduced. 5. The third ligature. After Bernard and Huctt*.
Fig. 2. The three Ligatures, 3, 4, 5, as before shown, being accurately
placed, the surgeon proceeds to freshen the edges of the fissure with a
probe-pointed bistoury, taking care not to cut the loops of the ligatures.
1. Forceps holding the free end of the palate. 2. The bistoury paring
off a strip.
Fig. 3. Operation of Warren. 1. The knife freshening the edge of the
fissure from above downwards. 2. The forceps steadying the margin so
as to favor its regular incision. Modified from Pancoast.
Fig. 4. The introduction of the Sutures by means of Physick's Forceps
and a curved needle. 1. Physick's forceps introducing the needle. 2.
Dressing forceps seizing its point at the moment when it is liberated from
the instrument of Physick. 3, 4, 5. Position of the sutures. They should
all be introduced at equal distances and as nearly parallel as possible.
After Pancoast.
Fig. 5. The operation of Staphyloplasty, as practised by Dieffenbach.
1, 2, 3. The sutures as tied, and closing the fissure. 4, 5. The two longi-
tudinal incisions made on each side of the soft palate, so as to remove the
Strain from the line of union. After Bernard and Huette.
<£*** ■■/■■% <*fc
STAPHYLORAPHY. 407
these two surgeons should devise similar expedients at the same
time, and yet each be ignorant of the proceeding of the other, only
shows the uniform tendency of different minds when devoted to the
same object.
After the operation of Dr. Warren, Dr. A. H. Stevens, of New
York, Sept. 1826, 1 also operated successfully by first inserting the
ligatures, and then paring the edges. 2
Dr. Mettauer, of Virginia, in 1827, operated for staphyloraphy,
and in 1837 published an excellent essay, 8 from which the reader
may gain much that is of practical value. Dr. M. employed the
leaden ligatures recommended by Dieffenbach.
Dr. Wells, of Columbia, South Carolina (1832), in a case of re-
cent wound, was enabled to apply the sutures by heating a common
(surgeon's) needle in a lamp, bending it to a proper curve, and pass-
ing it through the fissure by the aid of Physick's needle. 4 This
simple contrivance seems to have answered perfectly, and is cer-
tainly capable of supplanting all the more complicated instruments,
and has been successfully used by Drs. Mutter and Pancoast, of
Philadelphia, 5 in staphyloraphy.
Dr. Gibson, 6 of Philadelphia, operated with instruments of a
useful kind, some of which have been transferred to these pages.
Dr. Alexander Hosack, of New York, also published, in 1833, a
memoir upon this subject, with illustrations of his own instruments;
and Dr. N. E. Smith, of Baltimore, employs a peculiar hook or
needle for the suture.
In fact, there are few operations in which surgeons seemed to
have felt the necessity of more perfect instruments than in that of
staphyloraphy." Each one has, therefore, endeavored to improve
on those of his predecessor, and especially in reference to the intro-
duction of the needles, thus showing that placing the ligatures is
the most difficult step in the operation. The simplicity and effi-
ciency of Dr. Physick's forceps, as employed by Dr. Wells, of South
Carolina, and subsequently by Drs. Mutter and Pancoast, 7 removes,
1 North American Medical Journal, vol. iii. p. 233.
2 North American Medical and Surgical Journal, vol. iii. p. 233, 1827.
3 Amer. Journ. of Med. Sciences, vol. xxi. p. 309, 1837.
* Ibid., vol. x. p. 32, 1832.
s See Bibliography.
s Instit. and Pract. of Surg., vol. ii. p. 40.
» See Operative Surgery, by Jos. Pancoast, M. D., Philad., and the papers referred
to in the Bibliography.
408 OPERATIVE SURGERY.
however, this great obstacle to the rapid performance of the opera-
tion.
The advantages resulting from the transverse incisions suggested
by Koux, or the lateral sections practised by Dieffenbach, have re-
cently been more systematically presented and specially urged on
account of their anatomical relations, by Mr. Ferguson, of London,
in the Transactions of the Royal Medical and Surgical Society for
1845. 1 By many, the views of Mr. Ferguson are regarded as ori-
ginal; but the following facts show that he had been anticipated.
In connection with the history of an operation for fissure of the
palate, Dr. J. Mason Warren published, in the New England Quar-
terly Journal of Medicine and Surgery, No. IV., p. 544, April, 1843,
an account of the division of both the pillars of the palate, and of
its happy influence upon the union of the freshened edges of the
fissure. Mr. Ferguson's paper did not appear until December 21,
1844, when, in the Medical Times, he published an account of the
dissection, from which he was led to suggest the special division of
the levator palati and palato-pharyngeus muscles. As Mr. F. en-
tered minutely into the anatomy of the structure concerned, and
also demonstrated the importance of dividing these muscles, he has
doubtless aided the progress of the operation ; but it is apparent
from the references just made, that the idea was not a novel one,
having been put in execution nearly two years previously by Dr.
Warren. Froriep also appears to have been fully aware of the
value of this muscular division, having described and figured the
part in his Nottizen, early in 1823. 2
Dr. Mettauer, of Virginia, in 1837, also recommended the section
of the muscles by repeated lateral incisions, as a preparatory step
to the operation in cases of great loss of substance, allowing the
parts to heal by granulations, &c, as suggested by Velpeau in sta-
phyloplasty. 3
To Mr. Ferguson, however, is certainly due the credit of demon-
strating in a scientific manner the special effects upon the fissure, of
each of these muscles, though they had been previously divided
without any reference to the anatomical details of the region.
1 Ferguson, Practical Surgery, p. 506, Philadelphia edition, 1848.
9 Chirurgische Kupfertafeln. Weimar, 1823.
3 Am. Journ. Med. Sciences, vol. xxii. p. 309, 1838.
STAPHYLOPLASTY.
§ 2. STAPHYLOPLASTY.
In the operation of staphyloraphy, as just detailed, the attempts
of surgeons have generally been limited to cases in which the fissure
was only in the soft palate, the opening in the bony structure being
left untouched or covered up by a metallic plate. The following
ingenious operation, by Dr. J. Mason Warren, of Boston, presents
a means of remedying the opening in the bones, as well as that m
the soft tissues, by means of a portion of the neighboring structure.
As the opening is thus closed by a flap taken from the adjoining
soft parts, being made to slide over the fissure, as in plastic opera-
tions elsewhere, the operation has been termed Palatoplasty, Sta-
phyloplasty or Uranoplasty, according to the position of the open-
in^ eithe/of which names is sufficiently applicable to the opera-
tions on any part of this structure.
Operation of Dr. J. Mason Warren, of Boston.— The patient
being placed on a low seat, in a strong light, has his head firmly
supported against the breast of an assistant, who raises or depresses
it, as circumstances may require. The patient is then directed to
keep the jaws widely separated, to retain any"blood which may col-
lect, as long as possible, so as not to embarrass the operator and
restrain all efforts at coughing, in all which he should be encouraged
by the surgeon. The use of a speculum is deemed by Dr. Warren
altogether inadmissible, as it obscures <the light and prevents the
proper manipulation of the instruments. The mucous membrane of
the hard palate being now carefully separated from the bones with
a long double-edged bistoury, curved on the flat, should be Tather
peeled than dissected off, in consequence of the difficulty of making
any sawing motion with the knife in this confined position, the
obstacles being always greater in proportion to the obliquity of the
palatine vault. As the dissection approaches the connection of the
soft parts with the edges of the palate bones, where the muscles are
attached and the union most intimate, great care must be taken
lest the mucous membrane be perforated ; and as soon as this dis-
section is terminated, it will generally be found that, by seizing the
soft palate with the forceps, it can be brought into the median line.
If the fissure is wide, and this cannot be effected, then the soft
parts being forcibly stretched, a pair of long powerful French scis-
sors, curved on the flat, should be carried behind the anterior pillars
410 OPERATIVE SURGERY.
of the palate, and its attachments to the tonsil and to the posterior
pillar carefully cut away, when the anterior soft parts will at once
be found to expand and an ample flap be provided.
The edges of the palate may now be freshened by seizing them
on either side with hooked forceps, and removing a slip with the
scissors or sharp-pointed bistoury. A small curved needle, armed
with a strong silk thread, confined in forceps with a movable slide
(Physick's), should then be introduced at the upper edge of the
fissure, and carried from before backwards on the left side, and from
behind forwards on the right, or vice versa. Three or four ligatures
being thus introduced, the patient should clear his throat of mucus
and blood, the ligatures be wiped dry, and tied with deliberation,
beginning at the upper and proceeding gradually downwards, wait-
ing a little between each ligature in order to allow the throat to
accommodate itself to this sudden and almost imperceptible tension
of the soft parts. No forceps are required for holding the first knot
while the second is tied, the object being better effected by making
two turns of the thread instead of one, and by enjoining perfect
quiet on the patient until the second knot is tied.
Dr. Warren has always arrested the hemorrhage consequent on
the incisions by iced Avater and the finger, and does not wait before
introducing the ligatures. The ligatures also were generally re-
moved in forty-eight hours, or on the third day; drinks Avere em-
ployed with caution from an early period, and the patient was
nourished by oatmeal gruej in injections. 1
Velpeau operated successfully, and closed an opening in the
hard palate three-quarters of an inch long and half an inch broad,
by the following means: —
Operation. — Having noticed that the fibro-mucous membrane of
the palate, in consequence of its firmness and slight vascularity,
was very apt to mortify and slough, either in whole or part, the
operation was performed as follows : Two flaps, six to ten lines
long, of a triangular shape, were cut, one from in front, the other
from behind the opening and dissected off, and brought down
towards each other. Then, being united by means of a suture at
their apices, a wound was left, which gradually closed up the fistula
in every direction by the approximation and cicatrization of its
1 Operations for Fissures of the Soft and Hard Palate (Palatoplasty), by J. Mason
Warren, M. 1). New England Quarterly Journal of Medicine and Surgery, No. IV.
p. 358. Boston, 1843.
OPERATIONS PRACTISED UPON THE EAR. 411
borders, the cure being aided by a longitudinal incision, made from
time to time upon the two sides of the opening, as well as by occa-
sional transverse ones upon the root of each flap. 1
Dr. Pancoast, of Philadelphia, has repeated this operation, with
some modifications, and obtained partial success. 2
Statistics. — The results of this operation are shown by the fol-
lowing cases: Of twenty-four cases operated on by Dr. Warren, 3 it
appears that he has succeeded in twenty-three of them ; and Eoux,
in 1842, 4 obtained a success of two out of three in simple fissure,
but of only one out of three when it was complicated with a fissure
in the hard palate.
From a recent statement 5 by Dr. J. Mason Warren to the Boston
Medical Society, it appears that this surgeon "has latterly per-
formed five operations, in two of which the hard palate was badly
fissured, and that all had proved successful. In one of these,
where the fissure extended through the hard palate and alveolus,
the soft palate and a portion of the mucous membrane, which was
peeled off the palatine arch, united. In regard to the result of
these operations, Dr. Warren also states that he has recently seen
a young lady on whom he had operated some years since, and that
the power of speech was quite restored, so that she enunciated with
great distinctness. In almost every case the speech improved, the
deglutition was easier, and the fauces were relieved from the dry-
ness and inflammatory attacks to which they were formerly liable."
CHAPTEE XIII.
OPERATIONS PRACTISED UPON THE EAR.
The operations resorted to for the relief of disorders of the Ear
consist in those required for the external and those demanded by
the internal portions of this organ.
As the details of this department of surgery are sufficiently
extended to have engaged the entire attention of a special class of
1 Velpcau, Med. Operat., tome i. p. 681. 9 Operative Surgery, p. S57.
s See Bibliography, p. 80. ^ Gazette M6dicule.
6 Am. Journ. Med. Sciences, vol. xxv. N. S. p. 95, 1853.
412 OPERATIVE SURGERY.
PLATE XXVIII.
OPERATIONS UPON THE EAR.
Fig. 1. A Vertical Section of the Head, in order to show the angular
course of the Eustachian Tube and of the External Auditory Canal. 1. The
inferior turbinated bone. 2. The middle turbinated bone. 3. The pha-
ryngeal orifice of the Eustachian tube, directly behind the posterior ex-
tremity of the inferior turbinated bone. 4. The angular direction of this
tube. 5. The membrana tympani. 6. The external auditory canal ; its
direction completes the arch formed by the Eustachian tube. 1. The caro-
tid artery. After Bernard and Huette.
Fig. 2. A coil of silver wire forming a Spring for the retention of a
Catheter in the Eustachian Tube, and attached to the nostril.
After Bourgery and Jacob.
Fig. 3. Itard's Frontlet for the same purpose. After Itard -
Fig. 4. A view of the Frontlet as applied. " "
Fig. 5. Perforation of the Tympanum by Deleau's Instrument. 1, 2.
The instrument. 3. The membrana tympani at the point of perforation,
SO as to avoid the handle of the malleus. After Bernard and Huette.
Fig. 6. Removal of a Polypus, by the Forceps, from the External Audi-
tory Canal. After Bernard and Huette.
Fig. 1. Fabriji's mode of strangulating Aural Polypi by the repeated
application of the ligature with its canula. 1. The hand of an assistant
holding the canula. 2. The second canula and ligature about to be ap-
plied below the first. 3. The fingers of the surgeon passing its loop over
the first canula by means of a probe. After Bourgery and Jacob.
Fig. 8. A vertical section of the ear, showing the subsequent constric-
tion of the base Of the tumor. After Bourgery and Jacob.
ANATOMY OF THE EAR. 413
those who desire to be able to treat its various complaints, the
present account must be limited merely to the general auatomical
and operative details.
SECTION I.
ANATOMY OF THE EAR.
Of the two portions of the ear, one is external, being the ear of
common language, whilst the other is designated as the internal
ear, being the structure mainly concerned in the sense of hearing.
The External Ear consists of a fibro-cartilaginous and fleshy sub-
stance, which is covered by the skin and attached to the side of the
head by ligaments and muscles, and of a cartilaginous tube which
leads from the external meatus to the internal ear. The Lobus, or
soft and fleshy portion of the ear, is at the inferior extremity of the
organ. AYhen lost, it may be, in a measure replaced by a plastic
operation (technically known as otoplasty), in which a flap is taken
from the adjacent integuments and attached to the cartilaginous
portion, as will be detailed hereafter.
The Meatus Auditorius Externus, or orifice of the cartilaginous
tube, is at the bottom of the concha or fossa, found in the external
ear. Its orifice is about three lines in diameter. The canal itself
in the adult is an inch long from its orifice to the membrana tym-
pani, or septum which closes it inwardly, and it is narrower in the
middle than at either of its extremities.
This tube is also more expanded downwards than it is trans-
versely; consequently, foreign bodies lodged in it may be most
readily seized by forceps passed beneath and above the object. The
speculum should also be opened in the vertical line instead of
transversely.
As the cartilaginous tube runs inwards with a slight inclination
forwards, and with a convexity upwards in its curvature, it is requi-
site to pull the external ear upwards and backwards when it is wished
to look to the bottom of the canal.
The Membrana Tympani (Plate XXVIII., Fig. 1) is a complete
membranous septum interposed between the meatus externus and
the tympanum at the bottom of the canal just spoken of. It is
placed very obliquely across the meatus, so that its upper edge
414
OPERATIVE SURGERY.
inclines outwards, and its lower edge inwards, the latter forming a
very acute entering angle with the floor of the meatus or the carti-
laginous canal (Plate XXVIII., Fig. 1), which gives it an additional
length, and renders it difficult to see to its bottom. An examina-
tion of the part, therefore, requires a strong light.
The membraue of the tympanum is slightly tense, and has its
middle drawn inwards in consequence of its being attached to the
handle of the malleus.
In the Internal Ear, the tympanum is the portion which is
interposed between the meatus auditorius and the labyrinth.
At the fore part of the tympanum is the Eustachian tube, which
runs for six or eight lines in the petrous portion of the temporal
bone, and terminates in a cartilaginous and membranous portion,
which communicates with the pharynx at the posterior nares (Plate
XXVIIL, Fig. 1).
The orifice of the Eustachian tube is found in the upper part of
the throat, on a line with the posterior end of the inferior turbi-
nated bone. It is rounded, oval, or trumpet-shaped, and large enough
to admit the tip of the little finger (Plate XXVIIL, Fig. 1). The
canal in its whole length measures nearly two inches, and its course
is nearly horizontal, backwards and outwards towards the mem-
brana tympani, diminishing as it goes backwards, so as to receive
with difficulty a small probe. It is lined in its whole extent by a
fine and extremely delicate mucous membrane, which is continuous
with that in the throat. 1 In catarrhal affections, its mucous secre-
tions sometimes fill the whole cavity of the tympanum; and it is
also liable to adhesions of its side, as well as to stricture.
SECTION II.
OPERATIONS ON THE EAR.
§ 1. — OTOPLASTY.
The formation of a new lobe for the ear is a plastic operation,
invented by the late M. Dieffenbach, of Berlin, in which a proper-
shaped flap is taken from the side of the head, or rather from the
lateral portion of the neck, and, being slid from its original position,
is fastened by sutures upon the deficient part. After union has
1 Horner's Special Anatomy, vol. ii., Philadelphia, 1851.
OTOPLASTY. 415
taken place, the flap is cut free at its base, as in the operations of
Rhinoplasty.
Another mode of operating will be found in the following method
of Dr. Pancoast, of Philadelphia: 1 —
Operation. — A piece of integument, rather larger than the natu-
ral size of the lobe, was marked out by an incision in front of the
ear, and a semicircular portion of larger size, but narrowed where
it touched the cicatrix, dissected up from behind the ear or over
the insertion of the sterno-cleido mastoid muscle. A sharp-pointed
bistoury being then passed under the front portion of the ear, it was
freed from its attachments by a single sweep of the instrument, and
the everted edge of the tragus loosened with the knife, leaving a
raw surface, which was of considerable size, and bled freely, but
without requiring ligatures. The margins of the wound in front
being closed with the harelip suture and adhesive plaster, the poste-
rior flap was brought round over the lobe to the anterior portion
of the ear, where it was fastened with two stitches of the interrupted
suture; the parts presenting a good appearance, though the lobe
was purposely made larger than natural, in order to admit of the
shrinking which always ensues upon operations of the plastic class.
The lower point of the ear, which had been strained downwards by
the cicatrix, retracted when loosened during the operation to nearly
the natural length, and the success was perfect.
Remarks. — This operation of Dr. Pancoast is a slight modification
of that of Dieffenbach, and was performed to relieve the cicatrix
from a burn, the pinna being drawn close to the head, and the lobe
lost in the common covering of the face and neck.
Any operation for the restoration of the lobe is, however, one of
doubtful utility. At best, the restored portion cannot aid or affect
the hearing, and will not resemble the lobe, whilst the removal of
the flap produces cicatrices upon the neck, which are apt to cause a
greater deformity than that arising from the original defect.
The removal of tumors from the lobe requires the same steps as
those demanded by tumors elsewhere. In several cases reported
by Dr. Geo. W. Norris, of Philadelphia, 2 they resembled keloides ;
and, as it appears from Dr. Norris's statement, are most common in
the negro race, being the result of perforation of the lobe for the
use of ear-rinsrs.
O
1 Am. Journ. of Med. Sciences, vol. v. N. S. p. 100, 1843.
2 Am. Journ. Med. Sciences, vol. xx. N. S. p. 557.
416 OPERATIVE SURGERY.
§ 2. — FOREIGN BODIES IN THE MEATUS AUDITORIUS EXTERNUS.
Foreign bodies, as found in the external meatus of the ear, arc
very varied, and may consist of insects, beads, coffee-grains, or
similar articles, accidentally introduced into the meatus, or of col-
lections of hardened wax, combined with epithelial scales, wool,
hair, or other substances, either naturally or accidentally collected
in the tube itself.
I. EXTRACTION OF FOREIGN BODIES.
Operation. — Whenever it is desired to remove an insect from
the ear, the head of the patient should be inclined to one side, and
the meatus filled with any mild oil, which is to be retained in the
ear a few minutes, by keeping the patient's head in an inclined posi-
tion. The oil thus occupying the tube closes the respiratory pores
of the creature, and soon either kills it or causes it to seek the orifice,
to obtain air or to escape, when it may be seized, or subsequently
washed out with a syringe and tepid water, especially if inflamma-
tion exists, as this increases the sensibility of the part.
If the foreign body should be a hard substance, and one not
capable of absorbing water, then the best plan of removing it will
be to wash it away by the force of a stream of water thrown in on
one side of it, and made to fly outwards from the resistance created
to its entrance by the surface of the membrane of the tympanum.
II. TO WASH OUT FOREIGN BODIES.
Operation of Dr. Marion Sims, of Alabama 1 (now of New
York). — Introduce the point of a long, but large-nozzled syringe,
as near as possible to one side of the foreign body, there being very
few that will distend the meatus so completely as to prevent the
passage of a stream of water on one side. Then drive in a full
stream with all the force of the syringe, and the recurrent stream
will generally bring the foreign substance to a point where it may
be seized with the forceps or curette.
1 See Bibliography, p. 80.
POLYPI IN THE MEATUS EXTERNUS. 417
As the necessity of washing out the ear is often noticed in the
treatment of otorrhoea, the removal of hardened wax, or for the
examination of the membrana tympani, the following neat method
of accomplishing it is given, as, though a simple operation, I have
often seen patients soiled and annoyed by its imperfect perform-
ance : —
To wash out the Auditory Canal. — Direct the patient to hold
a large teacup close under the lobe of the ear, and press it firmly
against the mastoid cells. Then, whilst the ear is drawn upwards
and backwards by the surgeon's left hand, let him hold the body of
the syringe between his thumb and second finger, whilst his fore-
finger forces in the stream from the syringe by pressing on the
piston. If the force of the stream is not too great, the water will
all pass into and not over the cup, and the patient's neck and
clothing will not be in the least soiled, or even dampened.
Kemarks. — In introducing any instrument into the ear of an
adult, the peculiarity of the shape of the external canal should be
recollected. The operator should, therefore, pass it either from
above or below, so that it may correspond with the largest dimen-
sions of the canal, the vertical diameter of the meatus being
greatest in this direction ; but in a child it should be directed either
towards the front or back of the meatus, as the transverse measure-
ment is here the greatest. Hardened wax may be softened by
warm oil or water, and then either picked out with the scoop or
washed out with the syringe, the ear being drawn upwards, out-
wards, and backwards, in order to facilitate its escape, by straight-
ening the cartilaginous tube.
Should every other means fail, the surgeon may resort to the plan
of Paulus ^Egineta, and, perforating the cartilaginous tube from
below, introduce a probe behind the foreign body, and thus push
it outwards.
§ 3. — POLYPI IN THE MEATUS EXTERNUS.
Polypi in the ear, like polypi elsewhere, may be of different
kinds, that is, either soft, mucous, fleshy, or carcinomatous. Gene-
rally, these tumors arise from the tympanum, or its membrane, and,
distending the meatus, sometimes project externally (Plate XXVIIL,
Fig. 6). If of the soft kind, they may be removed by seizing them
27
418
OPERATIVE SURGERY.
with forceps, and rotating the latter until the polypus is twisted,
when simple traction will suffice to remove it; or, if it is possible
to pass a loop around the growth, its strangulation may be effected
by a wire or silk ligature in a small double canula like that of
Levret, as I have done in two cases successfully. If more firm,
the polypus may require excision in pieces, the hemorrhage being
readily arrested by compression in the meatus. In all cases, how-
ever, it is usually desirable to apply the nitrate of silver to the seat
of the tumor after its removal; to keep the meatus clean, by re-
peated syringing, and to employ astringent washes, occasionally.
Where the polypus is very large, and fills up the meatus externus
entirely, the repeated applications of the wire ligature will enable
the surgeon to remove it entirely.
Operation of Fabrizji, of Mopena. 1 — The patient being so
seated as to throw the light into the meatus, the surgeon should
pass the loop of a wire ligature, contained in a double canula,
around the polypus, passing it by means of a probe as far as pos-
sible into the auditory canal and towards the base of the tumor.
Then after firmly constricting it with this loop, let him next pass
the loop of a second ligature in its canula, over the first, drawing
upon the latter so as to carry the second ligature as deeply as pos-
sible, and, constricting the tumor by this, remove the first ligature
and canula. If the second thread does not cause the tumor to come
away, carry a silk or buckskin ligature in a flexible canula below
it, and twist it until the tumor is cut off. (Plate XXVIII Figs
7,8.)
§ 4.— PERFORATION OF THE MEMBRANE OF THE TYMPANUM.
Perforation of the membrana tympani was suggested by Sir A.
Cooper in 1800, in order to permit the entrance of air into the
middle ear when the Eustachian tube was permanently closed, or
when the membrane was too much thickened and changed' to
vibrate. Although a simple operation, it has not been much prac-
tised, owing, apparently, to a want of confidence in its utility, or
of fear, lest injurious consequences should result. Such fears are,
however, groundless ; the puncture being readily made, not pro-
ductive of great pain, and often healing with great facility.
1 Bourgery, M£d. Op£rat., torn. 7™*, p. 33.
PERFORATION OF THE MEMBRANE OF THE TYMPANUM. 419
Operation of Sir Astley Cooper. — After inclining the head,
so that a strong light shall fall directly into the meatus, introduce
a small trocar, or the instrument of Deleau (Plate XXIII., Fig. 19),
or the knife of Horner (Plate XXIIL, Fig. 17), at the anterior
inferior side of the membrane, and transfix it so as to avoid the
handle of the malleus.
Eemarks. — In cases where the Eustachian tube is closed by
mucus, and the surgeon finds it difficult to clear or dilate it by cathe-
terism through the nostril, or when he wishes to assure himself posi-
tively that this tube is patulous, perforation of the membrane of the
tympanum will enable him to act upon the cavity of the tube very
advantageously, and to test with great certainty the condition of the
inner portion of the ear by forcing a current of air from a syringe
through the meatus externus against the puncture in the membrana
tympani. As the wound in the membrane will heal readily, the
patient runs no risk of injury if the Eustachian tube prove to be
totally impervious, whilst, if choked, it can be thoroughly cleansed
by driving the mucus into the throat in the natural course of the
tube. By thus demonstrating the pervious condition of the tube,
the diagnosis of the character of the deafness will be much sim-
plified.
Operation of Dr. William E. Horner, of Philadelphia. —
A method, which the late Dr. Horner practised on many occasions,
enabled him to pass a stream of water or air from the meatus ex-
ternus into the throat, and thus clear the Eustachian tube more
effectually than can possibly be done by means of a catheter passed
into its orifice from the nose. It is accomplished as follows: Per-
forate the inferior half of the membrana tympani by a sabre-shaped
knife, one line in breadth, the edge of which is on the convex
margin (Plate XXIIL, Fig. 17), by first plunging the cutting edge
upwards, and then revolving it on its axis, so as to make the incision
either angularly or of the shape of a V, as this will leave a flap easily
moved. A small pipe, surrounded by a cork (Plate XXIIL, Fig.
21), being then introduced tightly into the meatus externus, so as
to plug it up, and a small syringe, holding an ounce and a half,
being adapted to the pipe, the water may be forced through the
hole pierced in the membrana tympani, as just directed, and thus
pass into the internal ear and out of the pharyngeal orifice of the
tube. The stream thus being thrown in, will now be found to
wash out the t} r mpanum and Eustachian tube, with great facility,
420 OPERATIVE SURGERY.
as may be readily ascertained by seeing the water escape from the
throat or nose. The air douche may also be most perfectly accom-
plished in the same manner; in any other way it is very defective,
and not to be relied on for what it professes to do, viz., to open the
Eustachian tube, as a very little reflection will prove. For example,
let the same cork be fitted into a vial, and then let the operator
try to inject air from the syringe into the bottle, and he will have a
representation of the real effect of the air douche by the catheter
introduced into the Eustachian tube from the nostril, as usually
practised.
Eemarks. — Though Dr. Horner often performed this operation,
he never knew it to do harm, but has, on the contrary, known it to
do good. The principal idea of the profession, at one time, in regard
to the cause of deafness, was (as evolved by the assertions of lead-
ing aurists), the fact of there being an obstruction of the Eustachian
tube. This Dr. Horner believed to be an error, the obstruction of
this tube being, in his experience, very unusual as a simple form
of disease, though large claims were made upon public credulity
by those who boldly asserted its existence.
In the air douche, by the catheter passed into the Eustachian
tube, as usually advised, the introduction of the air may be regu-
lated by a column of water acting on a large reservoir of air, or by
means of the cock in the canister (Plate XXIII., Fig. 23), or by
simply resorting to the caoutchouc bottle (Plate XXIII., Fig. 22).
§ 5. — CATHETERISM OF THE EUSTACHIAN TUBE.
When the position of the orifice of the tube in the pharynx ia
recollected (Plate XXVIII., Fig. 1), it will be seen that the intro-
duction of the ear catheter through the nostril and pharynx is also
a simple operation, though the verbiage in which it has often been
described tends to create a belief in its being difficult. Aurists
have recommended various instruments for the performance of this
operation, and the catheters most in repute are those figured in
Plate XXIII., Figs. 12, 13.
Ordinary Operation.— The patient being seated with the head
slightly thrown backwards and firmly supported, take the catheter
in the right hand, and, after oiling it, introduce it into the nostril
on the side to be sounded. Then, keeping its point upon the floor
CATHETERISM OF THE EUSTACHIAN TUBE. 421
of the nostril, and its convexity upwards and inclined against the
septum narium, slide it backwards until it reaches the soft palate,
as may be readily told by the sense of touch transmitted along the
instrument, or by the patient making a slight gulp or effort to swal-
low. At this moment, turn the point of the catheter upwards and
outwards by rotating it a quarter of a circle, and then, by a slight
movement forwards and backwards, slip it into the orifice of the
tube, and it will pass with as much, if not more ease than a catheter
can be made to enter the bladder. The proper position of the in-
strument may be at once known by its steadiness, as well as by the
sensation of the patient.
When it is desired to inject air or liquids through the instru-
ment, compress the nostrils and catheter in the fingers of one hand,
and employ the syringe or gum elastic bottle with the other, or
resort to a little wire spring (Plate XXVIII., Fig. 2), or to a front-
let (Plate XXVIIL, Fig. 3).
The frontlet, forceps, air-drum, &c, will all be found essential to
the operations of those who may wish to devote themselves espe-
cially to aural surgery; but, for the general operator, the instru-
ments, figured in Plates XXIII. and XXVIIL will prove sufficient.
Cases of deafness have been occasionally met with in which the
aurist has found it impossible to pass the catheter into the pharyn-
geal orifice of the ear, and the cause of the difficulty has been
either unknown or undescribed, in consequence of the rarity of a
post-mortem examination of this region.
The attention of the profession has, however, been lately called
by Dr. Jno. Neill, of Philadelphia, 1 to the results of several post-
mortem examinations, in which he has noticed a peculiar condition
of this orifice of the Eustachian tube, it being overhung at its supe-
rior and posterior border by a thickening and hypertrophy of the
mucous membrane with enlarged follicles, which is doubtless the
occasional cause of deafness. Dr. Neill thinks it probable that the
supposed enlargement of the tonsils which have so frequently been
supposed to be the cause of deafness, may be readily owing to the
condition which he has described.
Eemarks. — The almost universal necessity that exists in the
United States for every surgeon to practise several distinct por-
tions of his profession, as well as the absence of definite instruction
1 Medical Examiner, vol. ix. p. 626, 1853.
422 OPERATIVE SURGERY.
in these complaints, usually noted in the ordinary courses of educa-
tion in our medical schools, has, for many years, induced the ma-
jority of the profession to shun the treatment of aural complaints,
and forced patients into the hands of empirics. All the operations
upon the ear are, however, so easily practised, and the variety of
the complaints requiring them so very limited, that this condition
of things may be readily remedied by any surgeon.
In order to prove this, an effort has now been made to describe
all the ordinary operations required for the relief of deafness, as
fully as is necessary, and if the reader follows the foregoing descrip-,
tions, in connection with the plates, he will, it is hoped, find them
full enough for all general points of practice connected with aural
surgery. Washing out the external and internal auditory tubes,
with perforation of the membrana tympani, or perhaps the mastoid
cells, really constitutes the entire portion of aural operative sur-
gery, and are operations which can be easily executed by any one
who can lay claim to the qualifications of a surgeon. I think,
therefore, that it is to be regretted that the difficulties of aural
operations are so greatly overrated by physicians generally. The
prognosis of the complaints requiring these operations is, it is
true, often doubtful, or decidedly unfavorable, yet it should be re-
membered that, even when unable to cure, a practitioner may effect
much good by assuring the patient of the impossibility of his being
relieved, and every one should, therefore, gain such an amount
, of practical skill as will enable him to give an opinion. By wash-
ing out the meatus externus, and examining the condition of the
membrane of the tympanum; by catheterizing the Eustachian tube,
or by perforating the membranum tympani, and testing the per-
meability of the passage to the throat, as above described, much
advantage will often be gained by the patient, whilst the profession
will be able to rescue many persons from the hands of unprincipled
men, who, in the majority of cases, only do them harm.
If the general practitioner would only give these cases the atten-
tion that they deserve, or place them in the hands of a judicious
surgeon, he would do much to banish the wretched quackery in
aural complaints now so often seen. Or if he would devote himself
for a short period to the perusal of the excellent works of Mr.
Wilde, or of Kramer, he could soon obtain abundant evidence that
aural diseases are not as difficult to treat as he had at first, when
inexperienced, been led to suppose. When deafness cannot be
CATHETERISM OF THE EUSTACHIAN TUBE. 423
cured by a scientific course of treatment, it becomes the duty of
the practitioner to exert his influence in preventing the patient
from wasting his time and money among charlatans and ignorant
pretenders, whether pretending to cure by " Scarpa's acoustic oil,"
or by the magnetic, electropathic, or chronothermal plan of treat-
ment. Having often been compelled to notice patients who, whilst
incurably deaf, have yet received a tacit permission from medical
men to try some of these pretenders, I wish to call the reader's
attention especially to this point, and urge upon him the import-
ance of thus attending to his patients' welfare, if only on the simple
ground of " doing to others as he would they should do to him."
PAKT III.
OPERATIONS PRACTISED OX THE NECK AND TRUNK.
CHAPTER I.
SURGICAL ANATOMY OF THE NECK.
The Neck is usually described by anatomists as that region of
the body which is situated between the head and the trunk, being
bounded above by the base of the jaw, mastoid portion of the tem-
poral bone, and occipital part of the skull, and below by the cla-
vicles, sternum, and scapulae. In its general outline, this region is
cylindrical or cylindroid, with the base upon the shoulders. On
the front and sides it is decidedly convex, presenting certain well-
marked prominences, which, by establishing fixed points of refer-
ence, are highly useful to the surgeon. On its posterior face it is
flat and regular, presenting nothing deserving of especial notice.
The prominences and depressions seen on the front of a well-
formed neck indicate the position of certain important organs which
are often objects of solicitude to an operator. Thus, immediately
above the sternum, in the median line of. the neck, is a depression
called the supra-sternal fossa, near or in which are usually found
the roots of the large bloodvessels directly connected with the heart
as well as several important nerves. Above this, in the median
line, is the prominence caused by the larynx and trachea, and a
little outwardly on each side of this line may be seen the elevation
caused by the sterno-cleido-mastoid muscle. In front of this mus-
cle, or between it and the trachea, is the carotid fossa or depression,
where, from the superficial position of the vessel, its pulsations may
be readily felt. At the base of the neck, near the clavicles and
exterior to the sterno-cleido-mastoid muscle, is the supra-clavicular
426 OPERATIVE SURGERY.
depression or fossa, containing part of the subclavian artery and
veiu, together with some other vessels of importance; and at its
upper portion, in the space adjoining the base of the jaw, are the
parotid and supra-hyoid regions, which contain several important
parts, as will be referred to more in detail hereafter.
The cylindrical shape of the neck, and the enlargement at its
base, render the smooth application of a broad bandage around it
nearly impossible, and it will hence be generally found necessary
either to make all such pieces of dressing quite narrow, or to give
them a curved shape on the lower edge like that seen in the stocks
worn by men as an article of dress, in order to enable them to fit
the clavicular portion of this region. A similar shape will also be
requisite to adapt them to the upper and lateral parts of the neck,
and especially to the outline of the chin and sides of the jaw.
Owing to the great importance of the various organs contained
within the neck, and the necessity of an accurate knowledge of their
relations to each other, it has been found advantageous to divide it
into numerous sections or departments, either by imaginary lines,
or by following the course of well-known muscles. Each of these
sections demands special attention, the advantages of such a subdi-
vision being found in the facility as well as accuracy with which
the position of their contents may be recognized. Of the various
regions thus created by anatomists, none seems to me to present
points of greater practical utility than that employed by M. Blan-
din, in his Anatomie Topographique, and the following descriptions
will, therefore, be based mainly on the accounts furnished by him.
In mapping out the regions of the neck, M. Blandin has divided
its anterior or Tracheal surface into those parts which are above
and those below the os l^oides, and into such as are more or less
closely connected with the course of the sterno-cleido-mastoid
muscle. Of the portion above the os hyoides, he makes two regions,
one the Supra-Hyoid or Hyo-glossal region, being the portion near
the chin, and the other that about the parotid gland or the Parotid
region. The parts below the os hyoides, on the front of the neck,
he divides into the Laryngo-Tracheal and the Supra-Sternal regions,
whilst those on the sides are designated as the Sterno-Mastoid,
Carotid, and Supra-Clavicular regions. The boundaries of these
regions being, however, a purely conventional one, we find that in
mapping it out there is some difference in the descriptions of dif-
ferent writers.
THE SUPKA-HYOID OR GLOSSO-HYOID REGION OF THE NECK. 427
By some of the English anatomists 1 the disposition has been
shown to apportion the neck into regions of a more mathematical
character than those adopted by Blandin. Thus, on the neck being
extended, one-half of it is made to take the form of an elongated
square, which square is divided by the course of the sterno-cleido-
mastoid muscle into two triangles, one near the clavicle and the
other near the jaw, in both of which are parts of vital importance.
But though upon the subject, such a formation of regions may
answer the descriptive purposes of the anatomist, it will not prove
as useful to the surgeon as that adopted in the following pages,
from the fact that any difference in the extension of the neck must
cause the diagonal line to vary, and thus render the relations of the
various parts incorrect, unless the utmost possible tension of the
muscle is always obtained. As considerable experience has satis-
fied me of the practical utility of the system adopted by Blandin,
it is recommended to the study of those who desire to obtain such
a minute knowledge of this important section of the body as will
fit them for the duties of the operator.
SECTION I.
THE SUPRA-HYOID OR GLOSSO-HYOID REGION OF THE NECK.
The Glosso-hyoid portion of the neck is bounded above by the
inferior part of the tongue or base of the lower jaw; below, by
the os hyoides, and laterally by a line drawn from the angle of
the jaw to the extremity of the greater cornu of the hyoid bone,
or by the expansion of that process of the fascia superflcialis cer-
vicis which is attached to the stylo-maxillary ligament and angle
of the jaw. (Plate XXIX., Fig. 1.) The skin of this part presents
nothing requiring special description. Its muscles consist of a
portion of the platysma-myodes ; of the anterior belly of the
digastric, of the mylo-hyoid, genio-hyo-glossus, hyo-glossus, and a
part of the stylo-glossus, all covered by a fibrinous expansion or
fascia. This fascia being the second tegumentary covering of the
neck, as of several other portions of the body, is attached in this
region to the os hyoides and base of the jaw. It sends a triangular
process over the muscles at this part, surrounds the submaxillary
1 Surgical Anatomy, by Joseph Maclise, Philad. edit. 1851.
428 OPERATIVE SURGERY.
PLATE XXIX.
THE SURGICAL ANATOMY OF THE NECK.
Fig. 1. A view of the arrangement of the Fascia of the Neck. 1. Pa-
rotid gland. 2. Masseter muscle. 3. Submaxillary gland. 4. Os
hyoides. 5. A portion of the fascia superficial dissected from the side
of the face, and held down to show its relations to the stylo-maxillary
ligament and angle of the jaw, together with the septum which separates
the parotid from the submaxillary gland. 6. Deep process of fascia su-
perficial which forms the septum just spoken of. 7. Internal jugular
vein just beneath the angle of the jaw. 8. Deep cervical fascia. 9. Sterno-
hyoid muscle partly displayed. After Nature.
Fig. 2. A view of the Superficial Vessels of the Neck. 1. Inferior
maxillary bone. 2. Lingual artery. 3. Os hyoides. 4. Superior thy-
roid artery. 5. Descending branch. 6. Position of carotid artery. 7.
Sternal origin of sterno-cleido-mastoid. 8. Clavicle. 9. External jugu-
lar vein. 10. Its anterior branch. 11. Parotid gland and veins near
an°"le Of jaw. After Bernard and Iluette.
Fig. 3. A view of the deep-seated parts of the Neck. 1. The oeso-
phagus. 2. Omo-hyoid muscle. 3. Par vagum nerve. 4. Internal ju-
gular vein. 5. Carotid artery. 6. Digastric tendon. 7. Hypoglossal
nerve. 8. Facial artery. 9. Facial vein. 10. Occipital and internal
maxillary veins. 11. External carotid artery seen after removal of paro-
tid gland. 12. Masseter muscle. 13. Pectoral muscle and clavicle. 14.
Hook holding aside external jugular vein. After Bernard and Huette.
Fig. 4. A front view of the veins of the Neck. 1, 1. Base of lower
jaw. 2. Os hyoides. 3, 3. Internal jugular. 4. Omo-hyoid muscle.
5. Larynx. 6. Sterno-hyoid and thyroid muscles. 7, 8. Superficial
veins. 9. External jugular. 10. Sterno-cleido muscle.
After Bernard and Iluette.
Fig. 5. A side view of the Oesophagus and adjacent parts. 1. Facial
artery and vein passing on to the face. 2. Lingual artery. 3. Os hyoides.
4. Superior thyroid artery. 5. Oesophagus. 6. Trachea. 7. Inferior
thyroid artery. 8. Sterno-cleido-mastoid, cut across. 9. Primitive ca-
rotid. 10. Internal jugular. 11. Upper portion sterno-cleido-mastoid
HlUSCle. After Bernard and Huette.
THE PAROTID REGION. 429
gland, and then, by attaching itself to the stylo-maxillary ligament
and ano-le of the jaw, places the submaxillary gland in a kind of
pouch, which separates it by a perfect septum from the anterior
and inferior portion of the parotid. (Plate XXIX., Fig. 1.) This
reflection of the fascia superficialis and its attachment to the stylo-
maxillary ligament is a valuable point of reference in operating on
this and the adjacent regions. It also exercises a material influence
on the disorders of the part, by preventing suppurations in the
neighborhood of the parotid or submaxillary glands from commu-
nicating or travelling either forward or backward ; it has also con-
siderable influence on the development of tumors and their subse-
quent shape and condition.
The principal Arteries found in this region are the facial, lingual,
and sublingual. (Plate XXIX., Fig. 5.)
The Veins generally follow the course of the arteries, except the
lingual vein, which, it should be remembered, is separated from its
corresponding artery by the hyo-glossus muscle.
The Nerves are the hypo-glossal, lingual, glossopharyngeal, and
their branches. (Plate XXIX., Fig. 3.)
SECTION II.
THE PAROTID REGION.
The Parotid region of the neck comprises its superior andjateral
portions, and, though limited in extent, is of the highest importance
to the surgeon. Bounded in front by the ramus of the inferior
maxillary bone; behind, by the mastoid process of the temporal as
well as by the meatus externus of the ear; above, by the zygomatic
arch; below, by a horizontal line drawn a little below the level of
the angle of the jaw; and within, or in its deeper points, by the sty-
loid process of the temporal bone, as well as by the stylo-maxillary
and stylo-hyoid ligaments; this region is closely circumscribed by
dense tissues, and is generally accurately filled up by the parotid
arland and its vessels. The muscles near the srland are the sterno-
cleido-mastoid behind, to which, when enlarged, the posterior edge
of the gland is often firmly attached; and the posterior belly of the
digastric; the styloid muscles are within, or at the deepest side of
the gland.
430 OPERATIVE SURGERY.
The Parotid Gland, in its normal condition, being seated between
the angle of the jaw and the mastoid process of the temporal bone,
is limited to these points; but, when diseased, will be found to en-
croach considerably upon the surrounding parts. Owing, however,
to the expansion of the superficial fascia, and its attachment to the
angle of the jaw, as before stated, the parotid is separated from the
submaxillary gland, and cannot, therefore, extend itself to any great
degree forwards. The styloid process and ligaments limiting its
deeper progress, and the sterno-mastoid muscle resisting its poste-
rior development, nothing is left it but to enlarge outwardly or
towards the skin ; and, as its progress in this direction is resisted
by the portion of the fascia superficialis, which covers it and forms
its capsule, the engorgement of this gland generally causes severe
pain by pressing on the neighboring nerves. The dense character
of the fascia, and its strong adhesions around the gland, have also
an important influence upon the bloodvessels connected with it. In
two cases which occurred under my observation, it led to the entire
obliteration of the carotid artery, and in one to that of the internal
jugular vein, as well as the artery. When enlarged by scirrhus or
similar deposits, the shape of parotid tumors is always at first more
or less flattened in consequence of this expansion of the fascia over
the surface of the gland, though ultimately they may attain consi-
derable size and a globular form. Having no proper capsule, in
the normal condition, the parotid gland owes its shape, and the
continuity of its structure, to cellular substance, the induration of
which, as well as its adhesion to the fascia just alluded to, renders
the extirpation of the gland much more easy when diseased than
it is in the healthy condition.
The Arteries of the parotid region are numerous, and among the
most important of those found in the neck. The External Carotid,
entering at the inferior and internal portion of the gland, passes
through its substance not far from its internal or deeper-seated sur-
face, and extends between the ramus of the jaw and the ear to near
the level of the neck of the jaw-bone, when it gives off the internal
maxillary and the temporal arteries. The Internal Maxillary, wind-
ing around the neck of the bone between the pterygoid muscles, is
hence difficult to ligate, and sometimes gives rise to considerable
recurrent hemorrhage, even after the appi ication of a ligature to the
external carotid of the same side, as I hav e seen in three instances.
The Veins follow pretty generally the courso and distribution of the
THE LARYNGOTRACHEAL AND SUPRA-STERNAL REGIONS. 431
arteries; but, owing to their direct connection with the internal
jugular vein, caution is requisite in opening them, lest air be intro-
duced into the latter vessel, whence it may readily pass to the heart
and cause death.
The principal Nerve of this part is the portio-dura, which, emerg-
ing at the stylo-mastoid foramen, penetrates the substance of the
gland from above downwards and forwards. Lymphatic Glands are
also found in considerable numbers (Plate XXXIII., Fig. 1) around
as well as beneath the structure of the parotid, and the disease of
these glands has occasionally rendered the diagnosis of tumors in
the parotid region difficult, and led to mistakes in respect to the
structure involved in the complaint.
SECTION III.
THE LARYNGO-TRACHEAL AND SUPRA-STERNAL REGIONS.
The middle of the front of the neck, presenting points directly
connected with the trachea and larynx, has been named the Tracheal
region, and is formed by that portion which is bounded laterally by
the anterior edges of the sterno-mastoid muscles. The part of this
surface above the os hyoides has already been spoken of as the
supra-hyoid region. The region immediately below it constitutes
the Laryngo-Tracheal, the lower portion of which, or that nearest
the sternum, has been called the Supra-Sternal region.
The Laryngo-Tracheal region presents several useful points of
reference, which are apparent outside of the skin. Thus, in passing
from the os hyoides to the sternum in the median line, there is the
prominence of the hyoid bone, the thyro-hyoid depression or space
between the os hyoides and the thyroid cartilage, and indicated
chiefly by the notch in the top of the cartilage. Next may be felt
or seen the crico-thyroid space; the prominence caused by the de-
velopment of the thyroid gland ; then the rounded surface of the
trachea; and, lastly, the supra-sternal fossa or depression, the depth
of which is generally increased when the patient expands the chest,
as in taking a full inspiration. On the external or lateral portions
of the region, near the anterior edge of the sterno-mastoid muscles,
may be felt the pulsations of the primitive carotid arteries; and this,
as before stated, has led some anatomists to designate this portion
432 OPERATIVE SURGERY.
of the neck as the Carotid region, instead of viewing it as merely
the lateral boundary of the preceding part.
Examining the structures concerned in these portions of the neck,
but little time need be given to the skin, which differs in nothing
that is important from the same tissue elsewhere. Beneath it is seen
the common Fascia Superficialis, and beneath this, but separated by
sparse cellular substance, is the fascia known as the Cervical Fascia
of Allan Burns, 1 or the Fascia Profunda, a laminated expansion
which exercises a most important influence on the diseases of this
region. This fascia, arising from the larynx, forms a thin capsule
to the thyroid gland, and, being then closely attached to the inferior
margin of the gland, descends to the sternum in two lamina, so as
to form a perfect sheath for the sterno-hyoid and thyroid muscles.
At its inferior extremity it is firmly attached to the sternum, sternal
ends of the clavicles, and cartilages of the adjoining ribs, for about
one inch below the upper edge of the breast-bone, thus forming an
elastic and resisting membrane from the top of the sternum to the
larynx. Directly above the sternum, it surrounds the arteria inno-
minata and brachio-cephalic vein; and beneath it are the trachea,
roots of the large arteries of the head and upper extremities, and
the trunks of their veins, as well as important nerves. 2 Between
these organs and the fascia there is much loose cellular substance
filled with lymphatic glands, the former being liable to serous infil-
tration, and to extensive suppuration in the disorders of this and
the adjacent portions of the neck. The external border of the fascia
profundi colli is continuous with the sheath of the carotid arteries,
whilst it and the fascia superficialis are united together along the
anterior edge of the sterno-cleido-mastoid muscle.
The sterno-hyoid and thyroid muscles, on the median line of the
neck, are the only muscles useful as points of reference in this
region.
The Arteries are among the most important of the body. Count-
ing from the sternum upwards, we find the innominata passing
obliquely from left to right, and from below upwards. As it is only
about eighteen lines in length, its position is limited chiefly to the
supra-sternal fossa. Next to this may be mentioned the carotids
which are in the lateral boundaries, and extend usually to a level
1 Burns on the Anatomy of the Head and Neck.
2 Special Anatomy and Histology, by Wm. E. Horner, vol. i. p. 378, eighth edition.
THE LARYNGOTRACHEAL AND SUPRA-STERNAL REGIONS. 433
with the os hyoides without giving off any branches ; but, on reach-
ing this level, they give origin to the two superior thyroid arteries.
These, in connection with the two inferior arteries of the same
name, run to supply the thyroid gland and adjoining parts, and are
the only arteries which can be especially referred to as restricted to
this region.
The accompanying Veins are very numerous, being both super-
ficial and deep-seated, and bring the blood from the thyroid gland
and the surrounding organs into the jugular vein. The deep-
seated veins have three principal directions: the superior follow
the course of the superior thyroid arteries, and empty into the
internal jugular vein; the middle come out at the sides of the thy-
roid gland, and also enter the internal jugular vein; but the sub or
inferior thyroid pass down in numerous anastomoses towards the
left subclavian vein, crossing the inferior portion of the trachea in
an opposite course from that taken by the arteria innominata, and
being also more superficial than this vessel. (Plate XXIX., Fig. 4.)
The superficial veins are more variable, and anastomose in various
ways with the deep veins. 1
The variable size and direction of these veins renders a minute
and accurate description of them impossible, though their position
in regard to the operations of tracheotomy and others practised on
this region would render it desirable. The surgeon should, there-
fore, be upon his guard, in all incisions made upon this part, and
especially as he approaches the supra-sternal fossa. The relations
of the veins and nerves connected with the course of the carotid
artery, or those on the borders of this region, will be referred to
hereafter.
The other tissues of this portion of the neck may be briefly
mentioned at present in their relations to each other, as well as to
those which surround them. Commencing with the skin, there
may be noticed, first, a loose cellular tissue, on which it moves
readily; a layer of the superficial fascia; an anterior layer of the
deep fascia, with some veins; the sterno-hyoid and thyroid mus-
cles; a posterior lamina of the deep fascia; the thyroid gland,
covered by each layer of this fascia, and thus placed in a capsule ;
the larynx and trachea, with the condensed cellular tissue around
them, which latter has been designated 2 as the tracheal fascia ; then
1 Blandin, Anat. Topograpkique, p. 191.
2 Forter, Surg. Anat. of Larynx and Trachea.
28
434 OPERATIVE SURGERY.
PLATE XXX.
INSTRUMENTS EMPLOYED UPON THE 03SOPHAGUS AND TRACHEA.
Fig. 1. Stomach-pump of Dr. Goddard.
Scbiveley'a pattern.
Fig. 2. Physick's (Esophageal Catheter for the evacua-
tion of the contents of the stomach.
Fig. 3. Ordinary (Esophageal Probang.
Fig. 4. (Esophageal Hook and Probang of Dupuytren.
Charriere's pattern.
Fig. 4'. (Esophageal Hook of Dr. Nathan Smith.
After Smith.
Fig. 5. Blunt Hook, made of annealed wire, for the removal of foreign
bodies from the oesophagus.
After Bond.
Fig. 6. (Esophageal Bougie for dilating stricture, employed by Dr.
Horner.
After Horner.
Figs. 1, 8. Bond's (Esophageal Forceps.
After Bond.
Fig. 9. Sponge for cauterizing the Larynx, as advised by Trousseau.
Charriere's pattern.
Fig. 10. Instrument employed by Dr. Green for the same purpose.
Schireley's pattern.
Fig. 11. Tongue Depressor; by which a patient can depress his own
tongue without incommoding the operator.
Rohrer's pattern.
Fig. 12. A Ring made of watch-spring, so as to be readily adapted to
any neck, and employed by the author to hold open the sides of the
trachea after the operation of tracheotomy.
Schiveley's pattern.
Fig. 13. Ordinary tracheal tube or canula, intended to be placed in the
trachea immediately after the operation of tracheotomy.
Charriere's pattern.
The objections to the employment of this tube have been stated in the
text.
THE SUPRA-CLAVICULAR REGION. 435
the oesophagus; and last, the muscles on the front of the vertebras.
In this enumeration, no reference has been made to the great ves-
sels and nerves of the neck, as their relations, variable disposition,
and arrangement, can be better understood in connection'with the
special operations practised upon them.
SECTION IV.
THE SUPRA-CLAVICULAR REGION.
At the base of the neck, immediately above the clavicle, being
bounded internally by the posterior edge of the sterno-mastoid
muscle, and externally by the anterior borders of the trapezius and
splenius muscles, is the region designated as the supra-clavicular.
Being triangufar in its outline, with the base below, the clavicle,
together with the trapezius, and sterno-mastoid muscles form its
three sides. The skin and fascia covering this region, with a small
portion of the platysma-myodes muscle, require little notice, as they
present nothing of importance, and are chiefly noted by the surgeon
as indicating the coverings that he may expect to find on tumors
in this neighborhood. Of the numerous lymphatic glands situated
about this part, some are superficial, and some deep-seated (Plate
XXXIII., Fig. 1), as in other regions of the neck. When enlarged,
the movable character of the swelling, and its greater development
when superficial, will generally enable an operator to tell whether
the tumor is seated above or below the fascia, a matter of much
importance to decide when extirpation is contemplated.
The Arteries usually found in the supra-clavicular region are
such as supply the upper extremities and the adjacent parts of the
neck. Among the first is the Subclavian artery, which, in the
course taken from its origin to its escape through the subclavius
muscle (whence to the edge of the axilla, it is called axillary), forms
a curve, the concavity of which surrounds the cul-de-sac made by
the expansion of the pleura above the first rib. 1 The branches
given off by the subclavian artery may be divided into those which
run horizontally with, and those whose course is perpendicular to,
the line of the clavicle. (Plate XXXIII., Fig. 1.) Among the first
are the Posterior Cervical, which is two fingers'-breadth above the
1 Blandin, Anat. Topographique, p. 206.
436 OPERATIVE SURGERY.
clavicle, the Superior Scapular, which runs close along the posterior
margin of the bone (and is often in the way of the operator in at-
tempting to ligate the subclavian), and the Transversalis Colli, all of
which run towards the back of the neck and top of the shoulder ;
while the Vertebral, Inferior Thyroid, and others, coming off within
the scaleni muscles, run more or less perpendicularly. The perpen-
dicular arteries, constituting the Thyroid Axis, arise at the inferior
internal angle of this region, or at the space which exists between the
sternal and clavicular origins of the sterno-cleido-mastoid muscle.
The Veins follow the course of the arteries, being generally in
advance of them, or between them and the skin. The Subclavian
Vein, however, does not pass between the scaleni muscles, but in
front of them.
The External Jugular Vein terminates towards the inner side of
the supra-clavicular fossa, after receiving the superficial veins from
the shoulder, by emptying into the subclavian vein in front of the
scalenus anticus. Sometimes, instead of one trunk, there are two
or three which unite at variable distances above the clavicle.
The Nerves of this region belong chiefly to the brachial plexus;
the four lower cervical and the first dorsal forming a plexus, which
is more or less closely connected with the subclavian and the com-
mencement of the axillary arteries. (Plate XXXIII., Fig. 1.)
The other details of these parts will be given in connection with
the operations practised on the artery.
In dissecting this region, the layers are usually presented as
follows: First, the skin, then the superficial layer of the fascia, as
well as the platysma-myodes muscle. Next, loose cellular tissue,
containing numerous venous and arterial branches, the principal of
which have just been referred to, as connected with the subclavian
vessels. Around these vessels is a fibrinous expansion from the
deep fascia, which forms for them a sheath, close to which is the
cul-de-sac of the pleura, as it rises above the first rib. But the
elevation or depression of the shoulder, by moving the inferior
boundary of this region, will increase or diminish the apparent
depth of the vessels, as well as relax or stretch the various layers
which cover them.
OF THE DISEASES OF THE PAROTID GLAND. 437
CHAPTER II.
OPERATIONS PRACTISED ON THE PORTION OF THE NECK WHICH IS
ABOVE THE OS HYOIDES.
In the portion of the neck above the os hyoides we find two
regions, the Supra-Hyoid and Parotid, both of which may require
surgical operations in order to relieve their different disorders.
But as the importance of all the parts contained within the limits
of the neck renders it difficult to make a selection of any one as
specially worthy of attention, it has been deemed advisable to refer
to these operations in the order which has been adopted as the plan
of the work ; and, commencing at the portion which is nearest the
head, proceed from above downwards, according to the natural
arrangement of the tissues. The surgical affections of the skin and
fascia in this section of the neck, presenting nothing requiring spe-
cial operative interference, the disorders connected with the salivary
glands become the first subject to which attention should now be
directed.
SECTION I.
OF THE DISEASES OF THE PAROTID GLAND.
The diseases of the parotid gland, independent of the affections
of its duct of which mention has been already made in connection
with the operations practised on the face, consist either in such
simple departures from a healthy state as yield readily to medical
treatment, or in such degeneration of the cellular tissue and proper
structure of the gland as may necessitate its removal.
The position of several of the superficial lymphatic glands of the
neck, and the enlargement consequent on their diseased condition,
sometimes also creates such a tumor in the parotid region that any
one who is not cautious in forming a diagnosis, or who does not
accurately examine the anatomical relations of the surrounding
structures, may readily be led to suppose the enlargement to be
due to an affection of the parotid itself.
438 OPERATIVE SURGERY.
As caution is necessary in deciding on the structure involved in
the tumors of this region, a guarded prognosis should always be
given.
Pathology. — That the salivary glands, as a general rule, are less
liable to abnormal deposits or to degeneration of structure than
other glands, is a point on which most pathologists seem to agree.
Velpeau 1 expresses the decided opinion that all malignant growths,
when seated in the parotid or submaxillary gland, commence either
by a deposit in the lymphatic glands incorporated with them, or by
a change in the parenchyma of the glands themselves, rather than
by a degeneration of the proper secretory portion. Whether this
opinion is based upon microscopical examination, or is solely the
result of close observation, it has a special value in connection with
the question of the propriety of extirpating these glands when dis-
eased, which should be noted; because, admitting that the deposit
commences in the parenchyma of the gland, it is evident that it
cannot long be limited to its original seat, but must encroach on
the surrounding structure, so as either to cause its absorption or
disintegration. In the case of parotid tumors, such a change must
modify very materially the natural relations of the part, and marked
departures from the normal condition may, therefore, be looked for
when the removal of the diseased mass is attempted. Particles of
a gland, which, in the original state, were separate and distinct, or
very loosely attached, will often, when diseased, be found to be
blended in one common mass ; and portions which were deep-seated
and difficult of access in health, prove to be superficial, in conse-
quence of their close and condensed union with tissues nearer to
the surface. It has, therefore, been noticed that a diseased parotid is
often surrounded with a dense capsule, formed chiefly at the expense
of the surrounding cellular tissue and fascia, whilst its conglomerate
parts are so fused into one conglobate mass, that the deepest portion
of the gland had been pried out from the styloid process in conse-
quence of the attachment of the exterior of the tumor to the muscles
and parts about the angle of the jaw, as I have seen in several in-
stances of well-marked scirrhus. That surgeons have been misled
in relation to the difficulties of the removal of this gland, from
comparing the operation with that attempted on it in a state of
health, is certain, and daily experience is now leading many to
1 M6d. Optfratoire, torn. 3 me , p. G44.
EXTIRPATION OF THE PAROTID GLAND. 439
place confidence in the views of those surgeons of the eighteenth
century who advocated the practicability of accomplishing by an
operation the entire removal of a diseased parotid.
When, therefore, circumstances induce the belief that the removal
of the diseased structure can add to the patient's days, the operation
should be performed, as the entire gland has been extirpated beyond
all doubt ; though it should be remembered, in cases of malignant
degeneration, that the patient will only be subsequently placed in
the same condition with those who submit to an operation for the
removal of a scirrhus or encephaloid deposit elsewhere.
§ 1. — EXTIRPATION OF THE PAROTID.
For many years, the removal of the parotid gland entire was a
vexed question, the possibility of accomplishing it being denied by
high authority, among whom were Boyer, Eicherand, and others,
who, though dead, seem yet to influence a few surgeons of the
present day, there being some who continue to speak of the matter
in terms of doubt, notwithstanding the most positive proofs of its
feasibility and execution. Aware of the existence of these doubts,
and yet fully aware of the error of those who entertaiued them, the
late Dr. Geo. McClellan, of Philadelphia, exerted himself to prove
that the extirpation of the parotid gland was not only justifiable,
but also capable of being thoroughly accomplished ; and to his skill
and energy, more than to that of any other surgeon, is due, I think,
the credit of having demonstrated the reasonable character of the
attempt ; whilst by recalling attention to the means of treatment
advocated by Heister, Von Swieten, Garangeot, and others, who
had preceded him, in Europe, he secured for the operation a
degree of confidence which has since led to its more frequent
performance.
Extirpation of the parotid gland was, however, an operation
which had previously been frequently performed in the United
States, being first done by Dr. J. Warren, of Boston, who, as early
as 1798, removed the entire gland; 1 in 1805, Dr. McClellan, 2 of
Franklin County, Pennsylvania, did the same thing; in 1808, it was
also successfully performed by Dr. S. White, of Hudson, New
1 Dr. John C. Warren, in MS. 2 See Bibliography, p. 81.
440 OPERATIVE SURGERY.
York; 1 and in 1811, and 1814, and again in 1S-A1, Dr. Sweat, of
Maine, successfully repeated it.
But though it is evident from these facts that the operation was
well known to a few, it was not until the time of Dr. Geo. McClellan
(1826) that it was generally regarded as feasible, and that the diffi-
culties attendant on the entire removal of the gland in a diseased
state were found to be much less than those experienced in accom-
plishing the same end when it was in a healthy condition. Since
this period, the removal of the entire gland has been successfully
accomplished in numerous instances. 2
Operation of Dr. George McClellan, of Philadelphia. —
The patient, Dr. John Graham, at that time a student of medicine
in Philadelphia, had a tumor in the parotid region, the removal of
which had been attempted in Dublin, but desisted from, in conse-
quence of the opinion of the surgeons engaged in it, that, as the
parotid was involved, the attempt was unadvisable. Dr. McClellan,
thinking otherwise, proceeded to the operation, February 27, 1826,
as follows: —
Operation. — Two curvilinear incisions were made from a little
above the zygoma to a point two and a half inches below the angle
of the jaw, so as to include nearly the whole of the old cicatrix
between them. After reflecting the integuments from the surface
of the tumor, the dissection of the mass was continued down to the
zygoma and masseter muscle in front, and to the cartilaginous tube
of the ear and mastoid process behind. Being unable to dissect any
further in these directions, progress was made beneath the tumor
by burrowing under its lower edge. The posterior belly of the
digastric muscle being then divided, the fingers passed readily under
the whole body of the tumor, and an effort was made to wrench it
from its bed, but without success. Before proceeding further, the
trunk of the external carotid was insulated, just as it was entering
the tumor together with the descending veins; and then, instead of
cutting them across, they were torn out from the body of the tumor
with the thumb and finger. An instantaneous gush of blood deluged
the eyes and face of the operator ; but, before a ligature could be
placed around the vessels, the hemorrhage altogether ceased in con-
sequence of the retraction and contraction of the lacerated vessels.
1 Reese, Cooper's Diet., edit. 1849, p. 259. Article on Parotid.
8 See Bibliography, p. 81.
EXTIKPATION OF THE PAROTID GLAND. 441
After powerful and repeated efforts at wrenching, aided by an occa-
sional use of the knife, to divide the strong bands of cellular sub-
stance, and some of the fibres of the styloid muscles which adhered
to the tumor, the mass was elevated above the ramus of the jaw and
the mastoid process. The trunk of the portio dura, which was very
much eularged, being then seen mounting over the posterior margin
of the tumor, to enter its substance, was divided, and the upper
portion of the tumor separated from the zygoma by the scalpel, as
the layers of fascia were too strong fo'be lacerated.
In this step, the main trunk of the temporal artery was necessarily
cut, and a profuse hemorrhage coming from the recurrent circulation,
a ligature was placed on the vessel, this being the only one which
was ligated during the operation. The internal maxillary was not
discovered, having probably been ruptured in the act of wrenching
the deep-seated portion of the tumor from behind the angle and
ramus of the jaw. After waiting some time to see if hemorrhage
would occur, the edges of the wound were united by three stitches
of the interrupted suture, in order to prevent their being reflected
inwards; adhesive strips, a compress and head bandage completing
the dressing. The patient recovered, with less deformity than
existed before the operation. 1 The gentleman is believed to be yet
alive, and residing in the city of New York. 2
Operation of Dr. Valentine Mott, of New York. — Deter-
mining to ligate the external carotid artery before attempting the
dissection, the operation of Dr. Mott was commenced by an incision
about three inches long, which was carried from the posterior
angle of the lower jaw downwards and inwards, so as to lay bare
the artery. Owing to the tumefaction, this vessel was found to be
nearly three inches from the surface, and was tied immediately
below the digastric muscle, or a little above the upper border of
the thyroid cartilage.
An incision was next commenced above the jugum temporale,
and carried downward in a semicircular direction, until it terminated
upon the os occipitis, when the incision on the neck was extended
upwards to intersect the one over the tumor.
On detaching the integuments in the form of a double flap, the
gland was found in a melanotic condition. In order to free it, the
1 New York Med. and Phys. Journ., vol. v. p. 650.
2 See. also, Principles and Practice of Surgery, by the late Geo. McClellan, M. D.,
edited by J. II. B. McClellan, M. D., p. 335, note.
442
OPERATIVE SURGERY.
adipose and cellular tissue along the inner edge of the tumor was
divided until the masseter was exposed. The finger being then
introduced into the mouth and cut upon, in order to avoid the
division of the buccal membrane, the tumor was separated for some
distance from the masseter, to which it closely adhered, and then
separated from the jugum which had become carious from pressure.
The mass was next dissected entirely free from the digastric and
masseter muscles, as well as from the angle of the jaw; but, as the
patient complained of excruciating torture when the tumor was
raised from below upwards, the dissection was continued from above
downwards, and the adhesions being separated, with a few rapid
strokes of the knife, from the capsular ligament of the lower jaw,
the bulk of the mass was removed. The portion filling up the
space between the styloid and mastoid processes was then cautiously
detached with the handle of the scalpel and the portio dura rapidly
divided. Several arteries were tied during the operation, and the
trunk of the temporal yielded a profuse retrograde hemorrhage.
After waiting to see if there should be further hemorrhage, the
wound was dressed by sutures, adhesive strips, lint, a compress and
bandage. 1
At first the wound did well, the ligature on the carotid separat-
ing on the fourteenth day, but the disease promptly showed itself,
and the patient died of constitutional disturbance on the fifty-fourth
day after the operation.
Operation of Dr. J. Randolph, of Philadelphia. — The disease
being seated in the left parotid gland, the head was inclined to the
right side, and an incision made from the zygoma down to the edge
of the sterno-cleido-mastoid muscle ; a second one was then made at
right angles to this, and the flaps dissected back. The facial artery
being secured, an attempt was made to raise the lower edge of the
tumor and to secure the carotid artery where it enters the gland ;
but this being very difficult, in consequence of the close adhesions,
the tumor was dissected from its attachments, from above down-
wards. In doing this, the temporal and internal maxillary arteries
with some smaller ones were secured, and the deep dissection being
continued, the carotid was divided with the, last adhesions of the
tumor, and instantly secured by Physick's needle and forceps.
The internal jugular vein was also cut and secured at each end.
1 Am. Journ. Med. Sciences, vol. x. p. 17.
EXTIRPATION OF THE PAROTID GLAND. 443
The operation lasted fifty-nine minutes; but little blood was lost;
and Drs. Khea Barton, William E. Horner, Norris, Coates, and
others who witnessed the operation, all coincided in the opinion
that the entire gland was extirpated.' Having aided Dr. Randolph
in this operation, and subsequently had the charge of the patient, I
am fully persuaded that he succeeded in removing the entire gland.
The wound healed readily and the patient left the hospital well,
but about ten months subsequently I heard of his death from a
return of the disease. The tumor is now in the Wistar and Horner
Museum. 2
Operation of Dr. William E. Horner, of Philadelphia. —
A crucial incision over the centre of the tumor being freely con-
tinued along the base of the jaw, so as to include some enlarged
lymphatic glands, and also down the neck in the course of the
carotid artery, the flaps were turned back and the fibres of the pla-
tysma-myodes and the fascia of the neck freely divided. Com-
mencing behind, the tumor was then dissected from the anterior
edge of the sterno-cleido-mastoid muscle, to which it closely ad-
hered, and, by working gradually forward, the gland, which was
surrounded by a firm capsule, was gradually freed from its poste-
rior and inferior attachments. The primitive carotid artery being
then fairly brought into view by the progress of the dissection, was
found to have been so much involved in the disease as to show
considerable thickening of its coats, having the appearance of the
vessel when injected in the subject. A ligature was therefore
placed around it, nearly on a level with the larynx, but not tied,
the upper and anterior attachments of the tumor divided, the artery
tied, and the tumor removed from its deep adhesions. These were
by no means as close as in the healthy condition, the adhesion of
the tumor to the angle of the jaw having caused the exit of the
gland from its deepest points. The division of the internal max-
illary giving rise to considerable hemorrhage, the internal and
external carotids were also tied, lest, in their patulous condition,
recurrent hemorrhage should ensue through them also. The sub-
maxillary gland, and the lymphatics leading to and adhering to the
thyroid gland, were also removed, leaving the deep-seated parts of
this region perfectly exposed ; but, on a close examination, it was
1 Am. Journ. Med. Sciences, vol. xxiii. p. 517.
2 University of Pennsylvania, Philadelphia.
•A-i4 OPERATIVE SURGERY.
impossible to find either the internal jugular vein, or the par vagum,
of this side. The wound was then filled lightly with lint; the flaps
closed by sutures, and covered with adhesive plaster, compress, and
bandage. On the eighth day all the ligatures separated sponta-
neously, and the patient started for his home six weeks after the
operation. 1 When last heard from the disease had returned and
caused his death by exhaustion.
Statistics. — Of eleven cases in which the parotid gland was ex-
tirpated by Dr. George McClellan, ten recovered from the operation,
seven of whom were living in 1848, one died on the fourth day,
from coma consequent on the ligation of the carotid artery, and one
died three years subsequent to the operation. 2 Three cases have
been operated on successfully by Dr. John C. Warren, of Boston ; 3
one by Dr. John II. B. McClellan, of Philadelphia, successfully,
although the pneumogastric nerve was divided in the operation ;
and one each by Drs. Mott, Horner, Kandolph, Nathan K. Smith,
Wheeler, Shipman, Toland, Wedderburn, and J. Mason Warren.
Three cases were also operated on by Dr. Bushe, of New York. 4
The history of these cases is, however, too extended to permit more
than a brief enumeration, though it is right to say that in all of
them there was more or less of cancerous degeneration which had
involved the entire structure, or which, if limited to the areolar
tissue in the first instance, had produced such a change in the gland
that the original growth could not be recognized. From the ac-
count of the operations furnished by Velpeau, 5 it appears that there
are over thirty-five cases of this operation in which it was reported
that the entire gland was extirpated; though he seems to doubt the
fact because of the rarity of degeneration of the salivary glands as
a class. But this general statement when met by the positive as-
sertion of the diseased condition of the gland, by surgeons and
anatomists of good standing, and recognized as such even by Vel-
peau himself, only shows the diversity of sentiment that may arise,
when surgeons have not seen the same cases. Walshe 6 says, in
speaking of this opinion, that " it is certain that scirrhus and en-
1 Medical Examiner, vol. vii. N. S. p. 30, 1851.
2 McClellan's Principles and Practice of Surgery, p. 332.
8 Dr. Warren in MS.
* Bibliography, p. 81.
5 Velpeau, Op. Surg., by Mott and Townsend, vol. iii. p. 443.
6 Walshe on Cancer, p. 267.
EXTIRPATION OF THE PAROTID GLAND. 445
cephaloid do occasionally originate in the parotid, and run their
ordinary course."
As regards the possibility of accomplishing the extirpation of the
entire parotid gland, there is therefore in my mind no doubt. The
fact, however, is equally well established that the ultimate result to
the patient in these tumors, where the tumor is of a cancerous cha-
racter, will be found to correspond with the operations performed for
the removal of malignant growths in other portions of the body.
Eemarks on the Operation. — In the descriptions of the opera-
tive proceedings of the distinguished surgeons just referred to, we
see several varieties, each of them being more or less modified by
the peculiarities of the case. Certain general precepts may, how-
ever, be applied to every instance in which the removal of the gland
may be deemed proper.
1st. All external incisions should be free enough, at first, to ena-
ble the operator to work readily around the tumor.
2d. The tumor should be first loosened at its posterior part, then
at its superior and anterior borders, and lastly at its inferior. Br.
Mott, however, prefers to commence below, but always ligates the
carotid before commencing his operation.
3d. The attachments of the tumor to surrounding parts should
be stretched or torn as much as possible, instead of being dissected,
as the laceration prevents hemorrhage.
4th. The edge of the scalpel should be directed towards the
tumor as much as possible.
5th. The external carotid artery should be taken up, as nearly
below the tumor as may be necessary, at the moment of removing
the gland from its deepest and inferior connections.
The propriety of ligating, or even of passing a ligature around
the primitive carotid previous to acting on the tumor, is a question
that the majority of operators have now decided in the negative; and,
when it is remembered that, in some instances, the external carotid
alone is cut, whilst the internal remains uninjured, and that, in
others, the compression of the surrounding structures by the dis-
eased mass has caused great diminution of the caliber of the ves-
sels, or even their obliteration, this decision seems to be based on
sound principles. In three instances, it has fallen to my lot to
attend to the hemorrhage during this operation, and in all it was
readily controlled by pressure upon the main trunk of the artery
when the course of the dissection seemed likely to injure the ex-
446
OPERATIVE SURGERY.
ternal carotid, or by the direct application of the ligature to the
divided end of the artery, when it was cut free from the tumor.
In the operation performed by Dr. Ilorner, and in that of Dr.
John IT. B. McClellan, 1 the internal jugular vein was entirely ob-
literated; and in the others that have fallen under my observation,
the artery has either been much thickened in its coats or diminished
in its caliber, the most troublesome hemorrhage having been that
which arose from the recurrent circulation. The paralysis arising
from division of the portio dura, in one case, was subsequently very
much relieved, and in the others, during the short period when they
were under my charge, did not produce as marked deformity as that
created by the presence of the tumor. In a case reported by Dr.
"Warren, it had nearly disappeared a few months after the operation. 2
That the division of this nerve was the cause of the intense suffer-
ing, described by some of the earlier operators, is a point on which
every surgeon of the present day must have his doubts, the pain
then noted being doubtless due to the division of the branches of
the third branch of the fifth pair, or of the cervical nerves involved
in the disease. Dr. Mott, of New York, yet advises 3 the following
course, e. g., that the carotid should always be tied first. He also
recommends that an incision should be made in a vertical direction
over the tumor in the course of its long axis, and that another should
cross this, but not at a right angle ; and that, after dissecting back
the flaps, the operator should begin the separation of the gland from
below, and not from the zygomatic arch. In connection with this
operation, as well as in others upon the neck, he also cautions the
surgeon against the dangers of the entrance of air into veins that
may be wounded, and especially the jugular vein.
In reviewing the opinions thus stated in relation to the perform-
ance of the operation of extirpating the parotid gland, it may, I
think, be safely said that, though the operation is one which in-
volves a high responsibility, it is yet one which every good anato-
mist may succeed (p performing. But whether, after accomplishing
this much, the patient will be benefited for any long period, is a
point which the statistics of operations for malignant growths else-
where alone can settle. Certain it is that the removal of the tumor
has often relieved the individual of the distressing neuralgic pains
1 Principles and Practice of Surgery, p. 336.
2 Warren on Tumors, p. 290.
3 New York Register of Med., vol. i. No. x. p. 153.
RELIEF OF ENLARGEMENT OF THE PAROTID GLAND. 447
and oesophageal difficulties under which he formerly labored ; and,
as an euthanasial measure, or one capable of prolonging life for
even a limited period, its propriety should, therefore, be calmly
considered in every case where its performance may be demanded.
My individual opinion is favorable to it when other general or
local means have failed to check the progress of the disease.
§ 2. — RELIEF OF ENLARGEMENT OF THE PAROTID GLAND BY
OBSTRUCTING THE CIRCULATION.
In order to avoid the necessity of resorting to extirpation of the
parotid gland in cases of scirrhus, various other local means have
been tried, as leeches, friction, blisters, electricity, iodine, and press-
ure, though the latter can only be applied very imperfectly. Such
means can, however, only act as palliatives. A more certain method
of checking the development of the tumor, or inducing atrophy of
its structure, will be found in the interruption of the supply of
blood through the nutrient vessels of the parts, by ligating the
carotid artery. This operation has been successfully performed,
in two cases, by Dr. Alexander E. Hosack, of New York, and in a
third absorption had visibly commenced. 1 In the first case, the
patient was a woman aged fifty-five years, the tumor of considerable
size, and of three or four years' growth, and had been treated with
iodine internally and externally for two months, without benefit.
After ligating the vessel, the tumor not only disappeared, but left
a depression of the same form as the gland in its natural state.
But, in estimating the value of this operation, one difficulty cer-
tainly exists, and that is the utter impossibility of deciding whether
the tumor is formed by the parotid. In one of the cases reported
by Dr. Hosack, the account certainly justifies us in doubting whe-
ther the tumor was a cancer of the parotid, as these tumors are
seldom very large ; whilst if it was of the size of the encephaloid
degeneration it would hardly have taken three or four years to
have developed itself without inducing the death of the patient.
When the tumor is formed of the parotid, or even the adjoining
lymphatics, there would also be great difficulty in preventing the
1 Cooper, Surgical Dictionary. Appendix, by D. Meredith Reese, M. D., article,
Tumors. Also, Walshe on Cancer, p. 204.
448 OPERATIVE SURGERY.
return of the blood through the recurrent branches of the opposite
side, even when the carotid was tied. As, under ordinary circum-
stances, any surgeon who could accomplish the ligature of the artery
could also remove the tumor, and thus render the removal of the
diseased structure certain; whilst under the use of amesthetics he
would cause his patient but little additional suffering, I should
much prefer the chances of the extirpation in effecting a cure, or
even temporary alleviation of suffering, to those presented in any
other plan of treatment, except an appropriate constitutional one.
When this had failed, I would certainly operate, if only to alleviate
the patient's suffering, and enable him to obtain an easier death.
SECTION II.
OPERATIONS PRACTISED OX THE SUBMAXILLARY GLAND.
Owing to the remarks made in connection with the degenerations
of the parotid gland, there is but little necessity to occupy much
space in considering the disorders of this body. Like the parotid,
the submaxillary gland is rarely, or never, the starting-point of ma-
lignant disease, whilst the lymphatics in its neighborhood are often
involved. But, should circumstances induce the surgeon to attempt
its excision, he may accomplish it by the following plan : —
Operation. — Direct the patient to shut the mouth and throw back
the head, inclining it to the side opposite to that which is affected.
Then, by any incision which is adapted to the size of the tumor, cut
through the integuments, and dissect back the flaps thus created, so
as to expose the disease. Applying two ligatures to the facial vein,
and dividing the vessel between them, and also ligating the facial
artery near its entrance into the gland, or near the jaw, pass a needle
and ligature through the tumor, and forming a loop with the liga-
ture, remove the needle. Then drawing upon the loop, either down-
wards and backwards whilst the dissection is prosecuted in front of
the gland, or outwards and upwards when it is carried below and
behind the gland, free the latter from its pouch, avoiding all injury
to the surrounding parts, by directing the edge of the knife con-
stantly towards the tumor, and keeping its adhesions upon the
stretch, by drawing firmly on the loop of the ligature which was
passed through it.
SUKGICAL ANATOMY OF THE LARYNX AND TRACHEA. 449
The other tumors of this region will be referred to in the chap-
ter under diseases of the lymphatic glands of the neck, whilst the
treatment of ranula has been placed among the operations of minor
surgery. 1
CHAPTER III.
OPERATIONS PERFORMED ON THE LARYNX AND TRACHEA.
The operations practised on this portion of the neck are cauteri-
zation of the larynx from the mouth, and the opening of the larynx
or trachea, either for the removal of foreign bodies, or in cases of
membranous croup.
SECTION I.
SURGICAL ANATOMY OF THE LARYNX AND TRACHEA.
The upper extremity of the Trachea or the Larynx is formed by
five cartilages. These cartilages, of which the thyroid, cricoid, and
epiglottis (Plate XXXI., Fig. 2) are the most important to the
surgeon, as connected with the operations on this part, extend from
immediately below the os hyoides and root of the tongue to the first
ring of the trachea, being lined throughout by a mucous membrane,
between which and the cartilaginous structure is a sparse cellular
tissue, liable in certain forms of disease to dropsical or serous in-
filtration.
The trachea is four or five inches long in its entire length, though
not more than two and a half inches in the portion which is situated
between the top of the sternum and the cricoid cartilage. It is
about nine lines in diameter, and composed of sixteen or twenty
distinct rings, each of which is deficient in the posterior third, being
completed in this portion of the canal, as well as united to each other
by elastic ligamentous matter.
The tissues covering the trachea are the skin, superficial fascia,
1 See Smith's Minor Surgery, third edition, p. 373.
29
450 OPERATIVE SURGERY.
sternohyoid and thyroid muscles, and deep cervical fascia, together
with the thymus gland, which latter, or rather its isthmus, some-
times extends as low as the fifth ring. Beneath these parts is a
cellular tissue immediately around the tube, which has been spoken
of by Mr. Porter as the tracheal fascia, and which is liable to become
emphysematous when an opening is made into the trachea, unless
it is specially attended to. But the most important of the surgical
relations of this portion are the numerous bloodvessels, whose
varying position renders them especially troublesome to the sur-
geon. Between the isthmus of the thymus gland and the top of the
sternum are usually found several veins. Of these, the superficial
veins are found in front of the sterno-hyoid muscles (Plate XXIX.,
Fig. -i), and cause but little trouble in operating; but the plexus
formed by the deep veins, and especially by the inferior thyroid,
together with an artery (middle thyroid), all of which are behind
the muscles, will be found to be frequent sources of trouble in
tracheotomy.
There are also certain variations in the arrangement of the larger
vessels of the neck which may embarrass the surgeon when ope-
rating on this part. Thus, the superior thyroid artery occasionally
sends a large branch to the crico-thyroid ligament, and then turns
down to supply the thyroid gland ; sometimes the inferior thyroid
arteries are given off by the primitive carotids on a level with the
thyroid gland ; or the left carotid may arise from the innominata
and pass across the front of the trachea, as has been seen in several
instances by Blandin. 1
As the trachea follows the shape of the vertebral column, it is
most superficial at its upper portion, where the vertebrae are convex
in front, but becomes deeper as it approaches the chest, so that near
the sternum it is over an inch beneath the intesruments, or even
more in short, fat necks ; whilst the changes produced by oedema,
congestion, and the other consequences of disease of the windpipe,
especially in children, frequently add to the depth of this canal
from the surface of the neck, at this point.
1 Annt Topograph . p. IflC
CAUTERIZATION OF THE LARYNX. 451
SECTION II.
OPERATIONS UPON THE LARYNX.
The operations practised on the upper portion of the trachea
consist in such as are required for the relief of inflammation of the
part, and those demanded by the presence of foreign bodies.
§ 1. — CAUTERIZATION OF THE LARYNX.
The introduction of lunar caustic into the larynx is an operation
which may be demanded in the treatment of various forms of in-
flammation, and especially in membranous croup.
The credit of suggesting and applying this remedy is due to M.
Trousseau, of Paris, 1 who first introduced a strong solution freely
into the canal, both by means of a sponge as well as by a syringe ;
whilst in the United States particular attention has been called to
the advantages of its employment, by Dr. Horace Green, of New
York. 2 The operation is simple, and may be readily performed as
follows : —
Operation. — Place the patient before a strong light, with the
mouth widely opened, and the head supported, and, depressing the
tongue by any means that is found most convenient, pass the
sponge directly into the larynx (Plate XXXII., Fig. 2) on either
side of the epiglottis, and immediately withdrawing it, much less
inconvenience will be caused to the patient than might have been
anticipated.
The instruments adapted to this purpose may be seen on reference
to Plate XXX., Figs. 9, 10, 11, and include both those of Trousseau
and Green, the difference between them not being very marked.
Remarks. — Cauterization of the larynx is an operation of so
simple a character, that reference to it in these pages might seem
unnecessary, were it not that it is an important preliminary step in
the treatment of croup, and one that should always be employed
1 Traits de la Phthisie Larynge"e et des Maladies de la Voix. Paris, 1836. Mem.
de l'Acad., &c.
2 Diseases of the Air-passages. New York, 1846.
452 OPERATIVE SURGERY.
PLATE XXXI.
A VIEW OF THE OPERATIONS PERFORMED ON THE TRACHEA.
Fig. 1. A front view of the Surgical Anatomy of the Trachea. 1. Os
hyoides. 2. Thyroid cartilage. 3. Thyro-hyoid muscles. 4. Crico-thy-
roid muscles. 5. Thyroid gland and veins in front of crico-thyroid liga-
ment. 6. Rings of the trachea. 1. Common carotid artery. 8. Superior
thyroid arteries. 9. Inferior thyroid artery. 10. Carotid artery, as divided.
11. Outline of the top of the chest. 12. Innominata artery. 13. Inferior
thyroid vein. 14. Transverse vein. After Bernard and Huette.
Fig. 2. Relative position of the Larynx, Trachea, and Bloodvessels.
1. Os hyoides. 2. Thyro-hyoid ligament. 3. Thyroid cartilages. 4.
Crico-thyroid ligament. 5. Cricoid cartilage. 6. Trachea. 1. Internal
jugular vein. 8. Transverse vein. 9. End of inferior thyroid vein. 10.
Veins. After Bernard and Huette.
Fig. 3. Relative positions of the great vessels concerned in operations
near the top of the sternum. 1, 1. Internal jugular vein. 2, 2. Subcla-
vian veins. 3. Subclavian artery. 4. Transverse vein. 5. Inferior thy-
roid vein. 6. External jugular vein. 7. Arch of the aorta. 8, 8.
Primitive carotids. After Bernard and Huette.
Fig. 4. A view of the operation of Tracheotomy, as performed by Mr.
Liston. 1. The tenaculum inserted into the trachea. 2. Position of the
bistoury in incising the rings. 3. Line and termination of the external
incision. Aft cr Eiston.
Fig. 5. Extraction of a foreign body by Tracheotomy, the head being
thrown back and lowered, so as to facilitate the gravitation of the object.
1,1. Blunt hooks holding open the wound. 2. Hand of the surgeon in the
act of extracting the foreign body, by drawing it upwards from the bronchia.
After Bourgery and Jacob.
Fig. 6. A front view of the position and mode of retaining a canula in
the Trachea, as usually practised. 1. The incision. 2,2. A tape attached
to the wings of the canula and passing around the neck.
After Bernard and Huette.
Fig. 7. The appearance of the parts concerned in oedema of the Glottis.
1. The epiglottis cartilage, much swollen by serous infiltration of its sub-
mucous cellular tissue. After Gurdon Buck, Jr.
Fig. 8. The operation of scarifying the Glottis for the relief of oedema.
1. The forefinger in its position as a director. 2. The knife in the act of
scarifying the part. After Gurdon Buck, Jr.
I
V
OEDEMA OF THE GLOTTIS. 453
before tracheotomy is resorted to. Although this remedy had been
known to the profession for several years, incredulity, and a know-
ledge of the irritation usually created by the presence of even a
small particle of any substance in the trachea, prevented very many
in this country from attempting it ; and there are yet to be found
practitioners who deny the possibility of introducing a sponge into
the glottis. To Dr. Green, of New York, is, therefore, due the credit
of having done more than any other surgeon in the United States
towards establishing professional confidence in an operation, which
has since proved to be both easy and useful in many instances.
The tendency to quackery, so often observed in the treatment of
affections of the windpipe, dependent on chronic inflammation, has,
however, shown itself in this as in other rational plans of treat-
ment; and a measure which is capable of doing much good, when
judiciously directed, seems now likely to be cast aside by many, on
account of its liability to be misemployed. That the application
of a solution of nitrate of silver has been resorted to in cases
which did not require it, is doubtless true, but time will soon settle
the positive and correct indications which should direct its use,
and remedy the evils which always ensue upon the first employ-
ment of a fashionable remedy.
§ 2. — (EDEMA OF THE GLOTTIS.
Pathology. — In the rare form of disease of the upper extremity
of the larynx, which has been designated as (Edema of the Glottis,
there is commonly found an infiltration of the submucous cellular
tissue of the aryteno-epiglottic cartilages, in consequence of the de-
velopment of such a degree of inflammation, as results either in an
effusion of pure serum, or of a gelatinous serum or lymph, or of
pure pus, or of pus mixed with shreds of the membrane consequent
on sloughing of the tissue, though this last condition is said to be
rare. Owing to these changes, the mucous membrane lining the
opening or edges of the cartilages at the top of the larynx, becomes
distended and formed into folds, or doublings, which, rising up-
wards, and also extending downwards as far as the vocal chords
(Plate XXXI., Fig. 7), render the epiglottis thick and stiff, greatly
diminishing, or even closing the opening of the larynx, so as to
prevent the entrance of air into the lungs.
454 OPERATIVE SURGERY.
Originally named by Bayle, in 1808, (Edema of the Glottis, this
complaint has been described as if it were limited to that portion
of the larynx which is anatomically described as the glottis, whereas
it is really, as shown by Bouillaud and others, an cedematous in-
flammation of the larynx itself, consequent on, or accompanied by,
a similar condition of the surrounding parts. Though often the
result of the extension of inflammation from the pharynx to the
larynx, this complaint sometimes occurs spontaneously, three out
of the forty cases reported by Valleix having suffered from it
whilst otherwise in good health; it is also most common during
the convalescence from slow fevers or after pneumonia. In most
instances, however, it is the result of an inflammatory affection of
the laryngopharyngeal membrane, where it is expanded over the
tonsils, uvula, or soft palate, at which points the membrane is seen
increased in color, and accompanied by all the symptoms conse-
quent on tonsillitis, though at other times it is unnaturally pale
and swollen in this affection. Such a condition of parts, it is now
believed, existed in the case of General Washington, who, without
presenting marked symptoms of croup, yet died asphyxiated.
That the difficulty of respiration in his case was not alone due to
the angina, must be admitted by all who recall the anatomical rela-
tions of the parts ; and as oedema of the glottis was not thoroughly
understood at the period of his death, the explanation thus ad-
vanced is due to the observation of more modern pathologists, as
may be seen by referring to the views of various writers on this
subject.'
Sometimes oedema of the glottis, instead of being an acute com-
plaint, is merely a subacute affection, and is, therefore, difficult to
recognize solely by inspection, in consequence of the natural appear-
ance of such portions as can be discovered by the eye. Under these
circumstances, the sense of touch should be most confided in, as it
alone will often enable the surgeon to recognize the condition of the
top of the larynx, and enable him correctly to appreciate the dimi-
nished state of an orifice, which has sometimes been so completely
closed as scarcely to permit the passage of light into the trachea,
even when it was removed from the body. (Edema of the Glottis
appears to be much more common in males than in females, twenty -
1 See Cyclopedia Pract. Med., vol. iii., art. Laryngitis; Diet, de Science Medicale,
torn. xvii. ; Pract. of Med., by George B. Wood, M. D., vol. i. p. 743.
(EDEMA OF THE GLOTTIS. 455
nine out of the forty reported by Valleix 1 being males, and only
eleven females. Without referring to the medical treatment which
would be proper as preliminary to, or as an adjuvant of, the opera-
tion demanded for its relief, and, with the simple mention of the
utility of tracheotomy as a last resort, this account will be limited
mainly to the operation, and especially to the means employed,
with great success, in several cases, by Dr. Gurdon Buck, Jr., of
New York.
Operation of Dr. Buck. — The patient being seated on a chair,
with the head thrown back, and supported by an assistant, should
be first directed to keep the mouth as wide open as possible, or if
unable to do so, should have it kept open by means of a plug intro-
duced between the molar teeth. The forefinger of the surgeon's left
hand being then introduced at the right angle of the mouth, and
passed down over the tongue till it encounters the epiglottis, the
end of the finger may readily be made to overlap this cartilage by
being carried above it, as there is usually no difficulty in drawing
the epiglottis forwards towards the root of the tongue. The finger
thus serving as a guide (Plate XXXI., Fig. 8), a curved knife (Plate
XXXV., Fig. 15) should be conducted along it, the concavity of the
instrument being directed downwards till its point reaches the finger
nail. Then, by elevating the handle so as to depress the blade an
inch or an inch and a half further, the cutting extremity will be
placed in the glottis between its edges, when the instrument, being
slightly rotated from one side to the other, so as to give it a cutting
movement, may be made to incise the mucous membrane by with-
drawing it from the larynx. After repeating this two or three
times, on either side, without removing the finger, the margin of
the epiglottis, and the swelling between it and the base of the
tongue, as well as the margins of the larynx, will be freely scari-
fied; or scissors curved flatwise (Plate XXXV., Fig. 16) may be
used in the same manner. Though a disagreeable sense of suffo-
cation and choking is at first caused by the operation, the patient
soon recovers and submits to a repetition of the incisions after a
short interval. In all the cases operated on by Dr. Buck, the scari-
fication was performed twice, and in some instances three times, the
hemorrhage which followed it being encouraged by the use of warm
gargles. 8
' Me"m. de PAcad. Royale de He'd., tome xi. p. 121.
2 Transact. Amer. Med. Association, vol. i. p. 137.
456 OPERATIVE SURGERY.
Operation of Lisfraxc. — The patient being placed in a similar
position to that just referred to, a slightly curved bistoury with a
long and narrow blade, guarded with lint to within one line of its
point, should be held as a pen in the right hand. Then passing the
first and second fingers of the left hand through the isthmus of the
fauces to the cedematous swelling, pass the bistoury flatwise on the
fingers down to the part, and when it has reached the larynx, turn
its edge upwards and forwards, elevating or depressing the handle
so as to make gentle pressure with its point, and scarify the tissue,
when a little pressure of the fingers will readily evacuate the
serum. 1
In milder cases, resort may be had to the use of the nitrate of
silver.
Cauterization. — Dr. Horace Green, of New York, has obtained
much success from cauterizing the parts with a strong solution of
the crystals of the nitrate of silver, 9ij or 3i to si of water, and ap-
plied by means of the probang (Plate XXX., Fig. 10). A weak
solution Dr. Green thinks is injurious, five or ten grains to the
ounce only tending to increase the inflammation. His treatment is
as follows : —
Apply the sponge probang wet with the strong solution first to
the pharynx and top of the epiglottis, and after a delay of ten or
fifteen minutes apply it freely to the base of the epiglottis and over
the cedematous lips of the glottis. Eepeat this application every
hour or two according to the urgency of the disease and the effect
produced by the operation, attempting each time to introduce the
sponge into the glottis, which may be the more readily accom-
plished as the oedema subsides. 2 Should this fail to arrest the
disease, resort must be had to Tracheotomy.
Statistics. — Of six cases reported by Lisfranc, five were cured.
Of eight reported by Dr. Buck all terminated favorably, though in
one, tracheotomy was also resorted to ; 3 and in six additional cases
reported lately 4 as occurring in the hands of Dr. Buck, or in that
of other surgeons in New York, all were likewise cured. Dr.
1 Malgaigne, Operat. Surg., Philad. edit, p. 3G9.
2 Surgical Treatment of Polypi of Larynx and ffidcma of Glottis, by Horace Green,
A. M., M. D. New York, 1852.
3 Transact. Amer. Med. Association, toI. iv. p. 277: 1852.
4 Op. cit., p. 145.
(EDEMA OF THE GLOTTIS. 457
R. A. Kiulock, of Charleston, has also lately cured one case by
scarification, making twenty cures out of twenty-one cases.
M. Sestier, in a recent number of the Archives Generates, gives
the result of 168 cases, of which 127 died. In 132 cases the ordi-
nary treatment was adopted, and of this number 104 died. In 36
cases the operation of bronchotomy was performed, and of these 13
recovered and 23 died.'
Remarks. — Previous to the year 1821, there seems to have been
no operation practised for the relief of this complaint excepting
tracheotomy, though Dr. Marshall Hall had suggested the idea of
scarification at that time. This suggestion was, however, generally
discountenanced till Lisfranc, in 1823, resorted to punctures and
pressure. His idea seems also to have been forgotten, or at least
not generally resorted to, being viewed as a " fantastic operation,"
until Dr. Buck, of New York, called the attention of the surgeons
of the United States to the result of his operations. When we
recollect the serious nature of the complaint, and the fact that,
without opening the trachea, the danger of death is imminent, the
benefits conferred upon society by such a paper as that of Dr.
Buck, cannot be too highly estimated.
Among many points, on which he lays especial stress, is the
means of diagnosis previously pointed out by the French writers,
and especially by Tuilier, who proposed it in 1815, in his inaugural
thesis. 2 In seven cases out of the eight treated by Dr. Buck, there
was ample evidence to the touch of the puffy condition of the parts,
and in the eighth there was no proof that they were not swollen.
Of seventeen other cases which Dr. Buck has collected, the oedema
was present in fifteen, giving in all of them the sensation of a soft
pulpy structure. That a practice so long advised in severe cases
of oedema of the limbs, should not sooner have been resorted to in
a similar condition of so important an organ as the larynx, can only
be explained by the fact that the true nature of the disease has only
been accurately known within the last fifty years. As a substitute
for tracheotomy, and as a rational means of affording relief from a
distressing and dangerous complaint, the operation of scarifying
the glottis and epiglottis may be regarded as one of the most useful
of those suggested by the surgeons of the nineteenth century.
Cauterization is only likely to prove useful in the earlier stages.
1 Charleston Medical Journal, vol. viii. p. 97.
2 Diet, des Science Med., tome xvii.
458 OPERATIVE SURGERY.
§ 3. — POLYPI IN THE LARYNX.
In a valuable monograph by Ehrman of Strasburg, 1 professional
attention has recently been called to the occasional presence of
polypi upon the laryngeal mucous membrane, in which he describes
minutely a series of symptoms that have, perhaps, been more fre-
quently seen than recognized, as similar symptoms have sometimes
been noted without the observer being able to recognize the lesion
which occasioned them. Although alluded to once in the United
States, by Dr. Jno. C. Cheeseman, of New York, in 1817, 2 few
writers prior to 1850, seem to have investigated this complaint as
thoroughly as Professor Ehrman, and the student will find in his
work many practical details which want of space compels me to
pass, with only this brief allusion. As this account must, there-
fore, be limited to operative details, I shall only furnish a synopsis
of a case reported by Dr. Horace Green, of New York. 3 In this
case, the polypus was removed by excision, though generally
laryngotomy has been employed in consequence of the difficulty
of obtaining access to the polypus through the glottis.
Operation of Dr. Green, of New York. — A young girl, ten
years of age, after severe suffering, in connection with her trachea
was found to have a white fibrous-looking polypus, the pedicle of
which appeared to be attached to the left ventricle or left vocal
ligament, as it could be seen when the tongue was firmly depressed
and the patient coughed and gagged. This polypus being indu-
bitably recognized, Dr. Green proceeded to excise it by seating the
girl in a good light, with the head firmly held back by an assistant,
whilst he depressed the tongue until the epiglottis was in view.
Then gliding a slender double hook down to the tumor, when
raised by the patient's efforts to cough, he fished it up, and after
one or two attempts, succeeded in slicing it off from its pedicle
by cutting it from behind forwards by means of a probe-pointed
knife with a strong handle and a delicate slender blade. Some
coughing followed, and a few drops of blood, but this soon passed
away, and the young lady has for several years enjoyed excellent
health.
1 Histoire des Polypes du Larynx, 1850.
2 Transact. Physico-Med. Society, New York, vol. i. p. 413.
3 On the Surgical Treatment of Polypi of the Larynx and (Edema of the Glottis.
TRACHEOTOMY. 459
E em arks. — In a paper by Dr. Gurdon Buck, Jr., of New York,
read before the American Medical Association in 1853, and pub-
lished in volume six of their Transactions, it is shown that the cases
of pecliculated polypi of the larynx similar to the above are very
rare ; but Dr. Buck, whose experience in this disease has probably
been the most extended of any surgeon in the United States, regards
the operation of Dr. Green as especially well calculated for their
relief, and as highly creditable to the operator. In the majority of
the cases the morbid growths are, however, more extended in their
base, and seated lower in the larynx, requiring the performance of
laryngotomy for their relief. The method of treating them will
therefore be found in the account of this latter operation.
The prognosis of the disease when left to nature is almost always
a fatal one, and the chances of an operation, except as a means of
prolonging life, are also very slight, only two, that of Ehrman,
and that of Green, having recovered out of six, operated on.
§ 4. — TRACHEOTOMY.
The perforation of any portion of the trachea by means of a cut-
ting instrument, with the view of affording a new passage for the
entrance of air into the lungs, has long been designated as Bron-
chotomy, though, as the opening is limited to those portions of the
trachea which are above the sternum, the term Tracheotomy is
now more generally employed. Either may, however, be used .to
designate the operations practised on the larynx or trachea proper,
the opening of the larynx being, however, frequently spoken of as
Laryngotomy. As the operation of opening the windpipe varies a
little, according to the point operated on, the steps of each opera-
tion may be best described separately.
I. TRACHEOTOMY FOR CROUP.
The operation of tracheotomy dates back to a very early period,
Antyllus, A. D. 340, 1 having recommended and performed it in
several instances. It has also been performed at various times, and
1 See History of Surgery, Tart I., p. 18, of this volume.
460 OPERATIVE SURGERY.
in different manners, solely in order to meet the peculiar views of
the operator. To specify all these methods would, however, be a
useless task, and I shall, therefore, limit myself to such a general
plan of proceeding as may be advantageously resorted to under
most of the circumstances which demand this operation.
This plan having been first brought to my notice in a paper by
Dr. Joseph Pancoast, of Philadelphia, 1 and since then frequently
repeated by him, as well as tested by myself, has been selected as
presenting a methodical course of proceeding, as well as one which
opens the trachea perfectly without unnecessarily exposing the
patient to risk from hemorrhage, or to the subsequent inconve-
nience caused by the use of the canula.
Preliminary Measures. — When the operation has been decided
on, prepare a sharp scalpel; two curved spatula or blunt hooks; a
director; one straight, sharp, and one probe-pointed bistoury; dis-
secting forceps, and dressing forceps, if it is intended to remove a
foreign body ; a tenaculum or a pair of torsion forceps ; sharp-
pointed straight scissors ; threaded needles ; ligatures, and several
small pieces of sponge attached to sticks or quills as handles, as
well as one or two pieces of sponge, cold water, and towels, together
with such other articles as may be demanded in the dressing.
Operation" of Dr. Pancoast. — Place the patient upon his back,
with the head thrown sufficiently backwards over a pillow, yet not
so as to stretch it too much, or compress the trachea by contract-
ing the muscles in front of it.
Then, whilst standing on the right side of the patient, let one
assistant steady the head (Plate XXXI., Fig. 4), another confine the
arms and steady the shoulders, a third attend to the lower limbs,
and a fourth hand sponges, &c, as needed; or if the patient is a
child, bind its arms to the body by inclosing them in a folded sheet
or towel, so that one person may be able to hold it.
In commencing the operation, place the fingers of the left hand
upon the skin near the median line, so as to steady it, and make
an incision from the inferior part of the larynx down to near the
top of the sternum, so as to cut only through the skin, or puncture
a transverse fold of the skin when raised by the assistants and cut
from within outwards, and then raising the fascia superficialis on
the forceps, puncture it and slit it upon a director to the full
1 Amer. Journ. of Med. Sciences, vol. xvii. N. S. p. 307.
TRACHEOTOMY. 461
extent of the external wound. After finding the line of junction
of the sterno-thyroid muscles, separate them with the handle or
back of the knife, by tearing the cellular tissue between them, and
have them held back by curved spatulas so as to expose the parts
beneath, when the isthmus of the thyroid gland, if found to come
so low down as to be in the way of the incision, should be tied by
means of two ligatures passed beneath it by needles, after which it
may be divided between them. At this time the venous hemorrhage
from several points of the wound will often demand attention, and
such vessels as can be seen should therefore be ligated. Then,
pushing aside the two inferior thyroid veins, or ligating any anas-
tomosing branches, or the middle thyroid artery if it exists, divide
freely the condensed cellular tissue, which has been called by Mr.
Porter 1 the Tracheal Fascia, and dissect a small portion of it from
around the contemplated opening of the trachea, in order to prevent
the parts from subsequently becoming emphysematous and closing
the orifice. The trachea being now freely exposed, and the bleed-
ing checked, a tenaculum may be inserted in the median line of
the rings (Plate XXXI., Fig. 4), and the part thus raised excised
by sharp -pointed scissors ; or a bistoury may be at once passed in,
and the trachea slit open from below upwards, to the extent of
three or four rings, counting from the second; after which, the
wound may either be kept open by means of a dilator, as proposed
by Trousseau, or by bending a piece of lead or pewter, so as to
enable it to pass round the neck, and be attached to the sides of the
wound, as suggested by Dr. Pancoast, of Philadelphia, or by resort-
ing to what I have found to be a neater instrument, viz., an elastic
ring of broad watch-spring, which may be readily adapted to any
neck simply by turning the pivot that holds the two halves toge-
ther. (Plate XXX., Fig. 12.) The introduction of the old-fashioned
canula into the trachea is, I think, so objectionable, that it may suf-
fice at present simply to mention it, though, for the instruction of
such as desire to employ it, I have added a figure to show how it is
to be retained in the wound (Plate XXXI., Fig. 6). But whether
the cartilages are trimmed so as to leave an opening, as advised by
Messrs. Lawrence and Porter, of England, or simply incised, the use
of the blunt hooks, or the watch-spring, will always prove service-
able by keeping the soft parts from contracting and closing the
orifice in the trachea, as is very apt to be the case when the rings
' Surg. Anat. of Larynx and Trachea.
462 OPERATIVE SURGERY.
are merely divided without excising any portion of them ; but as
soon as the parts are sufficiently retracted, which happens some-
times in thirty-six hours, the hooks or springs should be removed.
After-Treatment. — The operation having been promptly per-
formed, the next most important point is the after-treatment, as on
this depends the success of the operation. To one familiar with the
pathology of croup, this will of course be simple, and may be
summed up in the employment of such measures as would gene-
rally be useful in relieving inflammation of the throat. As it is,
however, of importance that there should be no error on the part
of the operator, I will briefly state the means that are most likely
to contribute to the success of the operation. The temperature of
the chamber should always be closely watched, and seldom per-
mitted to sink below 80° Fahrenheit, as the air will now enter
the lungs through the orifice in the trachea, without having been
previously warmed in the mouth and nose. The atmosphere
should also be kept moderately moist by a vessel of boiling water
or vinegar and water being so placed as to favor the evaporation of
its contents. Then, if the trachea continues to be filled with the
false membrane usually seen in membranous croup, it may be
lightly touched once, with a camel-hair peucil wet with a solution
of the nitrate of silver 9j to 3j. The frequent resort to this solution
after the operation, though once practised, is now seldom employed,
as Trousseau has lately discountenanced it. When the edges of the
wound and the trachea become dry and disposed to crusts, it will
be found useful and agreeable to the patient to paint both surfaces
with glycerin and water, the constitutional treatment being as care-
fully pursued as it would have been before the operation was per-
formed. The object of the surgical treatment of croup, it should
be remembered, is merely to gain time for the efforts of nature to
effect the cure, the life of the patient and the success of the opera-
tion being almost entirely dependent upon the remedial measures
otherwise employed.
II. TRACHEOTOMY FOR THE REMOVAL OF A FOREIGN BODY.
The performance of tracheotomy, for the removal of a foreign
body, differs in no way from the operation just referred to in con-
nection with croup; but the following plan being presented in
TRACHEOTOMY. 463
connection, with a case of this kind, and showing the results of a
prompt incision into the trachea in order to check venous hemor-
rhage, is related in order to enable an operator to make a selection.
The chief difference between this and the preceding operation will
be found in the fact that Mr. Liston does not advise delaying the
opening into the trachea until the hemorrhage is arrested, as is
done in the method of Dr. Pancoast and others.
Operation of Liston. — In a patient, five years old, who had
swallowed a small glass seal, the operation of tracheotomy was per-
formed by Mr. Liston, as follows : —
The patient being securely fastened by a large sheet, wrapped
several times round the body and arms, and closely pinned, was
held by an assistant horizontally with his face upwards, and his
head between the operator's knee. The preliminary incisions being
made as usual, the blood gushed out freely from the veins, which
were greatly distended by the efforts of the child and the difficulty
of breathing, but none of these were tied. After waiting a few
seconds till the first rush of blood had somewhat abated, the tra-
chea, which was never still for a moment, rising and falling rapidly
with the hurried movements of respiration, was seized by means of
a small hook, and drawn forwards towards the mouth of the wound.
(Plate XXXI., Fig. 4.) The scalpel being then entered at the lower
extremity of the incision, with its point directed upwards and its
back towards the vertebral column, with the handle kept low, and
with a light hold of the instrument, so as to avoid injuring the oeso-
phagus by any sudden movement of the patient, two or three of the
rings were divided, and the assistant immediately directed to turn
the child over with his face downwards. For an instant, the little
patient seemed on the point of suffocation, as the first inspiration
drew in a certain quantity of blood, which could not be prevented
from flowing; but the next moment, by the change of position, the
blood trickled on the floor, a deeper inspiration was taken, the foreign
body was expelled with force, and, as if by magic, the breathing
became quiet, and the venous hemorrhage ceased spontaneously. 1
Eemarks. — In this mode of operating, the great object seems to
be to open the trachea promptly; but, unless in cases of threatening
suffocation, as from the introduction of a piece of meat into the
windpipe, there is no occasion for such haste. In removing other
1 Lectures by R. Liston, with additions by T. D. Mutter, p. 320.
464 OPERATIVE SURGERY.
foreign bodies, it sometimes happens that the opening of the trachea
produces such violent coughing as ejects the article solely from the
efforts of the patient ; but in others its escape is by no means so
easy or certain as in the case just detailed. Not unfrequently it
becomes necessary to remove it by means of narrow forceps (Plate
XXXI., Fig. 5), though sometimes, and in my opinion most fre-
quently, it remains for days and weeks, being subsequently thrown
up in a spasmodic attack of coughing. In some of these cases, the
performance of tracheotomy has been beneficial ; but in others the
patient has not derived such relief as would justify the operation.
Caution in diagnosis and prognosis is, therefore, a matter of much
importance with patients who are thus situated.
III. TRACHEOTOMY FOR EPILEPSY.
The suggestion of Dr. Marshall Hall, to relieve one of the forms
of Epilepsy (Laryngismus) by opening the trachea, seemed at one
time likely to lead to the frequent performance of the operation of
tracheotomy. Notwithstanding the able arguments adduced in
support of this theory by its accomplished author, the profession
have not generally coincided in its propriety, and many have even
regarded it as unjustifiable. In several of the patients on whom
the operation has been performed, the disease was only checked
temporarily, as had often been previously noticed after accidents
or other events calculated to make an impression on the nervous
system of the epileptic. Some of those operated on, in accordance
with the suggestion of Dr. Hall, have either had a return of the
disease or died, notwithstanding the existence of an opening in the
trachea, through which air was freely transmitted to the lungs ; and
in a paper read by Dr. Eadcliffe, of London, before the London
Medical Society, the opinion is expressed " that the convulsions have
been almost uniformly as bad as ever" after the operation. Many
members of the Society doubted, therefore, whether tracheotomy
was beneficial in this complaint. 1 In a case recently operated on in
Philadelphia, by Dr. Jno. Neill, the patient died with the tube in
the trachea. 2
1 London Lancet, 1853. 2 See Bibliography, p. 88.
LARYXGOTOMY. 465
IV. LARYXGOTOMY.
Laryngotonry may be demanded by very much the same cir-
cumstances as those which indicate the propriety of performing-
Tracheotomy, bat the former operation is less frequently employed
than the latter, in consequence of the greater risk of hemorrhage
in its performance, as well as the subsequent effects upon the voice.
It may be performed thus: —
Operation of Desault. — After dividing the skin and fascia
superficialis by an incision which extended from the projecting
angle of the thyroid cartilage to a little below the cricoid, but not
near so long as that required in tracheotomy, Desault separated the
thyroid muscles, placed his forefinger on the crico-thyroid ligament,
and feeling for the artery of the same name, endeavored to depress
or raise it out of the line of the incision, and then plunging the
scalpel into the ligament, cut it either upwards or downwards, ac-
cording to the position of the vessel.
When the incision is continued down through the cricoid carti-.
lage and first rings of the trachea, it constitutes the operation which
has been designated as laryngo-tracheotomy. In bad cases of Polypi
in the Larynx, it may also be necessary to prolong the incision up-
wards to the os hyoicles, as was done by Dr. Buck, of New York,
in the operation which is hereafter quoted.
V. LARYXGOTOMY FOR THE REMOVAL OF POLYPI IN THE LARYNX.
In two cases reported 1 by Dr. Gurdon Buck, Jr., of New York,
the operation of Laryngotomy, as recommended by Prof. Ehrman,
of Strasburg, was performed, and with considerable relief.
Operation of Dr. Gurdon Buck, Jr., of New York. — The
patient being seated before a window, in a low arm-chair, with the
head thrown back and the front legs of the chair raised about three
inches, on blocks, an incision was made for about four inches in the
median line of the neck, dividing the skin and subjacent tissues till
the laryngeal cartilages and the three upper tracheal rings were laid
hare, the latter being done partly by lacerating and partly by de-
1 Transact. Amer. Med. Association, vol. vi. p. 509, 1853.
30
±66 OPERATIVE SURGERY.
pressing the isthmus of the thyroid gland. The hemorrhage having
eeased, the crico-thyroid membrane was incised, and the incision
continued upwards in the median line, with the greatest precision,
throughout the whole extent of the thyroid cartilages, the division
being made with the scissors in consequence of the ossification of
the cartilages. The section being then continued through the cricoid
cartilages and the exposed rings of the trachea, the sides of the
larynx were stretched apart with retractors, thus exposing the poly-
pus growth attached to its lateral w r alls. On snipping off the polypus
the hemorrhage (which was of short duration) was absorbed by pieces
of sponge held in the forceps, and the blood thus prevented from
flowing into the trachea. A portion of the two upper rings of the
trachea being now removed on either side, the tracheal tube was in-
troduced, fastened by a tape passed round the neck (Plate XXXI.,
Fig. 6), and the respiration thus rendered easy and comfortable.
The wound subsequently healed kindly around the tube, which was
changed once in twenty-four hours, and the patient soon found
that by closing the outer orifice of the tube she could breathe
through the nostrils, and also blow her nose. The disease having
reappeared after three or four mouths, a second operation was per-
formed, the incision being carried along the median line, from the
upper margin of the opening occupied by the tube, to within one
inch and a half of the chin, so as to expose the whole of the larynx
and os hyoides. It was also extended downwards one inch below
the opening for the tube, when it was removed and the larynx
split open to its whole extent. After overcoming many difficul-
ties in removing as much as w r as possible of the tumor, the wound
was closed by three sutures above the tube, when the latter was re-
placed. The subsequent changing of the tube often caused con-
siderable hemorrhage ; and, the tumor again becoming developed,
a third operation, of a similar character, was performed. This
wound also healed kindly, but the difficulty in removing the tube
was again experienced ; and the disease again progressed, though
the patient did not die until nearly fifteen months after the first
operation, without which, Dr. Buck supposes, she could have lived
but a short time. In employing the tracheal tube, Dr. Buck advises
that it should be made with a large opening on the convex side of
its curve, in order to permit the use of the voice and the expulsion
of matter from the trachea when the outer orifice is closed.
ESTIMATE OF THESE DIFFERENT OPERATIONS. 467
§ 4. — ESTIMATE OF THESE DIFFERENT OPERATIONS.
Tracheotomy presents so few dangers that are not equalled by
the operation of laryngotomy, and has, in several diseases, so many
additional points of recommendation, that the latter is but seldom
resorted to. In selecting a mode of operating, preference may, it
is thought, be justly given to that employed by Dr. Pancoast and
others, and described at the commencement of this section. The
advantages which I think it possesses are, first, less risk of hemor-
rhage in consequence of the surgeon lacerating the parts about the
median line of the muscles, instead of dissecting them, as well as
from his ligating the isthmus of the thyroid gland previous to in-
cising it ; second, the preservation of the opening in the trachea
without irritating its lining membrane, or resorting to an instru-
ment that exposes the patient to the risk of suffocation by its escape
from the wound, or clogging with the secretions of the part; and,
third, the power of looking into the windpipe, and judging accu-
rately of its condition, or of applying remedies to correct it, if
desirable. Indeed, much of the success which has attended this
operation in the hands of Trousseau, Dr. Pancoast, and others,
seems to have been due to their judicious after-treatment; a few
drops of a solution of the nitrate of silver, ten or twenty grains to
the ounce of water, being dropped in or applied upon a little pro-
bang, or the trachea itself swabbed out by a similar instrument
whenever the clicking sound of the respiration led to the belief
that false membrane or mucus was collecting at this point.
The excision of even a small portion of the rings of the trachea,
in order to aid in preserving the opening, has been objected to by
some surgeons as being likely to cause a subsequent contraction of
the canal when the wound cicatrizes. But in the cases which have
recovered, both in the hands of Dr. Pancoast, of Philadelphia, II.
J. Bigelow, of Boston, and in those reported by others, this has not
been the case. In Dr. Bigelow's case, 1 after employing a tube two
days, it was deemed better to remove it, and excise a portion of the
tracheal rings, and subsequently a dilator of wire was kept at the
orifice of the wound.
The points especially worthy of notice in the performance of
1 Am. Journ. of Med. Sciences, vol. xxvi. N. S. p. 81.
468 OPERATIVE SURGERY.
tracheotomy may then be summed up as follows : 1st, to lacerate
and stretch, rather than dissect the parts about the trachea; 2d, to
check all hemorrhage by the ligature before opening the canal ; 3d,
to clear away the cellular substance (tracheal fascia) around the
proposed opening; and, lastly, either to excise a portion of the
rings, or keep the wound and orifice in the trachea distended by a
spring, or by hooks. (Plate XXX., Fig. 12.)
To those not familiar with the details of this operation, it may
also be useful to state that the puncture of the trachea generally
brings on a most violent and convulsive cough, during which little
or nothing can be done. This, however, usually passes off as soon
as the first stimulus of the cold air ceases to be felt. When, then,
an incision is to be made into the trachea, it should promptly follow
the puncture of the knife, or if a tenaculum is inserted, in order to
favor the removal of a portion of the rings, their excision should
be quickly effected after the hook is introduced, the violence of the
cough consequent on the puncture being sometimes so marked as
to alarm the bystanders for the life of the patient.
It is now doubtless apparent, from reading the above estimate of
tracheotomy, that I regard it as an operation requiring some skill
and preparation on the part of the surgeon, and that it should not
be attempted by any practitioner, unless totally regardless of con-
sequences. No matter how simple the operation may appear upon
the dead subject, or upon the healthy adult, it will often prove to
be a difficult one when the vessels are rendered turgid by dyspnoea,
or when it is to be performed on the short, fat neck of a child, or
when it is resorted to on a patient apparently at the last gasp, whose
larynx and trachea are actively raised and depressed at every respi-
ration. To the experienced surgeon such facts are well known, but
to those who have judged of the operation solely from its perform-
ance in the dissecting-room, such statements should create caution
and lead them to anticipate difficulties, if they are induced to operate.
In all cases, special precautions should be taken in regard to hemor-
rhage, as, in some instances, the flow of blood has been of the most
alarming and intractable kind. Desault, 1 whose skill no one can
doubt, was, it is said, compelled to give up an operation, on one
occasion, in consequence of hemorrhage ; and Eecamier has advised
surgeons to defer opening the trachea for several hours, lest the
1 Diet, de Med., torn. vi. p. 58.
ESTIMATE OF THESE DIFFERENT OPERATIONS. 469
patient should suffer from a flow of blood. Roux, also, is reported
to have saved one of his patients from the suffocation caused by the
blood escaping into a trachea which had been promptly opened in
hopes of arresting it, only by placing his own mouth to the wound
and sucking it out. In a recent number of the Gazette des Hupi-
taux, as translated by Dr. Fraser, and published in the Transylvania
Medical Journal for June, 1853, is also an account of a discussion
on Tracheotomy in the French Academy of Medicine, in which the
serious character of the operation is admitted both by Guersant and
Boyer. When, therefore, tracheotomy is spoken of "as an operation
not much more difficult than venesection," the opinion should be
received with some hesitation, as it may be the result of the want
of experience of those who utter it.
Supposing, however, that the operator is aware of these dangers,
and it is admitted that they are not universally encountered, the
question which has of late years occupied so much of the attention
of surgeons yet remains to be decided, to wit, Should tracheotomy
be resorted to for the relief of all patients who are liable to die
asphyxiated? That such a recommendation cannot be universally
admitted requires no argument, and the proposition may, therefore,
be more definitely settled by showing in what cases the performance
of this operation may be advisable.
That an opening may be made into a healthy trachea for the re-
moval of a foreign body, or in order to overcome a spasm of the
glottis caused by inhaling a noxious vapor, or in cases of oedema of
the glottis, is a point which I cannot but regard as settled by sta-
tistics. From an examination of the various papers referred to in
the Bibliographical Index, 1 as well as from a review of many of the
works upon Surgery, from a very early period, I am induced to
think that tracheotomy, in such cases, is not only a justifiable ope-
ration, but also one which furnishes the patient with a ready means
of escape from the dangers likely to ensue. And although instances
are recorded where even nails and coins have remained in the wind-
pipe for years, and even in the lungs, without destroying life, there
are others, well authenticated, where the presence of a small bean,
or of a grain of coffee or of corn, have induced laryngeal phthisis,
ulceration, and death. In oedema of the glottis, though the opera-
tion of tracheotomy may be required, I would not resort to it until
1 See Bibliography, p. 84.
470 OPERATIVE SURGERY.
scarification of the parts had been fairly tried ; but tins being done,
I should anticipate from the operation prompt and permanent
relief. In hydrophobia, I should certainly be disposed to try it
rather than see the patient die without the operation.
As to the propriety of advising tracheotomy in cases of mem-
branous croup, there is apparently so much of the result that might
be charged to the peculiarity of the mode of operating heretofore
employed, and to the delay that has generally preceded its perform-
ance, that the decision of the question must be considered as "sub
juclice." By referring to the statistics hereafter quoted, an opinion
of the success of the operation, as usually performed, may be rea-
dily obtained, and it is one which has gone far towards diminish-
ing professional confidence in this operation as a means of treating
croup. Very many of the best surgeons at different periods, have,
in their day, doubted its propriety or only advocated its performance
at the last moment. In the United States, the experience of Dr.
Physick was adverse to it ; and in Boston, the opinion of some of
the profession is at present opposed to its performance, as I notice
no reply was given 1 to the question proposed by Dr. Storer, of
Boston, to the members of the Society of Medical Improvement,
whether "Tracheotomy had ever been successfully performed in
that city in membranous croup?" More extended statistics, as col-
lected for this volume, 2 also show that the prognosis of the opera-
tion, as heretofore performed, should be very guarded.
In most of the cases as yet reported, tracheotomy has, however,
been deferred until the complaint had existed some time, and the
inflammation progressed from the koynx into the trachea, or in-
duced congestion of the lungs, or augmented the dangers from the
incisions, by causing engorgement of the vessels of the neck; whilst
in others there was an unhealthy condition of the lining membrane
of the trachea at the point operated on, or sometimes sloughing of
the wound, and constant irritation from the changing of the tube
employed to preserve the opening in the trachea. Until then we
can acquire such statistics as will show that in the cases operated
on at an early period after a positive diagnosis of membranous
croup has been made (and operated on so as to leave an opening
which by the use of glycerin would not be liable to clog with
mucus, whilst it is also kept free from the continued irritation of a
1 Amer. Journ. Med. Sciences, vol. xxvi. N. S. p. 81, 1853.
2 See page 473.
ESTIMATE OF THESE DIFFERENT OPERATIONS. 471
tube, by the use of the hooks (Plate XXX., Fig. 12) or ring), the
deaths correspond with the mortality under the former mode of
operating, this question cannot be regarded as settled. Cauterization
of the pharynx and trachea through the mouth, together with early
depletion, calomel and emetics, have saved many cases of true mem-
branous croup, and will, consequently, be a strong argument against
the performance of an early operation. But when croup occurs in
those who are hereditarily predisposed to it, or when other mem-
bers of a family have died from it, I would advise an early opera-
tion, and anticipate more success from it than I should from medical
means alone, provided the operation was resorted to before the in-
flammation had reached the portion of the tube which was to be
opened, and the wound in the trachea was kept open, either by the
hooks introduced upon its sides, or if that was not sufficient, by
their being placed upon the edges of the rings themselves. The
chief difficulty here, is to designate any signs which would indi-
cate that inflammation of the tracheal membrane had not gone too
far, since auscultation furnishes no evidence that can be relied
on, De La Berge and Moneret 1 citing one case, in which, though
the vesicular murmur was extremely pure and heard everywhere,
yet during the operation a false membrane was drawn out which
represented the trachea and division of the bronchia; and Dr.
Wm. Pepper, of Philadelphia, having also reported 2 one similar
case, and another in which, though the respiratory murmur could
not be heard, yet the exudation was strictly confined to the
larynx. The only test that I know of is the one recently suggested 3
by my friend, Dr. J. Forsyth Meigs, of Philadelphia, in which he
states that in some patients the pulse was much less rapid when
the disease was limited to the larynx and trachea than it was
when it had invaded the bronchia. In two cases involving
the bronchia the pulse counted 140 to 150 for several days prior
to death, whilst in two others in which only the larynx and tra-
chea were diseased, as shown post mortem, it counted only 120 or
130. In the case reported by Dr. Pepper, in which the disease was
found after death to be confined to the larynx, the pulse was also
only 120 the day preceding its termination. Dr. Meigs also suggests
1 Practical Treatise on Diseases of Children, by J. F. Meigs, M. D., 2d edit. p. Ill,
Philad. 1853.
2 Summary Trans. College of Physicians, Phila., vol. iii. p. 10G.
8 Am. Journ. Med. Sciences, vol. xvii. N. S. p. 332, 1849.
472 OPERATIVE SURGERY.
that the signs of asphyxia will have existed longer and come on
more slowly and gradually when the bronchia are diseased than they
will in those in which these tubes are not involved. lie therefore
advocates the operation in hopes of saving some who would other-
wise certainly perish. Although I am not so sanguine as he is
in regard to the frequent success that might ensue if the operation
of tracheotomy in croup was performed at an early period, I think
that it would be justifiable in many cases, and especially in those
with a pulse not above 120 ; but I would not advise it in any
patient with croup in whom the asphyxia was threatening, and
the blood had ceased to be well aerated. Like the operation for
strangulated hernia, tracheotomy, to be successful, must be per-
formed before the changes in the part are likely to render it use-
less.
§ 5. — STATISTICS OF THE OPERATION OF TRACHEOTOMY.
In order to show the data upon which the opinion just expressed
has been based, I have collected from various sources the results of
the operation, as performed for the relief of croup, as well as for
other purposes, and present them in the tabular form, as being that
which most readily exhibits the result.
I. TRACHEOTOMY FOR CROUP.
The following table shows the success obtained from the opera-
tion of Tracheotomy, as usually performed for the relief of mem-
branous croup, the wound being mostly kept open by means of a
canula in the windpipe. This table contains all such cases as
were reported so as to be accessible to me up to Jan. 1854, and
may be relied on, in the formation of an opinion, as far as any
mere enumeration of the result of any operation can be, unless
more details of the cases were furnished than is compatible with
the limits of this volume, as the Bibliographical Index presents a
full reference to such of the cases in the following table as were
reported by American surgeons. Those desirous of further details,
will find them in the journals there quoted.
STATISTICS OF THE OPERATION OF TRACHEOTOMY.
473
OPERATOR.
Amussat
Baudelocque
Blandin
Bretonneau
Gerdy
Guersent
Guersent, Hopital des Enfants,
Malades in 1850 had
in 1851 had
in 1852 had
This success was owing to greater
Maslieurat .
Petit .
Roux .
Velpeau
Trousseau .
Pancoast
Page .
Smith
Thompson .
E. Atloe
Townsend .
Van Buren
Buck, Jr.
Johnson
Goddard
Burgess
Mcllvain
Carter Johnson
Pitney
Ay res
Bigelow
OPERATIONS.
6
15
5
18
6
9
20 7 IS 4
30 13 17 4
59 16 33 4
attention to the treatment of the wound.
6>
15'
5 1
14'
2'
9'
2
G
4
6
153
9
365
1
3
41
4
2
1
1
1
98
1'
3 1
4'
6'
112 2
5 3
P
l 5
P
P
I s
P
5
P
P
P
P
P
5
5
p
257
From this it is seen, that of 365 cases of tracheotomy performed
for the relief of croup, in which the operation was not resorted to
until nearly every other means had been tried, only 98 were cured,
whilst 257 died, that is, in the 365 cases operated on, only seven
more than one-fourth of the patients recovered.
1 Condie on Children, edit. 1844, p. 310.
2 Lond. Med. Examiner, Aug, 1851, p. 134, from Gazette des Hopitaux.
vania Med. Journ., vol. ii. p. 325.
3 J. Pancoast, in MS. Jan. 29, 1852.
4 Transylv. Med. Journ., vol. ii. p. 325.
5 See Bibliography, p. 84, et supra.
Transyl-
474
OPERATIVE SURGERY.
The next table shows a very different result, the same operation
being performed at a period when the trachea was not diseased.
II. TRACHEOTOMY FOR THE REMOVAL OF FOREIGN BODIES, &C.
This table contains cases collected
Jan. 1854. 1
CURED. DIED.
John Newman, N. C. . . .1
Amassa Trowbridge, N. Y. .1
H. G. Jameson, Md. ... 1
"... 1
Samuel Cartwright, Miss. . 1
H. T. Waterhouse, N. Y. . .1
Joseph Palmer 1
Richard Burgess 1
Peter P. Woodbury, N. H. . 1
Calvin Jewett, Vt 1
U U 11 1
Enos Barnes, N. Y. ... 1
Abner Hopton, N. C. . . .1
Zadok Howe, Mass. ... 1
J. F. Hardy, N. C 1
Charles Hall, Vt 1
J. Mason Warren, Mass. . . 1 3
Twitchell, N. II 2
William Davidson, Ind. . . 1
W. II. Van Buren, N. Y. . .1
J. H. Kearny Rodgers, N. Y. 1
Evans, Ky 1
N. R. Smith, Md 1
Liston 1
Pancoast, Philad 3 1
Brainard 1
Gilbert 3
Morehouse 1
May 2
Neill 1
Hoyt 1
Trabue 1
W. H. Massey 1
Cured 38 Died 5
by myself, and reported up to
SUBSTANCE.
Bullet.
Bean.
Watermelon seed.
Pebble.
Watermelon seed.
Watermelon seed.
Bean.
Bean.
Bean.
Iron nail near two inches long.
Grain of corn.
Bean.
Watermelon seed.
Pipe stem.
Bean, pin, carpet-tack, nail.
Bean.
Grain of corn.
Plum stem and watermelon seed.
Cherry stone.
Vapor of hot water.
(Laryngotomy.) Cockle bur.
Glass seal.
Result not stated.
Abscess root of tongue.
Coffee-grain, raw potato, corn.
Almond shell.
Coffee and corn grains.
Epilepsy.
Bean.
Corn grain.
Soup bone (chip).
Total 43
1 See Bibliography, pp. 84 to 89.
SURGICAL ANATOMY OF THE PHARYNX AND OESOPHAGUS. 475
From this it appears that, in 43 cases of tracheotomy performed
for the removal of foreign substances from the trachea, 38 were
cured, and only 5 died — the trachea being allowed to close and
heal as soon as possible after the operation.
In comparing the results of these two tables, it is very evi-
dent that the dangers which ensue upon incising a healthy tra-
chea are comparatively slight, and that the great mortality which
has attended the operation, when performed for the relief of croup,
must be due to some other cause than the mere incision of the
windpipe. But whether this cause is to be found in the changes
produced by the disease, or whether it is the result of an incision in
an inflamed instead of a healthy structure — or whether it is not
owing to the delay usually attending the performance of the opera-
tion, is a point which can only be settled by each operator here-
after specifying the peculiarities of his cases.
CHAPTEE IV.
OPERATIONS UPON THE PHARYNX AND G3SOPHAGUS.
The (Esophagus, or musculo-membranous canal, which extends
from the mouth to the stomach, is liable to various affections, the
relief of which often demands more or less interference on the part
of the surgeon. Among the more important of these complaints,
may be mentioned those resulting from the passage of foreign sub-
stances, of a hard and irritating nature, which being inadvertently
introduced into the mouth, are thence carried down the oesophagus
towards the stomach, and liable to be arrested at various points ; as
well as the disorders consequent on inflammation in or around the
proper structure of the canal itself. From the importance of this
tube, and the difficulties of reaching it from the outside of the neck,
its relations to surrounding parts should be thoroughly studied by
the surgeon before attempting any of the cutting operations some-
times required for its relief.
476 OPERATIVE SURGERY.
SECTION I.
SURGICAL ANATOMY OF THE PHARYNX AND (ESOPHAGUS.
Although, to an ordinary observer, the (Esophagus is one con-
tinuous canal, which reaches from the mouth to the stomach, ana-
tomists have usually divided it into the pharynx, or that funnel-
shaped cavity, which extends from the base of the cranium to the
lower part of the cricoid cartilage, between the cervical vertebrae
and the posterior part of the nose and mouth, and into the oeso-
phagus proper, or the tube which extends from the same cartilage,
or lower part of the fifth cervical vertebra, to the cardiac orifice of
the stomach.
§ 1. — OF THE PHARYNX.
The Pharynx is composed of two coats, a mucous one, which is
continuous with the same membrane in the mouth, and a muscular
coat, composed of three constrictor muscles, placed one above the
other, the contractions of which convey the food from the mouth
into the oesophagus. In the mucous membrane of the pharynx
may be noticed a large number of muciparous follicles, which occa-
sionally enlarge and create irritation or inflammation about this
region. Beneath or behind the mucous membrane is a sparse layer
of cellular tissue, in which are found the bloodvessels and nerves of
the part, the arteries being branches of the carotid; the veins
emptying directly into the internal jugular, and the nerves being
branches of the glossopharyngeal, pneumogastric, and fifth pair.
The muscles of the pharynx mainly arise from the surrounding
bony prominences on each side, and, being joined to their fellows,
are enabled to diminish the transverse diameter of the opening, and
force the bolus of food or other substance downwards, till it reaches
the proper portion of the oesophagus.
§ 2. — OF THE (ESOPHAGUS.
The (Esophagus extends from the inferior extremity of the pha-
rynx to the stomach, is from ten to twelve lines in diameter, about
HYPERTROPHY OF THE FOLLICLES OF THE PHARYNX. 477
ten inches in length, and, when quiescent, flattened from before
backwards. In its descent to the stomach, this canal is between the
great vessels of the neck, directly upon the muscles in front of the
vertebrae, but inclined towards the left side of the middle line. At
the lower part of the neck it is yet more to the left side of the
trachea than behind it, and is united to adjacent parts by a loose
cellular tissue.
The (Esophagus presents three coats, which are designated as the
muscular, cellular, and mucous.
The Muscular coat has its fibres arranged circularly, internally
and longitudinally, externally. The Cell alar coat is well developed
adhering more closely to the mucous membrane than to the mus
cular fibres, presents a filamentous character, and contains numer
ous lymphatic glands.
The Mucous coat, in the undistended condition, presents itself
chiefly in longitudinal folds, thus favoring the passage of substances
to the stomach ; and is covered by a delicate epidermis, which,
under certain circumstances, becomes thickened and very distinct.
SECTION II.
OPERATIONS UPON THE PHARYNX.
Among the diseases of the pharynx requiring surgical treatment,
are the formation of polypi, as has been already referred to in con-
nection with the nose ; inflammation of the upper portion resulting
in stoppage of the Eustachian tubes, as mentioned in the diseases of
the ear ; and the formation of abscesses, the treatment of which
is to be accomplished by a simple puncture of the swelling at its
most prominent point, as is hereafter shown.
The other disorders, demanding surgical interference, are a
hypertrophied condition of the muciparous follicles, and the re-
moval of foreign bodies arrested by its walls.
§ 1.— HYPERTROPHY OF THE FOLLICLES OF THE PHARYNX.
Hypertrophy, or an enlarged condition of the follicles of the
mucous membrane of the pharynx, is an affection which has lately
478 OPERATIVE SURGERY.
received a degree of attention that it does not deserve, and were it
not that the accounts given of it are liable to lead the inexperienced
to regard it in too serious a light, this disorder might justly be
passed by without notice. In many instances, and especially in
those who smoke tobacco freely, it will be found that these enlarged
follicles have existed a long time without attention being directly
called to them, until they have been knowingly spied out as the
seat of symptoms with which they are by no means certainly con-
nected. But when, after a skilful investigation of the case, the
surgeon believes that they really cause the patient any inconve-
nience, he may do much towards removing it, simply by stimulat-
ing the surface of the membrane by the application of the nitrate
of silver, dilute nitric acid, strong tincture of iodine, sulphate of
copper, or some similar substance, applied either with a camel-
hair pencil, sponge, or swab.
§ 2. — TUMORS IN THE PHARYNX.
The Pharynx being lined with a mucous membrane, and attached
to the fibrous structure (periosteum and ligaments) which covers
the front of the cervical vertebras, as well as the basilar process
and sphenoid bone, is occasionally the seat of tumors, either of a
polypoid or fibrous character, which, encroaching upon this region,
interfere so much with deglutition, respiration, and speech, as to
require their removal. When they attain any size, their removal
will nearly always necessitate the division of the soft palate, or
even the cheeks, in order to expose them with sufficient freedom
to permit their extirpation ; but when they are of smaller size, they
may be strangulated, by means of the ligature and canula, passed
either through the mouth or nostril, the latter being preferable. The
following operation, as performed by Dr. L. A. Dugas, of Georgia,
fully illustrates the proceeding which may be demanded under simi-
lar circumstances.
Operation of Dr. Dugas.— A man laboring under a tumor of
the size of a large egg, which filled the pharynx, and extended
downwards as far as the larynx, and laterally from one tonsil to the
other, forcing down the right one, whilst it carried the soft palate
downwards, so as to constitute a prominence of the size just stated,
causing difficult deglutition, &c., was operated on in the following
manner: A ligature being passed beneath the right carotid arterv
FOREIGN" BODIES IN THE PHARYNX. 479
and left there to be tied when necessary, the patient was seated in
a chair, and an incision made through the cheek from the right
angle of the mouth to the masseter muscle, the divided facial artery-
being tied in the wound. A longitudinal incision being then made
in the soft palate from the side of the uvula to the roof of the
mouth, the palate was detached from the tumor, in the form of flaps,
exposing a bright glistening tumor which was adherent posteriorly
and laterally to the adjacent parts by strong cellular tissue. The
access to the parts being now free, the cutting instruments were laid
aside whilst the mass was seized with strong tumor forceps, and drawn
forwards, the attachments of the lower portion of the tumor being
torn asunder by the fingers. The left, upper, and part of the right
portion of the mass being then torn in like manner by the fingers,
this part of the tumor was removed, when another similar structure
was seen on the right side, in intimate connection with the right
tonsil, which it had passed downwards, being covered by a thin
stratum of muscular fibres, which were derived from the pharyn-
geal muscles. On dividing this stratum with the knife, and press-
ing it aside, this portion of the tumor was also removed with
the forceps and fingers, though not without great difficulty, as it
was found to be attached to the ramus of the lower jaw, near
the sigmoid notch, to the pterygoid process of the sphenoid bone,
and to the posterior aperture of the right nostril. The hemorrhage
was smaller than might have been anticipated, but required to be
checked occasionally by cold water, thrown into the pharjmx with
a syringe, after which the cheek was united by sutures and adhe-
sive straps, the ligature around the carotid artery being allowed to
remain until next morning as a precautionary measure. This pa-
tient soon recovered, and the microscope showed that the tumors
were purely fibrous, and without any evidence of a malignant dis-
order.
§ 3. — FOREIGN BODIES IN THE PHARYNX.
From the efforts made in swallowing, it occasionally happens that
foreign substances of various kinds, but especially those winch are
sharp and fine, are arrested in the pharynx, and retained there in
such a manner as enables them to be reached with the finger or
forceps. Generally, the most serious part of their removal is found
480 OPERATIVE SURGERY.
in the difficulty of recognizing their position. When the foreign
body is small and sharp-pointed, like a pin, needle, or fish-bone, it
may be looked for about the posterior half arches, or near the ton-
sils; as these articles, from their small size and pointed character,
are more apt to lodge in the line of the superior constrictor muscle
of the pharynx than those which are larger, and which, being more
readily seized by the muscles, are carried further into the oesophagus.
Thus, in eating fish, the softer portion of the bolus may pass, but the
constriction of the mass forcing the point of a bone into the upper
part of the pharynx, it will nearly always be seen presenting itself
transversely to the pharynx, or be found about the points just de-
signated. The same is true of pins or needles, of which one escaping
from the mouth, suddenly induces an effort to swallow, in which
effort the pharynx, being contracted laterally, the point pricks the
walls of one side, induces further spasmodic effort, until, at last, the
pin is found to have been buried by its point in the mucous coat,
or, perhaps, a little deeper. When foreign substances penetrate
deeply through the pharynx, there is, in addition to the inconve-
nience caused by their position, also some risk of their inducing
such inflammation of the tissues as may result in an abscess, or
they may cut their way into the larynx, 1 or injure the arteries of
the neck; for these reasons, they should be promptly removed, if
possible.
Operation. — Place the patient in a strong light, depress the
tongue with the forefinger of the left hand, and look for the foreign
body, or, if it cannot be seen, pass the same forefinger into the
throat, and feel for it. Then, using the finger as a guide, pass a
pair of suitable forceps along it, and endeavor to seize the substance
so as to extract it lengthwise and not transversely, lest its escape
be resisted by the contraction of the half arches consequent on the
gagging which the presence of the instrument will induce.
§ 4. — RETROPHARYNGEAL ABSCESS.
The formation of an abscess in the tissues situated- between the
posterior wall of the pharynx and the fronts of the bodies of the
cervical vertebras is an affection which, from its frequent fatal
result, by extension of inflammatory action to the glottis, and its
1 See Bibliography, article Oesophagus, p. 84.
OPERATIONS UPON THE (ESOPHAGUS. 481
effects upon the trachea, should be promptly treated. Although
long noticed by surgical writers, the dangers of this affection and
the necessity of prompt treatment have not been generally insisted
on. In a recent paper published 1 by Dr. Charles M. Allin, of New
York, the fatal character of the complaint is justly noted, as well
as the liability of the surgeon to overlook its existence. Of the
fifty-eight cases referred to by Dr. Allin, only twenty-eight were
relieved or cured, or about one-half died. Owing to the distance
of the abscess from the mouth, and the liability of the matter to
escape suddenly into the larynx, various means have been advised
for its evacuation, as the trocar and canula, &c. A simple and safe
method will be found in the plan pursued by Dr. Allin.
Operation. — The patient's head being firmly supported by an
assistant, pass the forefinger of the left hand into the mouth, de-
press the tongue, raise the velum palati, and press the point of the
finger against the tumor. Then pass a sharp-pointed bistoury, the
blade of which is covered with adhesive plaster, to within half an
inch of its point, along the left forefinger as a director, and make
a free incision through the walls of the pharynx, on the median
line of the throat, so as to open the cavity of the abscess. By this
free incision, fistulous tracks will be avoided, and simple detergent
washes will complete the cure.
SECTION III.
OPERATIONS UPON THE (ESOPHAGUS.
The (Esophagus being the principal channel by which substances
enter the system, is liable to various complaints in consequence of
the improper character of the articles introduced into the mouth.
Particles of food taken at a high temperature, or imperfectly masti-
cated; or foreign bodies intended to be held temporarily in the
mouth, but which are suddenly swallowed ; or a diminution of the
caliber of the passage, owing to various causes, are all instances of
the evils to which a patient may be exposed in the daily use of this
part. Two specifications will, however, embrace all the operations
required by this structure, independent of wounds, to which it is
1 New York Journ. Med., vol. vii. p. 325.
31
4S2 OPERATIVE SURGERY.
liable in connection with other parts of the neck, to wit, the re-
moval of foreign substances from it, or from the stomach, and the
restoration of its natural caliber, in cases of stricture.
$J 1. — REMOVAL OF FOREIGN SUBSTANCES FROM THE (ESOPHAGUS
AND STOMACH.
In order to estimate correctly the principles especially applicable
to the removal of foreign substances from the oesophagus, some
attention should be given to the anatomical relations of this part,
as well as to its functions.
In a well-written paper upon this subject, by Dr. Henry Bond,
of Philadelphia, 1 may be found some sound views of the physio-
logical action of the part, as well as of the means required for the
extraction of foreign bodies from the canal; and from this paper
many of the following facts have been extracted.
I. EFFECTS OF THE INTRODUCTION OF A FOREIGN BODY INTO THE
ESOPHAGUS.
The general anatomical relations of this canal having been already
stated, it is sufficient, at present, to mention that the posterior sur-
face of the trachea and larynx, as far as they are in connection with
the oesophagus, present to it a yielding ligamentous structure capable
of being impinged upon by any substance which may be arrested
in the latter. As the anterior wall of the oesophagus is that which
is chiefly expanded in the effort of swallowing, the foreign article is
generally brought more immediately in contact with the back of
the larynx and trachea, at those points where there is merely a liga-
mentous structure, where, by exciting the muscles of the glottis, it
causes irritation and efforts to cough, which occasionally become
spasmodic. If, then, an article should remain in the oesophagus, at
a point sufficiently high to enable it to impinge upon this portion
of the trachea, coughing or threatening of suffocation must ensue.
Cause it to pass either above or below the larynx and trachea, and
the most annoying symptoms will disappear. Two plans of treat-
ment in these cases have, therefore, been resorted to, the selection
1 North Araer. Med. and Surg. Journ., vol. vi. p. 278.
FOREIGN BODY IN THE (ESOPHAGUS. 483
of either being guided by the judgment of the surgeon at the mo-
ment, to wit, either to carry or force the substance into the stomach,
which answers very well when the article is an innocuous one, or,
when it is not, to remove it by some suitable means, such as the efforts
of the patient when excited by vomiting or by manual interference
on the part of the surgeon. For the accomplishment of the latter,
various means have been suggested, as forceps, hooks, and sponges.
But, without entering into the details of these inventions, it may be
sufficient merely to direct attention to such as will be found in Plate
XXX., among which can be seen the admirably adapted forceps of
Dr. Bond, and a hook, brought to the notice of the profession in the
United States by the late Dr. Nathan Smith, of New Haven. 1 An
instrument, very similar to this, is also represented as copied from
the European plates, the invention of which is assigned to Dupuy-
tren ; but, as no date is given to it, I have found it difficult to esta-
blish the priority of either, the difference in the character of the
two being very slight. Dupuytren has claimed the hook as his;
but whether he followed Dr. Smith, or preceded him, the latter
states explicitly that "his hook is unlike anything which he has
known to be employed for a similar purpose;" and he, therefore,
furnishes a drawing of it in the paper referred to, 2 deeming it espe-
, eially suited to the removal of coins. Both hooks, though adapted
to a certain class of foreign bodies, are not applicable to all, and, as
compared with the gullet-forceps, are thought to be inferior to the
instrument of Dr. Bond. The latter is capable of taking hold firmly,
and extracting safely any foreign substance, no matter how fine or
small, which is within the length of the instrument, that is, two or
three inches below the top of the sternum, measuring from the
mouth, and yet not liable to pinch the internal coat of the canal,
whilst the hooks are only adapted to larger objects.
Operation with the Forceps of Dr. Bond. — Place the patient
in a strong light, with the head thrown back, if the foreign sub-
stance is small, but if large, with the chin approximated to the
sternum, so as to relax the sterno-hyoid and thyroid muscles, lest,
by compressing the trachea against the bodies of the vertebrae, the
foreign article be caused to impinge on the larynx, and such a spell
of coughing induced as will materially interfere with the operation.
1 New York Med. and Phys. Journ., vol. iv. p. 576, 1825.
2 See Plate XXX., Fig. 4.
484 OPERATIVE SURGERY.
PLATE XXXII.
OPERATIONS PRACTISED ON THE CESOPIIAGUS AND LARYNX.
Fig. 1. A front view of the application of the (Esophageal Hook of
Dupuytren, as represented upon the subject, by a section of the mouth.
1. A longitudinal section showing the left half of the tongue. 2. A
vertical section of the lower jaw. 3. Top of the epiglottis cartilage as
applied over the glottis in the effort of swallowing. 4. The upper end of
the (Esophageal Hook. 5. Its lower extremity with the basket attached
to it. 6, 6. Dotted lines showing the course of the (Esophagus.
After Bourgery and Jacob.
Fig. 2. A front view of a section of the Mouth and Throat, showing
the application of the sponge to the Larynx, as advised by Trousseau and
Green. 1. Longitudinal section of the tongue. 2. Inferior maxilla, 3.
Os hyoides. 4. Section of the epiglottis cartilage. 5, 5. Sections of the
thyroid cartilage. 6. Point to which the sponge may be introduced. 7-
Upper end of the instrument. 8. Its lower end with the sponge in position.
After Bourgery and Jacob.
Fig. 3. A view of the relative position of the Surgeon and Patient in
the operation of washing out the stomach by means of the Stomach Pump
and (Esophageal Catheter, as suggested by Dr. Physick, of Philadelphia.
The patient is represented as reclining with the head thrown back, and the
jaws distended by a plug of wood introduced between the molar teeth.
The (Esophageal Catheter of Physick has been introduced into the sto-
mach, and then attached to the nozzle of the pump which is placed in a
basin close alongside of the patient. The surgeon is represented in the
act of drawing the liquid into the pump from the bowl. 1. Physick's
(Esophageal Catheter. 2. The Stomach Pump of Dr. Goddard.
After Nature.
FOREIGN BODY IN THE (ESOPHAGUS. 485
Then, placing a plug between the molar teeth, depress the tongue
with the forefinger of the left hand, and pass the forceps into the
cesophagus with the right hand, when the substance, if high enough
to be seen, may be readily extracted. But if lower down, the tongue
should be depressed by an assistant by means of the instrument
(Plate XXX., Fig. 11), whilst the surgeon, opening and shutting the
blades of the forceps, should carry the handles from left to right, or
the reverse, so as to sweep the cesophagus with the points of the
instrument. Should it be a coin, or a similar article, the dilatation
of the walls of the cesophagus will render the passage of the blades
on each side easy; but if it is a smaller body, as a- pin or fish-bone,
the operator need not fear an injury to the walls of the canal, as the
instrument is so constructed as to render such an event almost im-
possible.
Dr. Constantine Weever, of Michigan, has also published 1 the
description of a pair of forceps, consisting of a two-bladed whale-
bone stylet, which being inserted in a flexible catheter, is passed
down to the substance pushed out of the catheter so as to expand
on each side of the article to be removed, and then made to seize it
by pressing the catheter upon its blades. This instrument, which
acts on a principle similar to that of the litholabe of Civiale, may
prove useful where the foreign substance is very far down, and yet
of such a nature as should forbid its being pushed into the stomach
by a probang. If the article to be removed is barbed and sharp-
pointed, like a fish-hook and line, no expedient will probably answer
better than that suggested, under similar circumstances, by Dr. Brite,
of Kentucky, 2 to wit, the slipping of a sufficiently large and perfo-
rated bullet over the line and point of the hook, by directing the
patient to swallow the bullet.
When the dangers that may result from the perforation of the
aorta or trachea, 3 as the result of the continued presence of irritat-
ing articles in the cesophagus is recollected, it may be well for the
surgeon to be as unceasing as is prudent in his efforts to carry the
article either upwards or downwards.
Where the foreign body is so placed in the oesophagus that its
position can be distinguished by the touch externally, the propriety
1 Amer. Journ. Med. Sciences, vol. xiv. p. Ill, 1834.
2 See Bibliography, article (Esophagus, p. 83.
3 See Bibliography, p. 84.
486 OPERATIVE SURGERY.
of performing cesophagotomy is a question worthy of consideration.
Many substances of a durable nature have, however, been known
to remain for years in the oesophagus without creating intolerable
inconvenience, one of which is reported by the late Dr. Dorsey, of
Philadelphia, 1 and the possibility of such a condition should always,
therefore, be recollected. In this case, a copper coin remained
thirteen years in this tube without destroying life. On the other
hand, very small substances, especially when presenting sharp
edges, have ulcerated through into the trachea, or penetrated the
vessels or injured the important nerves about this region, though
they have also occasionally created abscesses, and thus been dis-
charged externally.
§ 2. — EXTRACTION OF NOXIOUS SUBSTANCES FROM THE STOMACH,
THROUGH THE (ESOPHAGUS.
The introduction of the (Esophageal Catheter, and the extraction
of any substance capable of passing through its channel, is so sim-
ple an operation as to require but a few words.
Operation. — After placing a plug between the back teeth, so as
to protect the fingers, or the tube, from being bitten by the patient,
pass the forefinger of the left hand to the root of the tongue, and
gently depress this organ. Then pass the catheter rapidly back-
wards till it reaches the back of the pharynx, when, if the resist-
ance that it meets with is not sufficient to depress its point, turn it
down by the forefinger previously introduced. ~By carrying the
point of the catheter towards either half arch, there will be little
risk of introducing it into the larynx, as the latter will be closed
in consequence of the gagging induced by the presence of the finger
in the pharynx. The introduction of the liquid, when it is neces-
sary, to wash out the stomach, may then be effected by the stomach-
pump (Plate XXX. Fig. I), 2 or by a large rectum syringe. In
withdrawing the catheter, its free end should always be closed by
the finger, in order to prevent the escape of any drops of liquid
into the trachea.
Remarks.— The performance of the operation of introducing the
stomach-tube is so simple an affair that the evacuation of the con-
1 Bibliographical Index, p. 83. a See Bibliography, p. 84.
NOXIOUS SUBSTANCES EXTRACTED FROM THE STOMACH. 487
tents of the stomach has more than once been done by a good hospi-
tal nurse. Within about fifty years, the extraction of poisons from
the stomach, except by emesis, was, however, an operation quite un-
known, until Dr. Physick, of Philadelphia, employed the now well-
known stomach-tube, or oesophageal catheter, the benefits resulting
from which have been, so great, that the profession in the United
States may well be jealous of the credit of the invention and appli-
cation of such a simple contrivance. In support of this assertion, I
would mention the following facts: In the American Medical Recorder?
Dr. Caleb B. Matthews published a paper, in which he showed very
satisfactorily the origin of this instrument, Dr. Philip Syng Phy-
sick, in 1800, having recommended it in his annual lectures in the
University of Pennsylvania. Dr. Dorsey, who was in Paris in
1803, also states that he had a gum-elastic tube, or catheter, made
to Dr. Physick's order, for the purpose of evacuating the contents
of the stomach, the length of which was so great as to excite con-
siderable curiosity among the Parisian manufacturers of catheters,
who could not divine for what purpose it was intended. In 1809
this instrument was employed by Dr. Dorsey, 2 and by others sub-
sequently, an indefinite number of times. From a claim afterwards
made for the priority of this invention by Dr. Alexander Monroe,
Jr., of Edinburgh, it seems that this gentleman had also conceived
the same idea, and in an inaugural thesis, published in 1797, pro-
posed similar means for extracting poisons, though he does not ap-
pear to have ever brought his suggestions into practice. Dr. Phy-
sick, though admitting at a later period the coincidence of this
suggestion, always stated his ignorance of the thesis in which it was
published; and being the first person who had one constructed and
employed, is certainly entitled to the credit of the operation, though
willing to share the originality of the suggestion with another.
In the paper advocating the claims of Dr. Physick, will also be
found a reference to the apparatus of Dr. Ewell, of Washington, as
proposed in 1808, and of Mr. Jukes, of London, who contrived simi-
lar means in 1822, as well as the testimonials of the distinguished
practitioners of that period, who by common consent seem to have
awarded the merit of the original manufacture and application of
the tube to Dr. Physick, he having, in the paper referred to, also
furnished drawings of the stomach-pump, to which it was adapted.
1 Am. Med. Record, vol. x. p. 322. Philad. 182*3.
2 Eclect. Repertory, October, 1812.
488 OPERATIVE SURGERY.
§ 3. — STRICTURE OF THE OESOPHAGUS.
Pathology. — The analogy existing between strictures of the oeso-
phagus and those of the urethra, has always attracted the attention
of surgeons when referring to this complaint. From the difference,
however, which exists between the surrounding tissues in these two
structures, a special description of the effects of the complaint, as
developed in the oesophagus, is essential to a correct appreciation of
the value of the various modes of treatment proposed for its relief.
In an able article, written by Velpeau, 1 will be found much valu-
able information, and to it I am mainly indebted for the following
details : —
The condition of the oesophagus, under the various causes pro-
ducing stricture, is very varied; but, however excited, the constric-
tion will generally be found to exist either near the upper or lower
extremity of the tube, and to be due to certain deposits around, or
changes in the mucous coat of the canal. Sometimes this coat is
simply thickened, though it has also been found to be decidedly
hypertrophied. When the stricture has existed for some time, or
lias commenced in the cellular coat of the oesophagus, the indura-
tion of the part is so marked as to present a mass closely analogous
to scirrhus, whilst it has occasionally been found to have changed
or entirely destroyed the ordinary characters of both the mucous
and muscular coats, thereby rendering it difficult to decide in which
tissue the disease had commenced.
The extent of a stricture in the oesophagus is very variable, usu-
ally it is not more than a few lines, though it may reach to the
length of several inches. At the seat of stricture there is often
found a central contraction, or bandlike thickening, above and below
which the indurated part is less constricted, whilst the portion of
the canal immediately around the seat of the stricture, has been
known to be dilated into a pouch capable of holding a quart of liquid.
Below the stricture, the oesophagus is occasionally more contracted
than natural, and its parietes are also found to be thicker than in
the normal condition. Frequently, on the contrary, it has presented
no marked alteration. Ulcerations have also been found in the
strictured portion of the canal, though they are believed to be more
1 Dictionnaire des Sciences Me"dicale, tome 21 me , p. 397. Paris, 1840.
STRICTUEE OF THE (ESOPHAGUS. 489
common above it, either in consequence of the particles of various
substances remaining in the dilated portion, or from the efforts of
the muscular coat of the canal to eject them, inducing increased
inflammatory action.
In many instances, the adjacent lymphatic glands are either en-
gorged or degenerated ; and when the stricture has been seated in
the neighborhood of the thyroid gland, the latter has been seen to
be either hypertrophied,. or very materially changed in its structure.
In some instances, adhesions have formed between the posterior face
of the trachea and the front of the oesophagus, or between the latter
and the carotid artery or the aorta, under which circumstances, a
perforation of the oesophagus at these points is inevitably fatal.
From this statement of the changes in the structure of the part,
every surgeon must see the dangers attending any attempt to over-
come old strictures of the oesophagus ; and he should, therefore, be
especially cautious, not only in his prognosis, but also in the em-
ployment of the various means that have been suggested for the
relief of the complaint.
The operations that have been recommended for the cure of
oesophageal contraction consist in dilatation of the stricture, in the
absorption or destruction of the diseased substance, or in a direct
incision through the constricted portion, so as to destroy the per-
meability of the canal.
I. DILATATION OF THE STRICTURE.
Instruments. — Without entering upon an account of the various
instruments that have been suggested for the purpose of dilating
the stricture, this account will be limited to the operation as accom-
plished by means of bougies. As originally suggested by Sir
Everard Home, these bougies were made of waxed linen in the
manner that will be referred to under the head of operations on the
urethra, and being passed into the oesophagus, by the manoeuvre
directed for the introduction of the stomach-tube, 1 were either held
for a few minutes against the seat of the disease, or gently pressed
through the stricture, so as to dilate the canal as they advanced.
The ordinary condition of these bougies, when made entirely of
1 See p. 486.
490 OPERATIVE SURGERY.
linen, does not, however, afford sufficient firmness to prevent tin-
pressure upon them causing a lateral deviation of the instrument,
in consequence of which the surgeon cannot tell accurately upon
what point of the oesophagus his force is applied. An instrument
which I have found to answer better, is one that was employed by
the late Dr. Wm. E. Horner, of Philadelphia, and represented in
Plate XXX., Fig. 6. It is formed by rolling a piece of waxed
linen, about three inches long, and cut bias, so as to give it a coni-
cal shape, around the end of a flexible piece of whalebone, like
that employed for the probang.
Operation. — After smearing the instrument either with molasses
or oil, pass it into the seat of the stricture, and make gentle pressure
at the obstruction until it yields, directing the point of the bougie
to the part that seems most constricted.
Eemarks. — In all attempts at dilating strictures of the oesophagus,
it should be remembered that gentle and continued pressure answers
better than violent efforts. In fact, the principles that would direct
the dilatation of a strictured urethra, are also those which should
guide the operator in relieving the similar condition of parts in the
oesophagus. But very little force should therefore be employed in
dilating oesophageal strictures, as the oesophagus about the seat of
the stricture is very liable to dilatation, as well as to softening or
ulceration ; if then the bougie is made to bear too forcibly on such
a point, perforation of the canal might ensue, and the patient be
exposed to all the risks of suffocation or infiltration of the sur-
rounding parts on the first attempt that is made to swallow liquids.
In the lighter forms of permanent stricture, in which the tissues are
not much changed, and in the spasmodic variety, dilatation presents
many chances of success ; but, dilatation of strictures in the oeso-
phagus, like those in the urethra, will prove but a temporary means
of relief if the surrounding parts are much indurated. Under
these circumstances, the application of caustic may be advantage-
ous, if judiciously and carefully directed.
II. APPLICATION OF CAUSTIC.
The caustic applied for the relief of strictures of the cesoph.
may be either the Kali purum or caustic potash, or the nitrate of
silver. From the difficulty of regulating the action of the potash,
STRICTURE OF THE (ESOPHAGUS. 491
and the peculiar advantages resulting from the application of the
lunar caustic to the mucous membranes generally, the latter is
decidedly preferable. It may be employed in the following man-
ner: —
Operation. — Pass a simple or unarmed bougie down to the
stricture, and mark accurately the distance of the disease from the
mouth. Then arm another bougie, by scooping a little hole in the
end of the waxed linen, and fitting in this a small piece of the
nitrate of silver : be careful to fasten it accurately in its place, so
that it may project a little beyond the level of the point of the in-
strument. Mark upon this bougie the distance of the stricture from
the teeth, as shown upon the former instrument, and passing it
rapidly to the seat of the disease, retain it in contact with the part
from one to three minutes. On withdrawing it examine the caustic,
in order to judge how much has been dissolved, and if it is deemed
to be too much, or such as might act upon the surrounding parts,
cause the patient to swallow some strong salt and water in order to
neutralize it and prevent its continued action.
Eemarks. — The application of the nitrate of silver in this dis-
ease is beneficial in two ways : 1st, by repeatedly creating a super-
ficial eschar on the surface of the stricture, it gradually destroys it;
and 2d, by allaying the irritability of the canal, or by stimulating
the absorbents, and modifying the action of the mucous membrane,
it does much towards the radical cure of the complaint. After a
few applications of it, the simple bougie will often be found to pass
readily, whilst the relief will be more permanent than that which
ensues upon the simple dilatation of the part, except in the spas-
modic form of the complaint. It need hardly be said that the
application of the caustic should be restricted to the diseased por-
tion of the canal, by placing it in such a position in the bougie, as
will prevent its action elsewhere.
III. (ESOPHAGOTOMY.
Under peculiar circumstances, as when it is necessary to remove
a foreign body from the canal,' or when, in cases of impervious
stricture, there is a necessity for the introduction of food in order
to sustain life, it has been advised to incise the oesophagus from the
outside of the neck. Although a rare operation, and one which
492 OPERATIVE SURGERY.
offers but slight chances of permanent relief in cases of stricture,
this operation has been successfully resorted to, an example of
which has been reported by Taranget, 1 where the patient was thus
nourished sixteen months.
Nearly equal success has, however, been obtained by a direcl
opening into the intestines or stomach, while the injection of nutri-
tive substances into the rectum presents a very good substitute for
such hazardous means of treatment. 2
In a paper by Dr. John Watson, of New York, maybe found the
history of a case in which the patient's life was considerably pro-
longed by this operation, though he ultimately died from the ex-
tension of the disease to the bronchia. OEsophagotomy is, however,
very rarely resorted to, having only been performed five times,
two of which were reported more than a century since.
Three modes of operating have been suggested, to wit, that of
Guattani, who incised the left side of the neck, and dissected to the
oesophagus, between the trachea and the sterno-hyoid and thyroid
muscles (Plate XXXVI., Fig. 6); that of Eikholdt, who made his
incision between the two origins of the sterno-cleido-mastoid mus-
cle ; and that of Boyer, who cut between the sterno-hyoid and
sterno-mastoid muscles. Boyer only opened the oesophagus for the
extraction of foreign bodies, and was, therefore, guided by the pro-
jection of the substance. Giraud and Yacca Bellingheri first in-
troduced a silver sound, so as to render the oesophagus prominent;
and Begin trusted entirely to the anatomical relations of the part. 3
Without further reference to these various plans of treatment, it
may suffice, as illustrative of a successful method of operating, to
state the manner in which it was accomplished by Dr. Watson, in
February, 1844.
Operation of Dr. Watson, of New York. — The patient being-
placed on a cot near a window, with his back well supported by
pillows, and his head thrown gently backwards, the incision was
commenced on the left side of the neck, midway between the os-
hyoides and the upper border of the thyroid cartilage, just in front
of the sterno-mastoid muscle, and carried down parallel with the
edge of this muscle to within an inch of the sterno-clavicular arti-
1 Diet, des Science Med., tome xxi. p. 412.
2 Bibliography, p. 84, art. Oesophagus, paper by Dr. D. J. Cain, of Charleston.
3 Malgaigne, Philadelphia edit., p. 37G.
STKUCTURE OF THE (ESOPHAGUS. 493
culation, dividing the skin, superficial fascia, and platysma-myodes
muscle.
A second incision, nearly an inch in length, was now made nearly
parallel with the upper edge of the thyroid cartilage, terminating
posteriorly at the upper extremity of the first and extending to the
same depth. After turning up the flap at the angle of these cuts.
a glandular tumor, about the size of a hazel-nut, was exposed and
removed from among the layers of the deep fascia. It proved to
be very hard, and contained a yellowish concrete pus in the centre.
The dissection being then continued through the deep fascia, the
omohyoid muscle was exposed and divided ; the superior thyroid
artery brought into view, secured by two ligatures, and divided
between them and the loose cellular tissue between the carotid and
the trachea, separated by the handle of the scalpel until the lower
portion of the pharynx and part of the oesophagus were fairly ex-
posed, this structure being put upon the stretch at every effort of
the patient to swallow. The edges of the wound being then dilated
by curved spatulse, an attempt was made to seize and puncture the
wall of the pharynx; but owing to the difficulty of accomplishing
it without endangering other parts, a silver catheter was introduced
through the mouth to the stricture, and, its point being cut upon,
the oesophagus was opened.
On passing an instrument into the opening, the seat of obstruc-
tion was found to be just below the incision but within reach of the
finger; and, as there was danger of wounding the ascending thy-
roid artery, in an attempt to divide it from within, it was found
necessary to open it from without. In order to obtain room, the
sterno-mastoid muscle was therefore divided transversely, and the
upper border of the thyroid gland turned down.
The recurrent nerve being now brought into view, one of the
branches of the superior thyroid artery was divided as it entered
the gland, giving rise to the only hemorrhage that required attention
during the operation, and this being arrested, the division of the
stricture was effected by an incision through it of at least an inch
and a half in length, the obstruction depending apparently on a
simple induration and contraction of the part not over five or six
lines wide. A stomach-tube being now introduced through the
wound, wine and arrowroot were administered. This tube was
then secured to the side of the head by its free extremity, the
transverse portion of the wound closed by a single suture, and the
494 OPERATIVE SURGERY.
remainder allowed to remain open. At the end of six days, the
tube being removed, a second one was introduced through the nos-
tril, down through the stricture, and worn twenty-five days, the
wound being closed by adhesive plaster. Several changes in the
catheters being made from time to time, the patient continued wear-
ing them for nearly seven weeks, the wound having healed around
it. At the end of this period, the tube was withdrawn on account
of the irritation in the throat, the obstruction in the oesophagus
reappeared, so as to require the reopening of the wound in the
neck, and the patient died about three months subsequently.
Kemarks. — That (Esophagotomy is an operation requiring much
deliberation on the part of an operator, in connection with its results,
is a point that has long been regarded as settled, and that it is a
formidable operation must, it is thought, be apparent to all who read
the account furnished by Dr. Watson. The question, therefore,
naturally presents itself, whether, in order to prolong life, it may be
right to advise a patient to submit to it. Deeming the relief afforded
by it dearly purchased at the risks of the operation, except in very
skilful hands, I cannot but think that the dangers of making an
opening directly into the stomach, as subsequently referred to by
Dr. Watson, in the paper before quoted, is certainly not greater than
that incurred in cesophagotomy. The number of instances in which
wounds and openings into this organ have not proved fatal will, on
examination, be found to be much larger than might at first sight
appear probable. 1 In addition to those which I have there men-
tioned, there is also a case reported by Dr. Watson, 2 as having
been seen by Dr. Archer, of Maryland, in which the stomach was
opened more than two inches by a wound Avith a, knife, and the
wound so well sewed up by an old soldier with an awl, needle and
thread (the stitches being only through the skin), that the patient
recovered, though an abscess of some size formed in the groin on
the ninth day, as the result of the wound in the stomach, and was
afterwards evacuated. The well-known case of St. Martin, and the
case reported by Etmiiller, where a fistula in the stomach remained
open ten years, together with numerous other facts collected by Dr.
Watson's extended research, and stated in his paper, also warrant
his assertion that an opening into the stomach is an operation that
is justifiable in urgent cases of stricture of the oesophagus, and
• See Bibliography, p. 101, art. Abdomen.
1 Am. Joum. Med. Sciences, vol. viii. N. S. p. 327.
OPERATIONS FOR RELIEF OF DEFORMITIES IN THE NECK. 495
probably quite as favorable to the recovery of tlie patient, as that of
uesophagotomy. In support of his suggestion, Dr. Watson quotes 1
several cases in which fistula communicating with the stomach have
continued for years, food being discharged at the opening after each
meal ; whilst on three different occasions surgeons have incised the
stomach for the removal of foreign bodies, and the patients reco-
vered. The removal of a teaspoon by opening the intestines, as
was successfully done by Dr. Samuel White, of Hudson, N. York ;
the excision of a part of the spleen by Dr. Powell, of Kentucky ;
the wound in the stomach reported by Dr. Ashby, 2 of Alexandria,
and the cases of Drs. Dugas, of Georgia, and Hart, of Mississippi, 3
as well as the free incisions made in the peritoneum in ovariotomy,
are all instances of the tolerance of patients under wounds of this
region, and may certainly be deemed sufficient to justify a surgeon
in opening the stomach in the extreme cases of impassable stricture
in the oesophagus referred to. But though these cases hold out
the prospect of success in the execution of similar incisions, no
one, it is presumed, would attempt gastrotomy with the view of
nourishing the patient unless specially urged thereto by the peculiar
circumstances of the case.
In the event of the distribution of property, or to accomplish
some great moral good, or in order to fulfil an important duty to
another, a patient might desire to prolong life, if possible, even for
a few weeks, and, under such circumstances, it may become impera-
tive on a surgeon to resort to such means as will enable him to
obtain the desired time.
CHAPTER V
OPERATIONS DEMANDED FOR THE RELIEF OF DEFORMITIES IN THE
NECK. ?
The affections of the neck Avhich lead to such deformities as
demand direct surgical interference in the way of an operation,
being due usually to contractions either of the skin, fascia, or mus-
1 Am. Journ. Med. Sciences, vol. viii. N. S. 1844.
2 Virginia Stethoscope, vol. i. p. 660. 3 See Bibliography, p. 103.
496 OPERATIVE SURGERY.
cles, it is generally necessary to employ some mechanical means
either to extend the contracted tissue, or to prevent the reappear-
ance of the deformity after the operation. In most instances,
therefore, the assistance to be derived from proper dressings and
mechanical contrivances should be remembered, and proper prepa-
rations made for their application before any incision is commenced.
The deformities of this region may be subdivided into those
affecting the skin and fascia, which are usually the result of burns,
and those confined to the sterno-cleido-mastoid muscle, the latter
being consequent on various causes.
SECTION I.
DEFORMITIES FROM BURNS.
The destruction of the skin and cellular tissue, consequent on
burns of this region, occasionally produces such a contraction of
the features as results in hideous deformity, or in an inability on
the part of the patient to perform many of the motions of the neck,
thus interfering with the action of the head, and preventing the
proper execution of such movements as are required in various
daily occupations. Among the most serious of these injuries is
such an adhesion of the skin of the neck to that of the chest as
results in an inability to elevate the head, or such a contraction of
the integuments about the chin as renders it impossible to close the
mouth, or draw up the* lower lip. Under these circumstances, ope-
rative surgery is capable of adding much to the comfort and happi-
ness of the sufferer, and, even in very marked cases, has produced
results that have been of the most gratifying kind.
In order to appreciate the value of the operations that have been,
at different periods, suggested for the relief of deformities from
burns, whether on the neck or elsewhere, it is important that atten-
tion should be given »o the changes produced in the tissues affected,
as well as to the almost unvarying tendency of the structure in-
volved to reproduce similar contractile tissues, unless the diseased
portion is removed, and the space filled in by healthy structure, the
latter being usually obtained by some means similar to those before
referred to in connection with the class of plastic operations upon
the face. 1
1 See Part II. p. 325, et supra.
DEFORMITIES FROM BURNS. 497
In an excellent paper upon Cicatrices and Cicatrization, hy S.
Laugter, in the Dicticmnaire tie Medecine, ou Repertoire des Sciences
Mi'dicales, tome vii., is an extended reference to the pathological
changes produced by destruction of the skin, as the result of wounds
and similar injuries; and from this and other sources the following
account has been condensed.
Pathology of the Cicatrices from Burns. — Delpech having
shown that in all wounds which suppurated freely, or did not unite
by the first intention, the granulations resulted in the formation of
a fibrous tissue unlike the ordinary structure of the part, aDd which
structure he named the "Inodular," all cicatrices, and especially
those resulting from burns, are often spoken of simply as the "Ino-
dular Tissue."
This tissue is always the result of suppurative inflammation, is
manifestly fibrous in its character, of a dull white color, without
the shining appearance of fascia or the satin-like character of the
surface of a tendon. In consistence and hardness it has been com-
pared to the strongest ligaments of the joints; but its fibres, unlike
these ligaments, run in all directions. 1 The contraction of this
structure, although at first highly useful in closing any wound, may,
by its continuance, create such traction upon surrounding parts as
will result in the evils just referred to in connection with burns ;
and, as it continues to contract for various periods after its forma-
tion, Dupuytren established three rules of practical value in the
selection of such cases as could be relieved by a surgical operation.
1st. He advises the surgeon not to attempt to correct the deformity
resulting from these cicatrices, until many months, or even years,
have elapsed after their production.
2d. Never to operate unless certain of obtaining a larger cicatrix
than that which it is wished to correct.
3d. To be certain that the operation can restore the parts to their
shape ; consequently, in cases of anchylosis of a joint, the operation
would be improper.
In relation to the different modes of operating, he also gives
directions of much value.
1st. In a long narrow cicatrix, he recommends the operator to
make several incisions so as to divide the cicatrix transversely
1 Diet, de Med., torn. 7 me , p 579, el infra.
32
498 OPERATIVE SURGERY.
through its entire thickness, without ever removing any part of it,
in order to facilitate its stretching.
2d. To stretch the parts, and bring them into a direction different
from that which the complaint had caused, in order to obtain a cica-
trix by the production of new skin. This extension must, however,
be practised with judgment, lest violent pain, inflammation, and
gangrene result, as in a case reported by Delpech.
In salient cicatrices, unaccompanied with retraction, he advises —
1st. To remove the prominence by a subcutaneous section, the
knife being introduced flatwise, and made to shave the skin from
the cicatrix as far as its extremities, in order to loosen the latter.
2d. To keep the edges of the wound open.
3d. Frequently to cauterize the surface, so as to keep it a little
below the level of the integuments.
Delpech, on the contrary, advocates the removal, as far as possi-
ble, of the entire cicatrix, and says that, when this is done, there
will generally be found sufficient skin to draw upon, in a direction
opposite to that which caused the deformity, thus enabling the
operator to obtain immediate reunion.
When it is possible to gain sufficient skin to permit this imme-
diate reunion of parts, the method of Delpech will be found prefer-
able ; but, in other cases, a large gaping wound would be formed,
which would create even greater trouble than the original com-
plaint.
The decision of either operation will, therefore, necessarily de-
pend chiefly upon the peculiarities of the case presented to each
operator at the moment.
In extensive cicatrices about the neck, where it is of great conse-
quence to obtain free motion, without being liable to a modified
reproduction of the difficulty from the newly-made cicatrices, some
of the various autoplastic operations will prove especially service-
able. 1 In these operations, the ordinary principles of plastic sur-
gery must be followed out, and the flap, which should if possible
be taken from a part of the skin where it is healthy, made of such
a size as may be demanded to fill up the wound left by dissecting
put the cicatrix, or by destroying its adhesions. This flap, allow-
ance being made for its contraction, should be closely attached to the
edges of the wound by numerous points of the interrupted suture,
1 See Plastic Operations on Face, Part II. p. 325.
DEFORMITIES FROM BURNS. 499
and then the sore left by the removal of the flap, either united or
allowed to heal by granulations.
In a paper by Dr. Thomas D. Mutter, upon the relief of deformi-
ties from burns, 1 these principles have been well illustrated, and,
from among several of the cases there reported, the folloAving has
been selected as applicable to the more severe injuries of this cha-
racter.
Operation of Dr. Mutter for the relief of Cicatrices from
Burns on the Neck. — The patient, a young woman, aged twenty-
eight years, had been burnt twenty-three years previously upon the
face, throat, and upper part of the thorax, from her dress taking
fire. She had been unable to throw her head to the left side, or
backwards, or to close her mouth for more than a few seconds
during the whole time. The right eye was also drawn down some
distance below the other, and when an effort was made to turn the
head, the eye became closed. The chin was drawn to within one
inch and a half of the top of the sternum, and this place was so
filled up by the cicatrix, that no depression existed in front of her
neck.
Operation. — The patient being placed in a strong light, on a
low chair, with her head thrown back as far as possible and sus-
tained by an assistant, an incision was commenced on the outside
of the cicatrix in the sound shin, and carried across the throat into
the sound skin on the opposite side. This incision penetrated
through the integuments as near the centre of the cicatrix as pos-
sible, and was about three-fourths of an inch above the top of the
sternum, the object being to get at the origin of the sterno-cleido-
mastoid muscles, which, in consequence of the long-continued
flexion of the head, were not more than three inches long.
After exposing the muscles, a director was passed under that of
the right side, and both its origins divided. The sternal origin of
the left muscle was next divided in a similar manner, when it was
found that the head could be placed in a proper position. The
elevation of the chin now left a wound six inches long by five and
a half wide, to fill which, a flap was formed from the shoulder by
an incision which, commencing at the left end of the wound in the
neck, extended downwards and outwards over the deltoid muscle,
so as to furnish an oval piece of integument six inches and a half
1 See Bibliography, p. 82. Deformities of the Neck.
500 OPERATIVE SURGERY.
PLATE XXXIII.
OPERATIONS PRACTISED ON THE NECK.
Fig. 1. A view of the Lymphatics, together with the Bloodvessels and
Nerves found on the side of the Neck. 1. Carotid artery. 2. Par vagum
nerve. 3. Internal jugular vein. 4. Subclavian artery. 5. Subclavian
vein. 6. Brachial plexus of nerves. 7. Lymphatic vessels and glands.
8. Fhrenic nerve. 9, 9. Sterno-hyoid and sterno-thyroid muscles. 10.
Thyroid gland. 11. Superior thyroid artery. 12. Lymphatic gland,
situated on temporal vein. 13. Lymphatic, at angle of jaw, imbedded in
parotid gland, and liable, when diseased, to be mistaken for enlarged
parotid. 14. Three superficial lymphatic glands on course of sterno-
cleido-mastoid muscle. 15. Deep-seated lymphatic at lower part of jaw.
1G. Facial artery and vein. 17. Lymphatic gland in advance of submax-
illary. 18. Submaxillary gland. 19. Three superficial lymphatics behind
steruo-mastoid muscle. 20. A large lymphatic gland situated outside, but
adjacent to sheath of bloodvessels. 21. A chain of lymphatic glands which
extend from side of neck to beneath the clavicle between the trapezius and
sterno-mastoid muscles. All the lymphatic glands above referred to are
the Occasional Seat Of tumors in the neck. After Bonnamy and Beau.
Fig. 2. Effects of a Cicatrix from a Burn of the Neck. After Nature.
Fig. 3. Myotomy as practised for the relief of Torticollis. 1. Right
hand of surgeon in the act of inserting the tenotome beneath the skin. 2.
His left hand raising the muscle. After Bourgery and Jacob.
Fig. 4. A view of the position and development of a Carotid Aneurism.
1. Common carotid artery. 2. Aneurismal sac. 3. Far vaguni nerve
displaced by the tumor. 4. Hypo-glossal nerve forced downwards and
forwards by the growth of the tumor. 5. Internal jugular vein. 6. Sterno-
cleido-mastoid muscle and skin drawn to one side by 7, a curved spatula.
After Nature, and John Bell.
Fig. 5. Ligature of Arteries about the Neck. L. Ligature of the lingual
artery. 1,1. Ligature passed beneath the artery. 2. Stylo-hyoid muscle.
3. Hypoglossal nerve. 4. Digastric muscle. 5. Incision through skin
and fascia. G. Platysma-myoideS muscle. After Bourgery and Jacob.
C. Relative position of the parts concerned in Ligature of the Primi-
tive Carotid. 1. Upper end of incision. 2. Skin and fascia. 3. Ab-
normal arterial branch from arch of aorta to pharynx, running parallel to
carotid artery. 4. Common carotid. 5. Descendens noni nerve. 6.
Par vagum. 7. Internal jugular vein drawn aside. 8. Sterno-cleido-
mastoid muscle held back. 9. Blunt hook. After Auvert.
A. Ligature of Axillary Artery. 1, 1. Line and extent of incision.
2. Pectoralis major as divided. 3. Axillary artery. 4. Ligature placed
beneath it, 5. Axillary vein. G. Brachial plexus. 7. Pectoralis minor
muscle. After Bourgery and Jacob.
TORTICOLLIS, OR WRY NECK. 501
long by six wide, which was left attached by its base at the upper
part of the neck. On dissecting this flap free from the shoulder, it
was twisted by a half turn on its pedicle, brought round into the
wound on the front of the neck, and retained there by numerous
twisted sutures and adhesive strips ; after which, the wound on the
shoulder was closed as far as possible by sutures and strips. The
head being now carried backwards, and maintained in this position,
the patient was put to bed, and union by the first intention took
place throughout the entire wound, with the exception of one small
point which healed by granulation. 1
Some additional steps relieved the eye and mouth ; and, twelve
months subsequently, the cure of the patient was complete.
SECTION II.
TORTICOLLIS, OR WRY NECK.
By the term Torticollis, or "Wry Neck, is usually designated such
distortion of the head, from muscular contraction, as brings the
back part of it forwards, downwards, and sideways, so as some-
times to turn the chin upwards and over the opposite shoulder, the
former being raised in proportion as the occipital bone is drawn
down. Although disease of the vertebras, injuries of the skin, or
other causes, may create this deformity, the present account will be
limited to the consideration of such cases as are mainly dependent
on an unnatural and permanent contraction of the sterno-cleido-
mastoid muscle.
Among the various causes that excite this deformity, there is
sometimes seen an unnatural contraction of one muscle, in conse-
quence of the partial paralysis of that of the opposite side, the con-
tracted muscle being generally felt like a tense prominent cord, or,
if not distinct, readily made so by any effort to turn the head to-
wards the sound side. To relieve this condition of things, and
bring the chin again to its natural line, the operation of myotomy,
or the subcutaneous division of the muscle or its tendon, and the
application of a suitable apparatus for making moderate extension
1 Am. Journ. Med. Sciences, vol. iv. N. S. p. G9; also Op. Surg., by J. Pancoast,
M. D., p. 359.
502 OPERATIVE SURGERY.
of the muscle, and preventing the future contraction of tHe new
tissue formed in the line of the incision, is especially calculated.
When, after an examination of the origin of the complaint, its
existence is found to be mainly due to a contraction of the muscle,
stimulating frictions, electricity, galvanism, and manual efforts to
restore the head to its proper position may be first resorted to; but
"when, after a trial of these and similar measures, little progress is
made towards a cure, the division of the muscle or its tendon Will
materially expedite the result.
Operation. — Various modes of operating have been suggested
by different surgeons, in order to accomplish the accurate yet safe
division of a muscle, which is known to be so closely connected
with important bloodvessels and nerves throughout most of its
course, as the sterno-cleido-mastoideus. These suggestions differ,
however, mainly in the shape of the knife or in the point at which
the muscle may be most advantageously incised ; but, as the sub-
cutaneous division is preferable to the old plan of dissecting clown
to the muscle, the description of the operation will be limited to
this mode of operating.
In the United States, the simplicity of the operation, or its fre-
quent performance, has apparently prevented the publication, by
surgeons, of such details as would be most serviceable to an inex-
perienced operator, and the two papers published by the gentlemen
hereafter quoted will, therefore, be found to furnish the principal
exposition of the views of surgeons, in this country, of an operation,
the utility of which has been doubted.
Operation of Dr. J. Mason Warren, of Boston. — A boy, six-
teen years of age, having fallen from a height when four years old,
was shortly afterwards found to labor under Torticollis. At the
time of the operation, the head was drawn to the left side, the ear
usually resting on the left shoulder, though it could be slightly
raised, the inclination to one side being accompanied by such a
rotation of the head as caused the face to regard the right shoulder.
There was also a lateral curvature of the spine, the left shoulder
being the highest. The sterno-mastoid muscle of the left side, on
being examined, was found to be strongly retracted, whilst the
deep-seated muscles of the neck, the scaleni especially, could also
be distinguished in an unnatural state of rigidity, the sterno-cleido-
mastoid being, however, the chief obstacle to the proper position
of the head. In addition to these changes, the whole of the left side
TORTICOLLIS, OR WRY NECK. 503
of the face was atrophied, and each of its component parts much
smaller than those of the opposite side. This alteration of the fea-
tures has been attributed by M. Gue"rin to the distortion which the
great vessels of the neck experience in consequence of the deformity,
whilst the curvature of the spine is regarded as due to the inclina-
tion of the cervical vertebras on the dorsal, of the dorsal on the
lumbar, and the lumbar on the sacral, in order to obviate the dis-
placement of the head, and bring it within the axis of the body.
In consequence of this condition of things, Dr. Warren deter-
mined to divide the sterno-mastoid muscle at its sternal origin,
the opinion being entertained, as suggested by Gue'rin, that the
complaint was mainly due to the retraction of this portion of the
muscle. Accordingly, its division was accomplished as follows : —
Operation. — The head being well supported and carried a little
forward, so as to throw the muscle outward from the subjacent
parts, a puncture was made with a lancet through the skin about
six lines above the clavicle, between the sternal and clavicular
origins of the muscle. A narrow blunt-pointed knife (Bouvier's)
was then introduced with its flat side towards the muscle, carried
behind the sternal origin, its edge turned towards the muscle, and
the section completed by a slight sawing motion, the effects being
indicated by a distinct cracking sound and by the partial restoration
of the head to its natural position. The little wound in the skin
beiug then closed by plaster, a cap was placed on the head, to the
back of which, opposite the right mastoid process, was attached a
strap, which, being drawn tight, was secured over the breast of the
same side. A stiff stock was also subsequently added to the dress-
ing, and, in the course of a fortnight, a great change in the position
of the head was perceptible, though it yet remained somewhat
inclined to the left, the clavicular origin of the muscle having
become more prominent since the division of its sternal attachment.
To remedy this, it was, therefore, decided to divide the clavicular
origin also, which was accomplished as follows: The head being
well supported, and the muscle sufficiently relaxed by inclining it
to this side, the body of the muscle just below the union of its two
origins, was readily seized between the thumb and fingers, and
completely isolated from the subjacent parts. A sharp-pointed
knife was then carried beneath the muscle, until it could be felt
under the skin by the finger on the opposite side, when, the patient
being directed to contract the muscle, its section was readily accom-
504 OPERATIVE SURGERY.
plished. In forty-eight hours the wound was healed, and nine
months after the operation the patient's appearance was so much
improved that his former friends could scarcely recognize him. 1
Operation of Dr. J. 0. Warren, of Boston.— A little girl, nine
years of age, also much distorted, was operated on as follows: —
The head being supported, and the muscles rendered tense, a
narrow sharp-pointed bistoury was passed flatwise between the
skin and the sternal origin of the muscle from without inwards
(Plate XXXIII., Fig. 3), and, the edge of the knife being then
directed upon the muscle, its division was accomplished. The knife
being now withdrawn and again entered at the same orifice, was
carried in front of the clavicular origin of the muscle, which was
divided in a similar manner. Bandages, similar to those employed
in the preceding case, were then applied, and two months after the
operation her head was so nearly straight that the deformity was
not perceptible to ordinary observers. 2
Dr. John W. Brown, of the Boston Orthopedic Infirmary, 3 after
dividing the muscle, employs a simple yoke to which bands from
a cap are attached, and has published in a paper on the subject an
expressive drawing of the apparatus, of which my present limits
forbid a description. In Plate XXXV., Fig. 1-4, may, however, be
seen a contrivance, made by Rorer, of Philadelphia, which I have
found to be well adapted to the object in view.
Remarks. — Having formerly followed closely the practice of M.
Guerin in Paris, and also noted the results of such patients as have
been presented to me in the United States, I am induced to think
that more or less benefit will be derived from the section of this
muscle in most of the cases which are unaccompanied by deformi-
ties in the bones, whilst, in those solely dependent on a contracted
condition of the muscle, a perfect cure may be anticipated. Of the
varions modifications suggested in the performance of the opera-
tion, there are none of great consequence; though the section of
the muscle from before backwards, as practised by Dr. John C.
Warren and others, is, I think, the safest. In operating in this
manner, attention should be given to the position of the external
jugular vein as it approaches the subclavian vein ; and when the
knife is upon the muscle, the division of the latter will be most
1 Boston Med. and Surg. Journ., vol. xxv. p. 123.
2 Idem., p. 124. 3 Idem., vol. xxvi. p. 58.
TUMORS OF THE NECK. 505
safely accomplished by holding the knife firmly against the muscle,
and causing the latter to press against the knife by carrying the
head in such a position as will make the muscle prominent. A
narrow straight bistoury, or a knife, like that in Plate XXXV., Fig.
13, makes so small a wound that, if care is taken to exclude the
air, but slight inflammation will ensue upon the operation.
Much of the success of this operation will, however, depend on
the proper employment of mechanical means subsequently. The
apparatus (Plate XXXV., Fig. 14), before referred to, is simple and
efficient ; but a nightcap and bandage, a tin frame, or any other
contrivance which will enable the surgeon to draw the head into
the proper position, will often be found to answer quite as well.
The division of the muscle, it should be recollected, only facilitates
the cure; the mechanical treatment accomplishes the most important
part of it, and also prevents that reproduction of the deformity
which is likely to ensue, when means are not taken to obviate it.
CHAPTER VI.
TUMORS OF THE NECK.
The word Tumor (tumeo, I swell) has been employed by Boyer
to designate "any preternatural eminence developed in any part of
the body;" by Hunter, as expressive of "a circumscribed substance,
produced by disease, and different in its nature and consistence
from the surrounding parts ;" whilst by Professor Miller, of Edin-
burgh, it is applied to "any morbid growth or new structure which
is the result of perverted nutrition in a part, independent of the
inflammatory process otherwise than as an exciting cause; and pos-
sessed of a power of formation and increase distinct from those of
the original tissues." These definitions, though not universally
applicable, are, however, sufficiently correct to present any one with
a good idea of the most general characters of this class of disorders,
and in that of Mr. Miller may also be found a brief account of their
physiology. As the changes of structure which result in tumors
may happen in all parts of the body, and as the account of the pa-
thology of the various kinds has been found sufficient to occupy
506 OPERATIVE SURGERY.
entire volumes, no attempt can possibly bo made in the present
limits to investigate the subject in all its details. In the excellent
volume by Dr. John C. Warren, of Boston, 1 may be found the
results of many years of study, combined with the experience fur-
nished by a long life of observation, and to this work, as well as to
the article on Tumors to be found in Miller's Principles of tiny,/, ,-,/,
the reader is referred for such an account of the general pathology
of these formations as would extend these pages beyond their
proper bounds. Without, therefore, doing more than mention
some of the different species of tumors found in the neck, as well
as elsewhere, I shall at present confine myself to a few general
remarks on such of the varieties found in the neck as require ope-
rative interference, and to a brief allusion to the means of diagnosis
applicable to most of them.
SECTION I.
GENERAL PATHOLOGY OF TUMORS OF THE NECK.
No matter what may be the peculiar characteristics of the tumors
found in this region of the body, no one can for a moment regard
their growth, without being curious to know in what way they have
originated, and what tissue has been made the nidus for their deve-
lopment.
The causes of tumors of the neck may, like those seen elsewhere,
be very varied ; thus a blow, strain, cut, burn, or chronic inflamma-
tion, may all, under proper conditions of the system, result in the
development of a tumor. In most instances, it may justly be pre-
sumed that these causes only produce a modification of healthy
inflammatory action, and that the abnormal growth originates, there-
fore, like the healthy tissues, in the deposit of a blastema, which,
instead of being reparative in its character, or proceeding to the
production of a healthy structure, results in the formation of one
whose character is dependent on -various circumstances. Thus, a
very slight modification of the primitive cell may result in the
production of what has been justly designated as an Analogous
tumor or a growth bearing considerable resemblance to the ordinary
1 Surgical Observations on Tumors, with Cases and Operations. Boston, II
GENERAL PATHOLOGY OF TUMORS OF THE NECK. 507
textures, whilst trie influence of constitutional causes may lead
to the formation of a Heterologous growth, or one which differs
widely in its appearance, general arrangement, and subsequent pro-
gress from that which usually results from healthy or euplastic
lymph.
In the neck, as in other portions of the body, the changes in
the nutritive action of a part may result in simple induration, hyper-
trophy, or increased formation of normal textures, or in the deposit
of cacoplastic lymph and morbific matter in the lymphatic glands,
or in the reticulated structure which is so freely developed through-
out this region. Whether the new growth be Benignant or Malig-
nant, it generally produces some change in the surrounding parts ;
thus, in most tumors, the surrounding cellular tissue becomes in-
durated, lamellated, or cystiforrn, so as to surround them with a
perfect sac; the muscular structure atrophied or hypertrophied,
the first being the more common; the fascia either increased or
diminished in density ; the larger vessels thickened or contracted ;
the capillaries engorged and augmented in size, whilst the whole
arrangement of parts will be more or less displaced in proportion to
the tension of tissue created by the growth of the tumor. So va-
ried, however, are the positions, structure, character, and modifying
influences seen in different cases of tumors, that it is impossible to
lay down concisely anything like a general law of progress. Usually,
the surgeon will not widely err in prognosticating the changes that
he will meet with in removing tumors of the neck, if he bears in
mind the facts that, with the exception of the dermoid class, all
tumors of this region are covered by a fibrinous expansion which
limits their external development and causes pressure on adjacent
parts ; and that the progress of the inflammation excited around the
mass will necessarily produce all the changes likely to result from
this process elsewhere, such as serous or fibrinous effusions, adhe-
sions, increased or diminished vascularity, and a general matting
together of parts usually distinct.
In the various attempts that have been made to group the differ-
ent kinds of tumors, writers have always found it difficult to arrange
them so that the classification would be accurate ; the varied de-
grees of departure from healthy structure exhibited by different
cases preventing anything more than an approximation to their
character. Among the older writers, the terms fleshy, fatty, pulpy,
honey-like, or encephaloid, designated their appreciation of the
5t)8 OPERATIVE SURGERY.
sensible characters of each class; whilst Abernethy and Lacnnec
described them as pancreatic, mammary, medullary, tuberculated,
melanotic, and carcinomatous sarcoma. Miiller has more recently
divided them according to their chemical nature, microscopic cha-
racter, and mode of development, into fatty, jelly-like, and albumin-
ous tumors, such substances being a principal characteristic in all
of these growths, though the proportions in each may be very
varied.
"The chemical constitution of tumors shows that the principles
chiefly found in the mare fat, gelatin, and albumen, and according
as any of these predominate, the nature of the tumor is found to
vary. Those which consist chiefly or wholly of fat contained in a
cellular parenchyma, are analogous, simple, and non-malignant.
Those which, by long boiling, are reduced almost entirely to gela-
tin are also non-malignant, and those which consist mainly of albu-
men include both analogous and heterologous formations; some
being malignant and others benignant, the carcinomatous being
almost entirely composed of albumen. 1
All tumors of the soft tissues are either solid, or contain solid and
liquid matter, more or less combined and variously arranged, con-
sisting either of a more or less compact fleshy growth, whose enve-
loping cyst is entirely a secondary formation, 2 being formed chiefly
at the expense of the surrounding cellular tissue, or of a cyst, which
is the original structure, and maintains the bulk and increase of the
tumor by its secretory power. 3
The solid tumors embrace those known as sarcomatous, adipose,
fibrous, cartilaginous, osseous, and cysto-sarcomatous, all of which
are benignant ; the tubercular or scrofulous, which is specific in
its nature ; and the carcinomatous, melanotic, medullary, and fun-
goid, which are malignant.
In studying merely the surgical treatment of tumors, many may
be disposed to say that the peculiarities of each of these classes
are a matter of little importance, provided the tumor is causing
such a train of symptoms as renders it essential to the patient's
safety or comfort that it should be removed. Though unwilling to
admit the truth of such an assertion, the character of the present
volume renders it inexpedient to spend more time on matters which
1 Miller's Principles of Surgery, p. 388. Philad., 1845.
* Miller, p. 392. 3 hoc. cit.
CHARACTER AND POSITION OF TUMORS OF THE NECK. 509
are truly within the province of the principles of surgery. Atten-
tion will, therefore, now be directed to the means of diagnosticating
the probable constituents of the tumor as well as its relations to
surrounding parts.
§ 1. — DIAGNOSIS OF THE CHARACTER AND POSITION OF TUMORS
OF THE NECK.
In diagnosticating these growths, the senses of sight and touch
are those mainly required to arrive at a correct conclusion, though
that of hearing may occasionally be called into play, in order to
detect vascular disorders or connections.
I. THE CHARACTER OF TUMORS.
On looking at a tumor in the neck, the general shape and posi-
tion of it should first be noticed. Tumors involving the glandular
structures, aud especially those of the lymphatic glands, will gene-
rally be seen to be nodulated or irregular, provided effusions into
surrounding parts have not created such changes in the integuments
as would equalize their surface. Those which are encysted or fatty
are, on the contrary, more smooth on the surface, and globular.
Pulsation, change in the color of the skin, as blueness or redness,
together with a turgescence of the superficial veins, are also points
that should attract the eye in this primary investigation.
On feeling the tumor, a judgment should be formed of its solid or
fluid character, of its hardness or softness, of its attachments to sur-
rounding tissues, of its pulsations, and of its sensibility. Hardness
will generally characterize albuminous deposits, the majority of
which are malignant ; elasticity, amounting almost to a sense of
fluctuation, characterizes the fatty class, whilst, unless the sac is very
full, or the contents decidedly jelly-like, fluctuation and the presence
of liquid may be readily told. Occasionally, the position of a tumor,
and its confinement by the fascia, give to it a sense of pulsation
that might lead to the supposition of its being a vascular enlarge-
ment. Under these circumstances, an effort should be made to
elevate it from the subjacent artery ; or the circulation be stopped
in the latter by pressure and the change in the size of the tumor
510 OPERATIVE SURGERY.
noted ; or the ear may be applied and the peculiar aneurismal
whir listened to. Some surgeons, in addition to these means, aid
their diagnosis by introducing a grooved or cataract needle into
the tumor, and noticing the character of what escapes, or the sensa-
tion of solidity given by the passage of the needle. When other
means have failed, and a consultation are in doubt, or when the
operator is prepared to remove the tumor at an early period, it
may be useful to resort to this instrument ; but personal expe-
rience has induced the opinion that, as a general thing, this aid
to diagnosis is liable to abuse and to the production of injury. If
the tumor prove to be malignant, its development will frequently
be rapidly accelerated by such an application. To assist such as
are not familiar with the general aspect of different tumors, and
thus diminish the necessity for the use of the lately fashionable
grooved needle, the following brief account of their external charac-
ters is presented as collected from various sources, but especially
from Miller's Principles.
The simple Sarcomatous Tumor has a smooth surface, a toler-
ably firm doughy feel ; does not fluctuate or give any sensation
approaching fluctuation; is not painful even when freely handled;
is loosely attached, and does not implicate adjacent parts; increases
slowly and without pain; possesses no more vascularity than a
similar bulk would naturally have, and varies from the smallest
to the largest size, weighing often many pounds. An example of
this kind of tumor may be seen in Plate XXXIV., Fig. 1.
The Adipose Tumor, often designated as the Lipomatous tumor,
may be either lobulated or non-lobulated, flat, globular, oval, or
cylindrical, and either smooth or studded on the surface with small
nodules. When touched, it is occasionally so elastic as to give a
sensation closely resembling fluctuation, and requiring considerable
skill to avoid an error in this respect. When handled, it is free
from pain; the skin is pale, loose, and movable at first; but it and
the tumor may become adherent by time and increased development
of the complaint. The growth is slow and steady, and if the tumor
is pedunculated, the skin will be stretched and elongated, so as to
resemble the neck of a sac. (Plate XXXIV., Fig. 3.)
The Fibrous Tumor is the most dense and firm of the benignant
class, being composed chiefly of dense fibrous matter. Its shape is
generally globular, the surface often nodulated, and the investing
cyst thick, strong, and slightly adherent to the tumor. It i.s gene-
CHARACTER AND POSITION OF TUMORS OF THE NECK. 511
rally perfectly circumscribed, movable, independent of adjoining-
tissues, painless, and slow of growth ; but it often causes trouble by
degenerating into the malignant structures, or by compressing ad-
jacent vessels and nerves.
Examples of the lymphatic and encysted tumors may be seen
well delineated in Plate XXXIV., Figs. 2 and 4.
II. THE POSITION OF TUMORS.
The large number of lymphatic glands found in the neck, and
the knowledge of their ordinary position, render a diagnosis of
many of the tumors of this part more easy than might at first sight
be supposed. According to the views of Allan Burns, nearly all
the glandular tumors of the neck may be referred to two classes,
those which are without and those which are within the fascia, the
existence of either being recognized by their mobility, or the ease
with which they can be drawn from their ordinary position.
On examining the structures mainly concerned in this class of
tumors, it will be found that the great chain both of the superficial
and deep-seated lymphatics of the neck follow the course of the
superficial and deep-seated veins (Plate XXXIII., Fig. 1). In the
healthy condition, these glands are for the most part flattened and
oval, varying from two to nine or ten lines in length. Of the su-
perficial glands there are, between the skin and the insertion of the
sterno-mastoid muscle, from four to six; in the interstice between
the clavicular origin of the sterno-cleido-mastoid and the anterior
edge of the trapezius, just above the clavicle, and bordering on the
external jugular vein, are half a dozen; between the skin and the
parotid gland there are two, one above or near the zygoma, and the
other below near the angle of the jaw. Disease and enlargement
of the latter are very apt to be mistaken for an affection of the
parotid itself. In the early stages of this tumor, its movable cha-
racter will, however, prevent such an error in connection with the
parotid. Around the submaxillary gland, especially at its anterior
and posterior extremities, there are eight or nine, and in it as well
as in the parotid, are lymphatic vessels and smaller glands which
are the primary points from which the disorder of these structures
originates. The deep lymphatic glands of the neck are also very
abundant ; they are placed along the sheath of the carotid artery
and jugular vein, and between them and the anterior edge of the
512 OPERATIVE SURGERY.
PLATE XXXIV.
APPEARANCE AND POSITION OF SOME OF THE TUMORS SEEN ABOl T
THE NECK.
Fig. 1. Large Sarcomatous Tumor of the right parotid region, caused
by the development of a sebaceous follicle in consequence of a blow upon
the part. Commencing as a lump the size of a nut, this tumor gradually
increased to nearly the size of the head; gave exit at one time to seba-
ceous matter; had a broad base;- was nearly immovable ; had the veins
enlarged upon its surface, and showed a small ulceration in front, from
which fetid, acrid, and bloody sanies had escaped. As the tumor enlarged,
the jaw became closed ; sensation of the face diminished, and there were
all the other symptoms due to pressure on the vessels and nerves of the
part. The tumor differs in appearance from scirrhus of the parotid gland
in its size and period of development. It was readily removed, and is re-
presented as an example of one of the class of tumors of the parotid region
not involving the parotid gland. After Auvert.
Fig. 2. Large Tumor of the Neck dependent on degeneration of the
lymphatic glands of the neck. Arising as a small swelling caused by an
enlarged gland below the angle of the jaw, it gradually increased until it
occupied the entire side of the neck, involving many glands, and reaching
from above and behind the ear to below the clavicle, so as to turn the
head to the opposite side. Its appearance was that of an irregularly
lobulated mass : it was unaccompanied by pain, was perfectly firm and
hard, and gave no sense of fluctuation at any point. Under the use of
chloroform, it was successfully removed by Dr. Mott. After Mott.
Fig. 3. Appearance of an immense Adipose or Lipomatous Tumor of
the Neck. This tumor was not painful; had no pulsation ; was formed
of numerous large lobes, with the superficial veins distended over them.
and was attached to the neck by a large pedicle which extended from the
angle of the lower jaw on the right side, down to the sternoclavicular
articulation; its weight being so great that the patient could hardly retain
the erect position. The tumor was found to be covered by a strong capsule
formed of the surrounding cellular tissue, and to have originated in a
hypertrophy of the surrounding adipose tissue. Aftei
Fig. 4. A large Encysted Tumor of the left Parotid and Submaxillary
Regions, which was to the touch semi-elastic, unequally lobulated, and
due to a chronic irritation of one of the sebaceous follicles, the duct of
which had become closed, and thus caused a retention and degeneration
of its secretion. Alter Auvert.
CHARACTER AND POSITION OF TUMORS OF THE NECK. 513
trapezius are about twenty. When enlarged, these glands project
beyond the sterno-cleido-mastoid muscle at its posterior edge, and
in the removal of some of them a section of the muscle may be re-
quired. Between the inferior edge of the thyroid gland and the
sternum, on the trachea, are four, and a chain of them extends from
these around the oesophagus, trachea, and bloodvessels towards the
heart' (Plate XXXIII., Fig. 1).
The tumors, formed at the expense of the deep lymphatics, are
exceedingly liable to contract adhesions, especially to the sheath of
the vessels, so that their extirpation will involve these parts so di-
rectly as to lead to danger unless caution is exercised. As a class,
these tumors are more fixed, and the finger cannot be passed around
them in the same manner as is often the case in the superficial
glands. When a tumor in the neck of a solid, or apparently semi-
solid consistence, is seated nearly on a line with the upper portion of
the larynx or towards the angle of the jaw, or close to the posterior
edge of the sterno-mastoid muscle, and seems to elevate the muscle,
or is rendered more movable by relaxing the latter, it will often
prove to be directly over the course of the great vessels if not at-
tached to their sheath. When a tumor in the neck is large, pedi-
culated, or shows a tendency to extend and elongate the skin, so as
to become pendulous, its attachments will generally be superficial.
But if the size of the tumor is not large (say not larger than a
lemon), if it is round or flat, hard, bosselated, and not easily moved,
or excites doubts as to its mobility, especially if its attachment is
near to, and in the line of the sterno-cleido-mastoid, it may be taken
for granted that it is deep-seated. A small tumor not larger than
a walnut, and apparently upon the edge of the sterno-mastoid mus-
cle, and whose removal seemed to be a very simple affair, was un-
dertaken by a fellow practitioner. Having noticed the liability to
error of diagnosis in such cases, I was prepared for hemorrhage,
and, in a very few minutes, was compelled to tie the internal jugu-
lar vein with two ligatures, the vein and sheath of the vessels being
so adherent to the base of the tumor as to mislead the operator as
to its actual position. So deceptive are the attachments of all
tumors of the neck, that it has been justly said " that no one can
tell how far he may be compelled to go in order to remove them,
until he has completed the operation."
' U. S. Dissector.
33
514 OPERATIVE SURGERY.
SECTION II.
OPERATIONS FOR THE REMOVAL OF TUMORS OF THE NECK.
la the treatment of the morbid condition of structures as varied
as those connected with tumors in the neck, it must evidently be
impossible to lay down any general mode of operating, that would
be applicable even to a majority of the cases that may be met with.
Surgical writers have, therefore, generally been satisfied with fur-
nishing directions in regard to the form of the external incision, or
in recommending that, in all operations for the removal of tumors,
the skin should be cut so as to create as little deformity as possible,
whilst, at the same time, the deep-seated attachments of the struc-
ture to be removed are freely exposed. In the neck, the latter re-
commendation is especially serviceable, as too much stress may be
laid on the deformity likely to arise from the cicatrix. When com-
pared with the increased difficulty liable to be caused by a limited
incision, the inconvenience created by the deformity from a cicatrix
does not deserve a moment's consideration. Wounds of the skin,
it is well known, generally unite with great facility, whilst a free
incision, by enabling the operator to see distinctly the structures
upon which he is acting, will greatly accelerate the accomplishment
of his object, and save the patient much unnecessary risk and suf-
fering. From the importance of the parts connected with tumors
in the neck, the first object of the operator should certainly be to
accomplish the removal of the disease with safety and certainty,
and nothing will aid this purpose so much as a free external inci-
sion ; the subsequent dissection being, if necessary, more limited in
its extent. The choice of the shape of an incision will also often
exert considerable influence upon the success of the operation; and
a brief reference to the adaptation of each of them to special cases
may, therefore, prove serviceable.
The straight incision is especially applicable to the removal of
small and superficial tumors, or those situated directly beneath the
skin. The elliptical incision exposes a part more freely, and is
chiefly resorted to when it is desired to remove an excess of integu-
ment, as in the case of a large or pendulous tumor. The V incision
is more free, and adapted to tumors of moderate size, so situated as
to render it necessary to insure the safety of particular parts; whilst
CHARACTER AND POSITION OF TUMORS OF THE NECK. 515
the crucial or the T, and especially the former, will be found the
best in all cases where the tumor is large, and likely to require a
free dissection. But no matter what line of incision is selected, it
is essential that the external or primary cut should extend at least
to the very circumference of the base of the tumor, as seen through
the skin, and in many instances it will be found advantageous to
carry it a few lines beyond this point. After incising the skin, there
are certain rules which are applicable to the removal of the majority
of tumors, and the observance of which will prove highly useful to
those who have yet to gain their experience. Thus, Dr. Alexander
H. Stevens, of New York, in an able lecture on the removal of
tumors, directs the operator first to cut down to the tumor before
commencing its dissection; and, second, to remove the whole of the
tumor, and nothing more.
Malgaigne also advises that the dissection should be made by
extensive cuts (by which I understand the sweeping motion of a
good dissector, and not the hacking and pricking of tissue occasion-
ally seen), the edge of the scalpel being directed as much as possible
from those parts which it is important to leave untouched, whether
they be in the tumor or in the healthy structure. In connection
with the dissection, conducted in the neighborhood of important
organs, whether nerves, vessels, or muscles, he also directs that they
should be drawn or put to one side by means of blunt hooks, the-
fingers, or forceps. When the principal portion of the tumor is
removed, especially if it is of a suspicious character, the surgeon
should endeavor to satisfy himself that no particle is left behind, lest
it serve to reproduce the disease; and when any of the remnants
are thus found, they should be removed either with the knife or
scissors, the wound being left undressed until all the vessels are tied
and the flow of blood arrested, when an effort may be made to heal
it by the first intention. 1 On this latter point surgeons have always
differed, and in this case I must dissent even from such good autho-
rity as Mr. Malgaigne is generally admitted to be. In tumors of
any size above that of a walnut, union by the first intention will
not usually be possible, especially if ligatures have been required,
and individual observation has rather led me to the observance of
the practice of the late Dr. Physick, in the introduction of a little
slip of linen at the inferior angle of the wound, so as to insure a
1 Malgaigne, Op. Surg., Philad. edit. p. 104.
516 OPERATIVE SURGERY.
vent for any pus that may be secreted. The surface of an incised
wound generally unites without difficulty; but the deeper-seated
parts are more obstinate, and in the neck it is especially important
that pus should be prevented from burrowing, and that a free vent
should be guaranteed it by other means than those furnished by
bringing the ligatures out at the lower angle of the incision.
In the extirpation of tumors about the neck, Langenbeik 1 pro-
ceeds as follows: He first makes a free division of the integuments,
dissects the muscles from over the tumor, but avoids cutting through
or injuring them if possible, thus making the tumor sufficiently
movable, whilst by preserving the muscles he is enabled to know
accurately the place of the chief bloodvessels. Then, when the
surface of the tumor has been cleared, its separation is to be com-
menced on that side which presents the least risk, or where the least
considerable vessels are, and the dissection carried from thence
towards the more hazardous portions. This distinguished surgeon
has also recommended that the knife should not be introduced
deeply where there are any large bloodvessels, but that the tumor
should be strongly pulled outwards, so as to separate it from the
vessels, and put the cellular substance around them on the stretch.
The latter recommendation will be found especially serviceable, and
the operator will be well able to carry it out if he takes the pre-
liminary step of passing a strong ligature deeply into any solid
tumor immediately after incising the skin.
Directions like those of M. Langenbeck, though of a general
kind, should be firmly impressed on the mind of every surgeon,
when operating on tumors of this portion of the body, or indeed
elsewhere. In every operation upon tumors in the neck, the sur-
geon should always be on the watch, to prevent the entrance of air
into the veins, and, when it occurs, immediately resort to stimulants
to the nostrils, frictions, and artificial respiration, in order to restore
the heart's action. But, though sufficiently useful, as far as they go,
they do not furnish such an accurate account of the best mode of
overcoming the difficulties likely to be met with in the removal of
tumors from the course of the great vessels of the neck as is de-
sirable, and I have, therefore, made a selection of a few difficult
cases, with a view of furnishing the best possible substitute for the
individual observation of any young operator, viz : the experience
1 Cooper's Surg. Diet., by Dr. D. M. Reese, New York, p. 377.
REMOVAL OF GLANDULAR TUMORS. ' 517
of those whose skill and lifelong practice have enabled them to con-
tend with difficulties in every shape. As these cases contain im-
portant practical precepts, they are furnished in full, in order that
nothing of the details of the extirpation of tumors in this region
may be overlooked.
§ 1. — REMOVAL OF LARGE LYMPHATIC GLANDULAR TUMORS.
Operation of Dr. Valentine Mott, of New York. 1 — A little
boy, five years old, had a tumor on the neck which had resisted
every plan of treatment. It occupied the entire side of the neck,
reaching from above and behind the ear to below the clavicle, going
underneath and also lapping this bone. In front, it passed beyond
the central line of the larynx and trachea, crowding these parts to
the opposite side ; and behind, it passed under the trapezius muscle,
so as to turn the head also towards the opposite side. In appear-
ance, the tumor was irregular and lobulated, whilst to the touch it
was firm and without fluctuation at any point. (Plate XXXIV.
Fig. 2.)
The patient being placed completely under the influence of chlo-
roform, the operation was then commenced.
Operation of Dr. Mott. — In order to command the whole tumor,
a crucial incision was made in the integuments, the first cut extend-
ing from behind the ear to the clavicle, and the second a little
obliquely to this from the anterior to the posterior edges of the
tumor, so as to traverse the longest axis of the whole mass. These
incisions being carefully conducted through the skin, platysma my-
odes and under layer of the superficial fascia so as fairly to denude
the tumor, the dissection of the lower flap was first commenced,
the veins and arteries being tied as they were divided. In dissect-
ing off this flap, the mastoid muscle was found to be so incorporated
w r ith the tumor as to make it necessary to divide the muscle about
two inches from the sternum and clavicle. This division exposed
the lower portion of the tumor, and showed the internal jugular vein
running through its substance. On the inner side of the mass, the
common carotid artery could be dissected bare for several inches,
but the vein was so imbedded in the tumor that it was totally im-
practicable to save it. Being, therefore, seized with a pair of forceps,
1 Transact. New York Acad, of Med., vol. i., part i., p. 90. New York, 1851.
518 OPERATIVE SURGERY.
it was divided, and a ligature instantly placed beneath the forceps,
the upper end being held by the fingers of an assistant, whilst the
dissection was continued. The tumor being thus separated from the
vein was found to have destroyed by its pressure the sterno-hyoid
and stcrno-thyroid muscles, and was now detached from the upper
and inner edge of the clavicle as far as the anterior edge of the tra-
pezius muscle. Getting under the mass in this way, the tumor
could be more readily and safely detached from the parts below,
and, on dissecting it from over the scalenus anticus, careful attention
was given to the phrenic nerve. The posterior and upper part being
then dissected from over the mastoid process and turned down, a
portion of the diseased structure was seen to pass beneath the mus-
cle, and to be so incorporated with it as to require the division of
the muscle at this point, the middle third of it being left attached
to the tumor.
The anterior and upper part being then separated from the side
of the pharynx and larynx, it was found, after dissecting the
tumor from the common carotid artery, opposite the thyroid and
cricoid cartilages, that the deep jugular vein could not be safely
detached. A second ligature was, therefore, applied to this vein
about an inch below the angle of the lower jaw, and the vessel di-
vided below it, leaving several inches of the vein in the tumor, after
which the whole mass readily came away. More than twenty liga-
tures being applied to different arteries and veins, and the effects of
the chloroform being allowed to pass off, the wound was closed by
stitches, adhesive strips, lint, and a bandage. When the parts had
sufficiently healed, care was also taken by resorting to bandages and
position, to prevent the head becoming awry, and the patient reco-
vered without inconvenience, notwithstanding the loss of the middle
third of the mastoid muscle.
§ 2. — EXTIRPATION OF A LARGE MALIGNANT TUMOR OF THE
LYMPHATIC GLANDS OF THE NECK.
Operation of Dr. John C. Warren, of Boston. 1 — In this case,
the tumor had existed over a year; occupied the whole of the left
side of the neck from the ear to the clavicle, and from the trachea
to the spine; the mastoid muscle and all the arteries, veins, and
1 Warren on Tumors, p. 175.
EXTIRPATION OF TUMOR OF THE NECK. 519
nerves of the neck being presumed to be included in its substance,
whilst a process extended under the jaw into the pharynx, and filled
the left half of this cavity with a red tumor which greatly impeded
deglutition, the whole structure being very hard, knotted, uncolored,
and insensible.
Operation. — In commencing the operation, the patient being of
course fully etherized, an incision was made from behind the ear to
the anterior third of the clavicle, the surface of the tumor un-
covered, and the mastoid muscle sought for, but found to be partly
absorbed and partly buried in the tumor. After clearing the latter
from the ear, the jaw, larynx, and dorsal muscles, an attempt was
made to get under the tumor just above the clavicle, and then the
difficulties of the operation appeared, the carotid artery, internal
jugular vein, and par vagum nerve being covered by it, and con-
nected with processes of the mass in such a manner as to render
it difficult to distinguish them. This being at last accomplished by
breaking down the lower part of the tumor, the vein was found to
be obliterated and the artery diminished in size, but pervious. A
ligature being then applied on the latter, the par vagum nerve was
separated as carefully as possible, though not wholly cleared of the
tumor, and the separation of the latter from the nerves at the upper
part of the neck next attempted and successfully accomplished, with
the exception of the sublingual nerve, which so barred the access
to the pharyngeal part of the tumor that it was determined to divide
it. This being done, the operation was finished by breaking down
such parts of the tumor as could not be separated from the other
nerves, when the parts were brought together, and the patient put
to bed, there being but little hemorrhage, a fact stated by Dr. War-
ren as common in large and hard tumors. The patient at first did
well after the operation, but died about a year subsequently of an
ulceration of the throat, which created a difficulty in swallowing.
A yet more complicated and severe operation was performed in
another case by Dr. Warren. 1 "In this patient, the tumor extended
from the spinous processes of the cervical vertebrae to the lower
jaw, pharynx, oesophagus, and larynx, running upwards behind the
ear and downwards to near the clavicle. This tumor, which had
existed for thirty years, had turned the face to the opposite side,
impeded the motions of the head and neck, and caused dizziness,
headache, and dyspnoea. After examining and considering the case,
' Warren on Tumors, p. 177.
520 OPERATIVE SURGERY.
Dr. Warren was induced to think that the tumor had originated in
the lymphatic glands behind the posterior edge of the sterno-cleido-
mastoid muscle, had extended backwards under the trapezius to the
spine, and forwards under the mastoid muscle to the pharynx; that
it adhered to the splenius, complexus, and trachelo-rnaistoideus
muscles, and also involved the digastricus, as well as all the styloid
muscles; that the external carotid artery, with all its branches, ex-
cepting possibly the superior thyroid, were involved ; and that the
jugular and smaller veins, together with the three or four superior
cervical nerves, the par vagum, sublingual and its descending
branch, the glossopharyngeal, laryngeal, and great sympathetic,
were also connected with it.
After a full consultation and statement to the patient of the dan-
gers of the operation, and the impracticability of disengaging the
whole tumor, the propriety of submitting to it was left to the pa-
tient's decision, and the latter deciding to do so, the operation was
performed at Lincoln, near Boston.
Operation of Dr. J. C. Warren. — " The patient being seated
in a chair with his head supported, an incision was made from the
spine to the angle of the jaw, to meet another incision which was
carried from this point downwards to near the clavicle in the direc-
tion of the anterior edge of the sterno-cleido-mastoid muscle. This
flap of integuments being turned down after a laborious dissection,
in consequence of its close adhesion to the tumor, the posterior half
of the latter was exposed from the spine to near the trachea, show-
ing the mastoid muscle firmly imbedded in the scirrhous mass.
Having dissected the muscle from its inferior adhesions, the carotid
artery was exposed and tied. The superior flap of the integuments
being then raised, an attempt was made to disengage the mastoid
muscle from the furrow it occupied in the upper portion of the tumor,
in order to pursue the dissection beneath it; but this being found
impossible, it remained either to divide the muscle and the accessory-
nerve, or to divide the tumor through its middle behind the muscle.
The latter course being chosen, the mass was cloven in two, the pos-
terior half dissected out, and the anterior then disengaged by great
care from the posterior face of the sterno-mastoid and digastric
muscles as well as from the nerves, bones, parotid, and sub-max-
illary glands ; but some portions remained adherent to the fore part
of the bodies of the vertebras and to their transverse processes,
and could not be wholly dissected without exhausting the patient's
EXTIRPATION OF TUMOR OF THE NECK. 521
strength. The actual cautery was, therefore, applied to them with-
out causing much complaint.
"In the latter part of the operation, the patient was occasionally
seized with a spasmodic cough produced apparently by the division
of some of the branches of the accessory nerve. The internal jugu-
lar vein, being buried in the tumor, was compressed between it and
the clavicle, and then divided and tied, a few bubbles of air which
entered the open mouth of the vessel being arrested and forced
back again by a finger applied below the opening. The principal
branches of the first and second cervical nerves were now seen and
divided, and others in the substance of the tumor were also divided
as indicated by the patient's sensations, although they were not
seen.
" The integuments being then laid down on the face of the wound,
and moderately secured so as to protect it without too much con-
fining the parts destroyed by the cautery," 1 the operation was
completed, and the patient is believed to have recovered.
The details and symptoms after the operation, as well as the sub-
sequent treatment, may be found in the valuable volume from which
so much has now been quoted, that my limits prevent their being
further referred to. Since it was written, Dr. Warren has availed
himself so generally of the benefits of anaesthetics, that I feel no
hesitation in urging their use in connection with all operations of
a similar character, believing that he would do so at present. Ope-
rations of a similar character by Drs. Rodgers and Stevens, of New
York, Hayward, of Boston, Gibson, of Philadelphia, Spencer, of
Virginia, and Nathan R. Smith, of Baltimore, will be found referred
to in the Bibliographical Index, pp. 89, 90.
Remarks. — From the details furnished in the preceding accounts
of the removal of a most dangerous class of tumors of the neck, a
good idea can be obtained of the anatomical as well as operative
skill requisite for their execution. In fact, no surgical operations
require a nicer discrimination of structure than those arising from
the removal of tumors in this region, muscles, nerves, arteries, and
veins being all liable to be displaced and changed in character to a
greater or less extent, yet, all requiring to be accurately recognized
at each step of the dissection. But, though an operation for the
removal of large tumors is important and highly dangerous, it does
1 Warren on Tumors, p. 182.
522 OPERATIVE SURGERY.
not really deserve as much consideration and caution as those in
which the disease is less developed. In a case of the magnitude
of those above cited, danger is so evident that prudence and fore-
thought are ready to contend with it, the presence of skilful as-
sistants, together with all the adj uvants likely to prove serviceable,
being naturally prepared by the operator.
The truly dangerous cases, in my estimation, are the small and
apparently inconsiderable tumors of the neck, the removal of which
seems to be so simple and easy that they might almost be designated
as traps to catch the inexperienced and foolhardy, or those in whom
boldness takes the place of discretion. The younger surgeon can-
not, therefore, be too much upon his guard when consulted in refe-
rence to small tumors of the neck. In these cases, when he has
decided to attempt their removal, let him always think that, before
his operation is completed, he may be compelled to open the sheath
of the vessels and ligate the carotid artery, and, with such a pros-
pect before him, his operations will not only be well performed, but
acquire a simplicity of character that will be mainly due to his
thorough preparation for all the contingencies that may arise, in
consequence of the difficulty of settling a question that can only be
decided by his operation, to wit, the attachments of a tumor in the
neck.
SECTION III.
BRONCHOCELE, OR GOITRE.
In the preceding section, the account of the operative proceed-
ings requisite for extirpating tumors of the neck has been limited
to such as are sanctioned by the highest authorities, and therefore
presumed to be fit cases for such operations. There remain, how-
ever, a class yet to be described, the propriety of removing which
is extremely doubtful, and seldom now thought of, except in cases
where the patient's sufferings from suffocation are most urgent.
§ 1. — BROXCHOCELE, OR GOITRE.
Pathology. — Bronchocele (fyo^os, trachea, and xjjm?, a tumor),
is a well-known disease, which consists in the enlargement of either
BRONCHOCELE, OR GOITRE. 523
one or both lobes of the thyroid gland, though the same name has
been occasionally applied to a degeneration of the surrounding cell-
ular structure and lymphatic glands. According to Dr. John C.
"Warren, 1 " the thyroid gland is subject to two kinds of enlarge-
ment, one of a temporary nature, known as goitre; the other a
permanent scirrhus."
True goitre exists at all periods of life, especially in the female
sex, and consists in a chronic inflammation of the thyroid gland
itself, which, beginning at some one point, is apt to extend until, as
in a case related by Alibert, it reached to the thighs of the patient.
The changes within a goitre vary with its development; presenting
sometimes a soft gelatinous matter, or a more hardened structure
interspersed with cysts containing a serous, glairy, or melicerous
substance, and occasionally pus, fibrin, calcareous concretion, or
pure blood. 2 Vascular derangement being here very evident, the
thyroid arteries are commonly found to be much enlarged. In
some cases, the swelling seems to consist almost entirely of a con-
geries of varicose veins, and, under these circumstances, there may
be considerable sanguineous effusions, the blood being poured into
the enlarged vesicles, or into the connecting cellular substance of
the gland. 3 Besides the hypertrophy of the parts consequent on
chronic inflammation of this gland, the thyroid body is also some-
times the subject of scrofulous, lymphatic, or scirrhous degenera-
tion.
In the Scrofulous Goitre, the cellular tissue enveloping the gland
and prolonged throughout its structure is thick, compact, and re-
sisting, so that each portion is transformed, as it were, into a cyst
which is filled with a matter of varied color and consistence, though
all the elements of the gland may yet be recognized.
In the Lymphatic Goitre, certain fluctuating points are readily
recognized, the cysts being found to contain serous, albuminous,
lactescent, or puriform matter, or the points which appear to fluc-
tuate, consisting of a spongy structure analogous to that of the pla-
centa. 4
The Scirrhous Goitre presents a tumor covered by a firm fibrous
capsule, and consists of a spongy texture, in which appears a consi-
1 Warren on Tumors, p. 302.
2 Pathological Anatomy, by Samuel D. Gross, p. 407.
3 Opus citat.
4 Diet, de Me"d., tome xiv. p. 172.
524 OPERATIVE SURGERY.
derable number of cells, some of which are of large size, and con-
tain a bloody fluid. Its consistence is often firm, but not scirrhous,
except at the upper part, which sometimes has the texture, consist-
ence, and white color of true scirrhus. 1
Diagnosis. — The Goitrous tumor has a smooth surface, a some-
what elastic feel, follows all the motions of the larynx, especially
in swallowing, and gives no sensation of crepitation, fluctuation, or
pulsation.
Cysts of the thyroid region, unless enormously distended or mul-
tilocular, give the sensation of fluctuation. Tumors similar to these
have been described by Maunoir as "Hydrocele of the Neck."
Scrofulous enlargement about the thyroid gland tends to suppu-
ration, and the patient shows the marks of a scrofulous diathesis.
In Scirrhus, the tumor grows very slowly, is small, and its sur-
face is hard, lobulated, or tuberculated ; it is accompanied by pain,
and is liable to ulceration. In Fungoid degeneration, there is the
ordinary constitutional disturbance of the complaint, as seen else-
where.
Owing to the position of the thyroid gland, it has occasionally
happened that its proximity to the carotid artery has led the ob-
server to regard it as an aneurism, a case of which has been pub-
lished by Dr. Samuel Griffiths, of Philadelphia. 2 In this case, dis-
section alone revealed the disease. As a general rule, however, the
pulsations of an aneurism give a motion to the whole tumor; and
Boyer has facilitated the diagnosis of one from the other, by direct-
ing the relaxation of the muscles by inclining the head to one side,
by which means the impulse will be checked, if it is a goitrous
tumor. 3
The propriety of operating on these tumors is a point on whicli
most surgeons are very decided, the opinion being almost universal
that any attempt to extirpate them is most hazardous. It is pre-
sumed, therefore, that any surgeon who may be called on to treat a
case will first resort to every remedial measure, and especially to
the use of iodine internally and externally for many months, before
entertaining for a moment such an idea. To those who desire more
detailed information of the pathology of this disease than is to be
1 Warren on Tumors, p. 307.
2 Eclectic Repertory, vol. ix. p. 120.
3 Diet, de Med., tome xiv. p. 177.
TREATMENT OF GOITRE BY COMPRESSION. 525
found in most of the general works which treat of this tumor, I
would recommend the articles in the volumes above quoted ; an ex-
tended article by Dr. William Gibson, of Philadelphia, 1 reference to
which has been accidentally omitted in the Bibliographical Index;
and the memoir of Dr. Benjamin Smith Barton, of Philadelphia,
published in 1800.
Although the extirpation of a goitre cannot be regarded as a jus-
tifiable operation in most instances, the distress of breathing and
swallowing which it sometimes causes may render it imperative on
the surgeon to attempt some means of affording relief; but even
then local depletion, iodine, and similar means should be first fully
tried before resorting to so dangerous an operation.
Treatment of Goitre. — In a tumor which has presented such
varied pathological changes as those seen in this gland, and in which
many points have not been described with the accuracy that might
be desired, it is not surprising that various plans of treatment
should have been recommended, in addition to the general remedial
measures just spoken of, surgeons having at different periods ad-
vised the use of a seton, or of caustic, as well as the ligature of the
whole tumor, or of a ligature upon the thyroid arteries, compres-
sion, and extirpation. That some of these means are better adapted
to the mere cystic tumors of this region than to the cure of a true
goitre, cannot be doubted, and such suggestions can therefore be
regarded only as indicating the different views in relation to the
condition of the diseased part held by those who have suggested
them. Any operation upon a true goitre being usually deemed
inadmissible, except as a last resort, I shall only refer to such
means as have been employed in the United States, and of these
the operation of compression will be first mentioned, as being that
which may be most readily and safely tried.
§ 2. — TREATMENT OF GOITRE BY COMPRESSION.
Operation of Dr. Wm. C. Dwight, of New York. 2 — After
preparing " three straps of good glazed brown cambric, spread with
emp. ol. lini cum plumb, sem. vit. oxid. (diachylon), each of half the
1 Philadelphia Journ. Med. and Phys. Sciences, vol. i. p. 44, 1820.
2 Transact. Am. Med. Association, vol. iv. p. 248, 1851.
526 OPERATIVE SURGERY.
width of the tumor, and of a length sufficient to reach from the
lower edge of the scapula of one side obliquely up the opposite side
of the neck and across the lower part of the tumor, and passing
thence around the neck and across the shoulder, down to the lower
edge of the opposite scapula, he warms and applies them to the
part in the line mentioned, so that each strap may cross behind the
neck like suspenders. The first strap, being drawn quite tightly,
produces very considerable turgescence of the bloodvessels of the
face, and causes the patient to shrug his shoulders for a few minutes,
until the thyroid vessels become sufficiently compressed to enable
him to breathe more comfortably, when the countenance usually
resumes its natural appearance, as is often the case in less than five
minutes. The second strap being then passed in the same manner
across the upper part of the tumor, or from half an inch to an inch
from the first, according to the size of the tumor or length of the
neck, this strap should also be drawn as tightly as the first, and the
same time allowed for the change in the countenance, when the
third strap being applied over the intermediate space, the operation
is completed.
" Ordinarily, these plasters adhere to the part for ten days, or a
fortnight, if the weather is cool, and, on becoming loose, ought to
be removed, when, if the pressure has been well applied, the tumor
will be found to have become slightly less, and the skin somewhat
reddened and tender. When this is seen, it will be better to wait
till the integuments assume their natural appearance, when the
application may be renewed.
"The first application of these strips has, in one case, been suffi-
cient to effect the cure, but the average repetition of them has been
as high as four times in each case. When the bronchocele becomes
diminished to half its size at the time of the first application, the
tumor will continue to disappear without further care; Dr. Dwight,
in twenty cases, having had no failure from this mode of treatment.
The iodine had not succeeded with him in several instances. In
two patients, the disease returned at the end of two years, but dis-
appeared on a new application of the strips/ 11
1 Buffalo Med. Journ., Jan. 1851.
SUBCUTANEOUS LIGATURE OF GOITRE. 527
§ 3. — LIGATURE OF ONE OF THE THYROID ARTERIES.
Operation of Dr. Horatio G. Jameson, of Baltimore. 1 — An
incision, about an inch long, being made parallel with the trachea,
and about midway between it and the inner edge of the sterno-mas-
toid muscle, and, having reached the thyroid artery by a very cau-
tious dissection, so as to avoid dividing any considerable branch of
the nerves, an animal ligature was applied to the vessel, and the
wound allowed to heal over the ligature. Several months subse-
quently, the tumor, by actual measurement, was considerably less.
The ligature of all the thyroid arteries would only be a repetition
of this operation, but would certainly increase the patient's danger,
and require a perfect anatomical knowledge of the structures con-
cerned. Four cases of cure from the use of the ligature have been
recorded by European surgeons.
§ 4. — subcutaneous ligature of goitre.
Operation of Ballard and Eigal de Gaillac. 2 — "The goitre
being very large, was tied in three portions, each being strangled
by a separate thread, as follows : Two long waxed ligatures, each
armed with three needles, viz., one, straight and cutting, being applied
at one end of the thread; the second, round and pointed, in the middle
of the thread, to be drawn double across the tumor ; and the third,
armed at the other end of the thread with a curved needle, were each
properly arranged. Then a vertical fold of the skin, being raised
opposite the superior part of the tumor, was traversed by the straight
needle at one end of the thread, and, the fold being let go, the liga-
ture was made to describe a curve round the upper part of the tumor,
so that an end hung out on each side of the goitre. Through the
same punctures, but beneath the tumor, the round and pointed
needle was then passed and directed from one side to the other, so
as to draw with it the middle of the ligature, which, when passed,
was removed by cutting across the loop, so that there was now a
complete loop surrounding the superior third of the tumor at its
base, with its two ends hanging out of one puncture, whilst the
1 See Bibliography, p. 89. 2 Malgaigne, Philad. edit., p. 378.
528 OPERATIVE SURGERY.
other thread, or that passed across and beneath the upper third, was
destined for its middle portion. The second and third ligatures
being then passed in like manner, it was only requisite to form
round the middle third a complete and subcutaneous loop, which
was effected by using the remaining curved needle, when all were
tightened by a serre-nceud."
A reference to the diagram accompanying the account will render
this operation easy of comprehension.
Febrile reaction followed, and on the fifth day a puncture with a
lancet was necessary to give exit to a little pus and gas which had
accumulated under the skin, but the patient was subsequently cured,
with only a slight trace of the affection.
I. DISSECTION OF THE SKIN AND LIGATURE OF THE TUMOR.
Operation of Mayor. — The tumor being exposed by a double
elliptical incision, which turned back the skin to the right and left,
the base of the tumor was traversed by two ligatures, the two ends
of the same ligature being tied so as to strangulate separately each
half of the tumor.
A somewhat similar operation has been successfully performed
by the late Mr. Liston, of London, and is represented in Plate
XXXVII., Fig. 1.
Extirpation of a Scirrhous Thyroid Gland, by Dr. J. C.
Warren, of Boston.' — The patient being in the upright position,
an incision nearly four inches long was carried along the anterior
edge of the sterno-mastoid muscle, so as to expose the platysma-
myoides, which was incised so as to present the edge of the sterno-
mastoid. On turning this aside, the sterno-hyoid and thyroid muscles
were perceived to cover the tumor in such a way that it was neces-
sary to separate them and dissect between them. The surface of the
tumor, being then brought into view, was fully exposed by dissec-
tion, and separated from the sheath of the carotid artery by the
handle of the knife. This apparently loosened its attachments, but
a solid adhesion being found to the trachea for one or two inches,
and also to the oesophagus for a small extent, which required the
use of the knife, the dissection was pursued upwards and back-
1 Warren on Tumors, p. 305.
SUBCUTANEOUS LIGATURE OF GOITRE. 529
wards, in order to extract the superior corner of the gland. The
superior thyroid artery being divided in so deep a position as to
prevent its ligation between the muscles, the common carotid was
therefore tied. The inferior thyroid did not bleed, or was supposed
not to exist, and the patient, after serious symptoms, recovered in
about one month.
Eemarks. — Of the different operations just detailed, compression
is certainly the safest, and, judging from the account furnished by
Dr. D wight, the most successful. Ligature of the thyroid arteries,
although successful in a few cases, is so hazardous and difficult an
operation that few will probably be disposed to attempt it; in addi-
tion to which, there would certainly be good reason to fear a return
of the circulation through the numerous anastomosing branches.
As the ligatures must also be placed near the origin of the thyroid
arteries, there has not always been a sufficient amount of the vessel
left to prevent secondary hemorrhage, a case being on record, where,
from the proximity of the carotids, the loss of blood has been most
alarming, nothing but compression by the fingers of assistants,
during eight consecutive days, having rescued the patient.
Although I have placed among the preceding operations an ac-
count of the extirpation of the thyroid gland as performed by Dr.
Warren, it has been done rather to complete the record than from
a wish to lead any one to its repetition, even when sanctioned by
such excellent authority. Though occasionally performed, an attempt
to extirpate a goitrous tumor is so liable to cause immediate death
from hemorrhage, that few, as before stated, deem the operation
justifiable, more than one patient having died on the table. The
ligature, both by the subcutaneous method and also after the expos-
ure of the tumor, has succeeded, yet the obstruction of the circu-
lation through the part by this method has also been followed by
alarming symptoms of suffocation and congestion of the brain.
Every surgeon, therefore, should avoid operating on any case of
true goitre, unless fully prepared to encounter great difficulties, or
with the view of relieving certain suffocation. In the operative
treatment of this tumor, it may well be said that "discretion is the
better part of valor."
34
530 OPERATIVE SURGERY.
SECTION IV.
HYDROCELE OF THE NECK.
Pathology. — The term Hydrocele (t>8«e, water, and zn*% tumor),
though generally limited to collections of fluid within the tunica
vaginalis testis, has also been applied by Mr. Maunoir, of Geneva,
to encysted tumors found in that portion of the neck near the thy-
roid gland, which are filled with liquid. These tumors are met
with at various periods of life, in both sexes; their progress is
slow, and they often arise without any appreciable cause from the
cellular spaces of the thyroid gland, being occasionally congenital.
Though seldom larger than a walnut, they may acquire the size of
an orange, and impede respiration and deglutition. Their contents
vary from a thin serum or oily liquid to a thicker consistence, the
cyst itself varying in thickness from the fourth of a line to a quarter
of an inch or more. The skin covering the tumor seldom undergoes
any change except when attenuated by the size of the tumor, when
the subcutaneous veins may become apparent. The tumor is free
from pain or tenderness on pressure, fluctuates slightly, and, if seated
over an artery, might be mistaken for an aneurism, or, if over the
thyroid gland, be supposed to be a goitre. 1
Operation. — These cysts may be treated on the same principles
with those seen elsewhere, that is, evacuated by a simple puncture,
or with a trocar, or cured by exciting inflammation within the cyst
itself by means of a seton, or by acupuncturation, or by injecting
iodine, or wine and water, or a solution of sulphate of zinc, or by
excising the cyst, or by incision and tents, as proposed by Porta,
of Padua, and accomplished by Dr. Pancoast, of Philadelphia. 2
The selection of any of these plans of treatment will depend
somewhat on the patient's constitution and circumstances. The use
of the seton has led to such irritation as to induce death. Erysipelas
is apt to follow the injection of iodine or other stimulating liquids,
and the excision of the cyst, like any operations upon an enlarged
thyroid gland, exposes the patient to the risks of severe hemorrhage
if the proper structure of the gland is invaded. All these plans of
1 Liston's Surgery, by S. D. Gross, M. D., Louisville, p. 386.
1 See Bibliography, p. 91.
HYDROCELE OF THE NECK. 531
treatment have, however, sometimes succeeded, and, when the sur-
geon is aware of the risk attending them, under certain circum-
stances, the selection of either plan may justly be left to the decision
of the moment. As illustrative of the treatment by excision, I
quote the following operation: —
Operation of Dr. J. Pancoast, of Philadelphia. 1 — A vertical
cut being made through the skin, over the longitudinal axis of the
tumor, the fascia and platysma-myodes muscle (which was very red,
thick, and vascular) was divided upon a director. The tumor, thus
exposed, was blue or livid from the coagulated blood which filled
it. The cellular tissue over the top of the gland being now opened,
the superior thyroid artery was drawn out by a blunt strabismus
hook and tied. A strong pulsating branch on the outer edge of the
gland, which came from the inferior thyroid, was also isolated and
tied ; after which the cyst was seized with the forceps, and separated
from the body of the gland with the handle of a scalpel, its attach-
ments being feeble. The tumor being detached, a little arterial
bleeding followed from the bottom of the deep cavity left in the
gland, but this was arrested by ligature, the whole operation causing
the loss of but little blood. The wound was lightly dressed, some
suppuration followed, and in three weeks cicatrization was complete.
Dr. Pancoast regards this as the only instance of a similar dissection
made in this country, though Prof. Porta has done it repeatedly. It
is, however, an operation requiring a good amount of anatomical
knowledge, as well as practical skill in operating.
Eemarks. — From the resemblance of these tumors to those seen
in other regions, they are generally regarded as belonging to the
encysted class; and the application to them of the term "Hydrocele
of the Neck" is, therefore, liable to lead to error. In the opinion
of Percy, those found over the thyroid gland were simply "softened
bronchocele." I have seen these tumors twice in this position, and
once over the parotid gland, in both of which they were nearly of
the size of an orange. The fluctuation being evident, puncture and
the introduction of a seton accomplished the cure.
1 Medical Examiner, toI. vii. N. S. p. 504, 1851.
532 OPERATIVE SURGERY.
CHAPTEE VII.
ANEURISMS IN GENERAL.
The term Aneurism (avtvpwstv, to dilate) has long been employed
to designate such tumors as were caused by dilatation, or rupture
of the coats of an artery, in consequence of which the patient was
sooner or later liable to sudden death by hemorrhage, from the
giving way of the sac, or diseased portion of the vessel.
The plans of treatment proposed for the relief of this state of the
vessels have been very varied, most of them being based on the
idea of arresting the flow of blood through the weakened portion of
the artery. In addition to the employment of such constitutional
means as would prevent the too great distension of the sac by dimi-
nishing the force of the circulation in these tumors, we therefore
find that they have also been cured by obstructing the course of
the blood through the artery by means of the ligature, so as to
compel it to pass by collateral branches until it could again enter
the main trunk beyond the seat of the disorder; or by retarding
the flow of the blood by external pressure until its more fibrinous
portion was deposited in and about the sac on the weakened side,
so as to enable these parts to sustain the force of the current as it
passed through the main channel of the artery. "Without entering
into the details of the various kinds of aneurism, as well as the
modifications of treatment suggested and practised at different pe-
riods, it must suffice at present to show the diagnostic signs of the
complaint, and the different operations applicable to its relief.
SECTION I.
DIAGNOSIS OF ANEURISM IN GENERAL.
When an aneurism has occurred in an artery which is so situated
as to permit the use of the sense of sight, and the expansion of the
vessel has not attained any very great size, there may often be no-
ticed, when pressure is made upon or near the usual course of the
vessel, a round or ovoid tumor. This tumor gives to the fingers
DIAGNOSIS OF ANEURISM IN GENERAL. 533
the sensation of elasticity, disappears more or less under pressure,
reappears when the force is removed, softens and diminishes when
the main trunk is compressed between the tumor and the heart,
and may be felt pulsating synchronously with each contraction of
the ventricles. The skin over this tumor will at first preserve its
natural appearance, but in the progress of the disease it will
present us with signs of venous congestion, then of inflammation,
and lastly, of ulceration or sphacelus. Most frequently this tumor
increases slowly, and without much pain, though sometimes the
latter is very acute, especially if a sentient nerve is put upon the
stretch, or compressed by the development of the complaint. When
the tumor has existed some time, it becomes more and more firm
in consequence of the fibrinous deposit going on in its interior, or
from the formation of clots. In consequence of these changes, the
pulsations in it, which were before plainly perceptible, now become
less distinct, so that in some cases it may be necessary to resort to
the aid furnished by auscultation, either by applying the ear directly
to the tumor, or, where it is wished to circumscribe the part that is
to be examined, by employing the stethoscope. On ausculting the
tumor, in either of these methods, the surgeon will hear either a
sawing or bellows sound, or the peculiar noise which has been
designated as that produced by rapidly pronouncing the letter r,
creating a "whirring sound."
Apparent pulsation in the part is, however, liable to lead to grave
errors. If, as has been before stated, a solid or firm tumor should
be seated over the course of an artery, and be bound down to it by
fibrinous or muscular expansions, pulsation may apparently be
perceived in the tumor, and yet be caused solely by the proximity
of the vessels; but if such a tumor be drawn to one side, or the
muscles be relaxed by change of position, then the pulsation will
cease, which is not the case in aneurisms. The diagnosis in these
cases is, however, often one of great difficulty, and many instances
have been recorded where the most experienced surgeons have been
mistaken. Several years since, I saw in the Blockley Hospital,
Philadelphia, a large abscess in the iliac region pulsate so as to
simulate an aneurism, and the difficulty of diagnosticating it was so
great that an eminent surgeon spoke of it as a decided example of
vascular enlargement.
In all cases of doubt, palliative measures alone should be resorted
to until the character of the complaint can be more positively esta-
blished. But if delay does not elucidate the case, and the pain and
334 OPERATIVE SURGERY.
other urgent symptoms require a prompt decision, the practice of
Gruattani may be repeated, and an exploratory puncture made, the
hemorrhage, if it be an aneurism, being arrested by pressure. The
opening of the aneurismal sac, under these circumstances, has not,
however, been attended by the serious results that might at first be
anticipated. Several instances of its having been done, in a more
extensive manner, without causing serious difficulty, have been
mentioned by surgical writers, among which is one by Dr. John
Rhea Barton, of Philadelphia, 1 where an empiric plunged a lancet
into the tumor, under the supposition that the disease was an abscess.
Fainting arresting the hemorrhage at the time, the patient lived six
weeks, and afterwards died of mortification of the limb ; when, on
a post-mortem examination, the inguinal tumor and femoral artery
Avere found in such a condition that Dr. Barton expressed the
opinion "that, if the patient (aged seventy years) had had a little
more vigor of constitution, the opening of the aneurismal tumor
would have cured the complaint." Lest, however, such fortunate
results should not always ensue, it will be safer for the surgeon,
when compelled thus to test the character of the tumor, to be pre-
pared to ligate the main trunk of the artery immediately.
SECTION II.
TREATMENT OF ANEURISM WITHOUT AN OPERATION.
In cases where the diagnosis of an aneurismal tumor is difficult,
or in any case where circumstances render it desirable to delay the
more certain method of curing the complaint, e. g. by the applica-
tion of a ligature, the surgeon may find it desirable to try the effects
of the constitutional plan of treatment suggested and practised by
Valsalva, or to employ compression, as suggested by Guattani, in
Italy, in 1757, and employed by Sir Win. Blizard, of England, in
1802; by Drs. Physick and Parrish, of Philadelphia 2 , in 1811, and
by Bushe, of New York, in 1826. The method of treating aneurism
by gradual compression of the vessel between the tumor and the
heart, has also been recently (1842) brought to the notice of the
profession by Dr. Hutton, of Dublin, and carried yet further (in
1843), by Dr. Belli ngham, of the same city.
1 Philad. Journ. of Med. and Phys. Sciences, vol. i. N. S. p. 127.
2 Eclect. Repert., vol. i. p. 50(L
TREATMENT OF ANEURISM WITHOUT AN OPERATION. 535
§ 1. — PLAN OF VALSALVA.
Valsalva proposed the following plan for the cure of large internal
aneurisms, and in some few cases it has been attended with much
benefit. After bleeding the patient very freely, he gradually dimi-
nished the quantity of the food, until the patient was reduced to so
feeble a condition that he could hardly get out of bed, when the diet
was gradually increased until this extreme debility passed away.
REMARKS. — In cases of large aneurismal tumors, the benefits de-
rived from the plan of Valsalva have been very great ; an autopsy,
in one case, showing that the dilated artery had become contracted
and callous under this treatment. But, though very plausible, this
plan has not been followed by the general success that might have
been anticipated, and Boyer, Sir A. Cooper, Eoux, and many other
surgeons, incline, therefore, to the opinion that the quickening of
the pulse, which is the result of his method, often does as much
injury to the tumor as the natural force of the circulation. 1
§ 2. — TREATMENT BY COMPRESSION.
The relief of an aneurism by means of external pressure applied so
as to check the current of blood passing through an artery, seems to
be one of those natural suggestions that must have presented itself,
at an early period, to the mind of every surgeon. "We find, how-
ever, that it was not until 1765, that Guattani succeeded in curing
an aneurism of the femoral artery by these means, pressure having
been applied upon the centre of the tumor, through two compresses
in the form of the letter X, and another compress placed over the
entire course of the artery, the whole being confined by a band-
age, whilst Valsalva's plan of treatment was persevered in to a cer-
tain extent. In 1802, Mr. Blizard, of England, employed com-
pression by means of a circular tourniquet applied so as to preserve
constant pressure, but the patient not being able to endure it, his
artery was subsequently tied by Sir A. Cooper. 2 In 1810, after
noticing the spontaneous cure of an aneurism of the femoral artery,
in which, however, pressure by means of a bandage to the limb
had been once employed, Dr. Physick, of Philadelphia, suggested
the following method of applying gradual pressure: —
1 Cooper's Lectures, vol. ii. 2 Clielius, vol. ii. p. 483.
536 OPERATIVE SURGERY.
Physick's Method. 1 — Apply to the diseased region, a truss-like
pad, so arranged as to preserve very gradual pressure on the femoral
artery near the groin, having it so fastened with a screw that a
half turn of the screw may be made every day until the requisite
amount of compression is effected. By applying the pressure in
this gradual manner, Dr. Physick thought that the patient would
be able to bear it without difficulty, and that the anastomosing
vessels would have time to enlarge, and thus carry on the circula-
tion through the limb.
Compression as practised by Dr. Belling ham, of Dublin. —
The patient having been kept at rest, and occasionally depleted for
a week or ten days, two or more compressors, such as are repre-
sented in Plate III., Fig. 2, are to be kept at hand, so that as the
pressure of one becomes painful, another may be applied at some
new point between the heart and the tumor, whilst the first is
removed; or, both being applied on the upper portion of the vessel,
one may be alternately tightened and slackened, as the feelings of
the patient may direct.
Eemarks. — In attempting the cure of an aneurism by means
of compression, it is important to remember that during the entire
course of treatment the limb should be kept in the horizontal posi-
tion, and neatly bandaged from the extremity upwards, so as to
guard against oedema or inflammation of the skin. It is also essen-
tial to success that the pressure should be applied very gradually,
as it is sufficient to moderate the circulation without obstructing it.
Unless thus conducted, compression will not only fail to cure the
complaint, but also be likely to induce sloughing of the parts at the
seat of pressure, or even gangrene of the limb. When judiciously
employed, this treatment has often been followed by the most favor-
able results, having checked all pulsation in a tumor in ten days,
though it usually requires a much longer time, amounting some-
times to six weeks. The success of compression, especially in the
treatment of femoral and popliteal aneurism has been decidedly
great. In the paper on statistics, &c, by Dr. Geo. W. Norris, of
Philadelphia, 2 it is shown that out of thirty-seven cases thus treated,
thirty-five were cured, one dying of disease of the heart and one
being ligated; whilst in two hundred and four cases treated by the
ligature (Hunterian method), fifty died, and six were compelled to
1 Eclect. Repert., vol. i. p. 510.
2 Am. Journ. Med. Sciences, vol. xviii. N. S. p. 334.
NEEDLES INTRODUCED INTO THE SAC. 537
submit to amputation of the limb. In one case of popliteal aneurism,
in my own practice, I succeeded in accompli shing a cure in twenty-
two days, and in a recent case of varicose aneurism at the bend of
the arm, where the tumor was nearly as large as an egg, obtained
a cure in four weeks. In the latter case, the pressure was applied
over the tumor, as well as in the course of the artery above the
bend of the arm. A reference to the Bibliographical Index, page
141, will exhibit some of the cases cured by pressure, as applied by
Drs. I. Parrish, of Philadelphia; Heustis, of Alabama; Jameson, of
Baltimore ; Bushe, Church, Wood, and Van Buren, of New York,
and Bennet, of Connecticut.
§ 3. — APPLICATION OF GALVANISM BY MEANS OF ACUPUNCTURE
NEEDLES INTRODUCED INTO THE SAC.
The idea of inducing a fibrinous deposit within the sac by means
of galvanism, as suggested by Mr. Phillips, of England, in 1832,
may be carried out as follows: Two acupuncture needles, varnished,
so as to prevent their rusting, being introduced obliquely into the
sac, on opposite sides, so that their points may touch, whilst the
circulation in the vessel is diminished by pressure upon the artery
above the tumor, pass a galvanic current through the needles as
strongly as the patient can bear, and continue it for a few minutes,
or repeat it occasionally. Caution, however, is necessary, lest such
an amount of inflammation be induced as will result in suppuration
or gangrene, rather than in the formation of such a number of fila-
ments in the blood as will serve for a mes'hwork for the subsequent
formation of a coagulum. 1
Eemarks. — The treatment of aneurism by compression has, in
addition to other advantages, the marked one of permitting the
application of a ligature to the main trunk in such cases as resist
these plans of treatment.
The plan of Valsalva is chiefly useful in hopeless cases, as those
of the aorta, whilst acupuncturation is of very doubtful utility,
having failed in 21 out of 32 cases operated on in Europe.
The injection of the perchloride of iron, as recently suggested in
France, is also a very dangerous operation, and has resulted in
death.
1 Miller's Principles, Philad. edit. p. 551, 1852.
538
OPERATIVE SURGERY.
SECTION III.
GENERAL PRINCIPLES TO BE OBSERVED IN THE LIGATURE OF
ARTERIES.
Tbe accumulated experieuce of the profession in the application
of the ligature to an artery having established certain general rules,
as essential to the proper performance of the operation (although
some few surgeons have modified them, or substituted others, either
to meet particular difficulties, or because they were more in accord-
ance with their individual experience), it will be found useful to
follow them in the application of every ligature. As the object
to be attained in ligating a vessel is a direct change in the course
of the natural circulation, these rules may be condensed into two
general ones, and on these all surgeons, it is believed, agree, to wit:
1st, always to expose the vessel without opening it; and 2d, to ligate
it with as little disturbance as possible of surrounding parts. These
general principles have been carried out in various ways; but as
the views of Lisfranc in relation to the details, are not only the
soundest, but also tested by personal experience, I shall adopt them
as those most likely to prove useful to the young operator.
In ligating any artery, Lisfranc advises the surgeon —
1st. To expose the vessel without opening it, and in order that
he may do so, suggests the following method of proceeding: —
a. To make sure of the position of the vessel.
Special anatomy, as usually taught, presents every medical man
with accurate information in regard to the ordinary position of the
arteries; but, as these vessels are liable to various anomalies, and
to irregular distribution as well as to the changes consequent upon
disease, special attention should be given to the position of the
vessel upon each patient at the time of the operation.
b. To find the artery.
In seeking the vessel, notice should be first taken of the position
of such muscles as usually indicate the course of the artery, or of
those which have been termed "muscles of reference," so that by
causing these muscles to contract and become prominent, the sur-
geon may readily recognize any deviation of the artery from its na-
tural relations with these parts; or he may feel for the pulsation of
the artery ; or, if the tissues are too much thickened, or the vessel
PRINCIPLES OBSERVED IN THE LIGATURE OF ARTERIES. 539
lies too deep to admit of this, lines may be drawn from such fixed
points of the skeleton as normal anatomy teaches us will cross or
follow the usual course of the artery.
2d. To ligate it with as little disturbance as possible.
After recognizing the position of the vessel, its exposure becomes
the next point for consideration, and, in order to prevent any varia-
tion from the proper line of incision, as well as to fix the skin, Lis-
franc advises the operator to bring the four fingers of his left hand
to the same level, and then, placing them perpendicularly on the
skin, to be careful not to draw the latter to one side, whilst he incises
the integuments by drawing the scalpel close along the edges of the
nails. Malgaigne, however, objects to this direction as being likely
to displace the integuments over the vessel, though my own expe-
rience is favorable to it.
When the artery is superficial, the incision through the integu-
ments should be parallel to its course ; but, when it is deep-seated,
an oblique incision, by affording a greater line for any variation,
will add much to the facility with which the vessel may be found.
When the aponeurosis of the part is directly in contact with the
sheath of the vessels, it is generally safer to open it on one. side
and then slit it up upon a director. On reaching the sheath of an
artery, or the artery itself, the vessel may generally be told by its
yellow or dull-white color, by its pulsation, and by its becoming
flattened and collapsed when the circulation is interrupted between
it and the heart.
In order to isolate the artery with as little disturbance as
possible of surrounding parts, the relative position of the adjacent
veins and nerves should be recollected, and the adhesions of the
sheath and other tissues only loosened sufficiently to permit the
passage of the ligature. To do this, it is important that a good
needle be selected, that is, one which is neither so sharp as to ex-
pose the vessels to perforation, nor so thick and dull as to render
it difficult to pass its point through the cellular tissue of the part.
When in passing the needle around the vessel, the point appears
beneath any dense cellular structure, the latter should be supported
by the pressure of a finger in order to facilitate its perforation by
the instrument.
Another rule, which is an excellent one, and which Malgaigne 1
1 Operat. Surg., Pliilad. edit. p. 140.
oiO
OPERATIVE SURGERY.
PLATE XXXV.
INSTRUMENTS EMPLOYED IN THE LIGATURE OF ARTERIES; WRY NECK;
OEDEMA OF THE GLOTTIS, AND HERNIA.
Fig. 1. Parrisk's knife for dissecting about the sheatli of arteries.
Rorer's pattern.
Fig. 2. The Philadelphia aneurism needle, employed by Drs. Parrish,
Hewson, and Hartshorne. Rorer's pattern.
Fig. 3. Another form of this needle. Each needle has two eyes, and
the ligature is passed through the one nearest the handle. Rorer's pattern.
Fig. 4. Another needle, very much curved. Rorer's pattern.
Fig. 5. Blunt points, adapted to a common shaft, and intended to be
detached in order to pass the ligature around the artery. Rorer's pattern.
Fig. 6. Sharp points, intended to be similarly attached and detached.
Rorer's pattern.
Figs. 7, 8. Needles of other curves and lengths, adapted to deep arteries
in Confined points. Rorer's pattern.
Fig. 9. A hook to be inserted into the eyes near the points of Figs. 5
and 6, when unscrewed from the shaft, in order to draw them arouud the
vessel. Rorer's pattern.
Figs. 10, 10. Knot-tiers, to tighten deep-seated ligatures. "
Note. — The above set comprise the instruments included in the operat-
ing case of the late Dr. Jos. Parrish, for the use of which I am indebted
to the politeness of Dr. Isaac Parrish. The full account of the investiga-
tions of Drs. Parrish, Hewson, and Hartshorne may be seen in the Eclectic
Repertory, vol. iii. p. 229, 1813.
Fig. 11. Horner's aneurism needle. Schiveiey's pattern.
Fig. 12. Gibson's aneurism needle. A watch-spring is passed beneath
the vessel, and the ligature being attached is thus drawn round it.
Schiveiey's pattern.
Fig. 13. Tenotome or knife adapted to the section of the sterno-cleido-
mastoid lUUSCle. Schiveiey's pattern.
Fig. 14. Apparatus to bring the head into position in cases of wry neck,
especially after the division of the muscle. Rorer'a pattern.
Fig. 15. Gurdon Buck's knife for scarifying the glottis in cases of oedema,
After Buck.
Fig. 16. Curved scissors for the same object. " "
Fig. 17. EnterOtome Of Dupuytren. Charriere's pattern.
Fig. 18. Blandin's enterotome. " "
Fig. 19. Cooper's Hernia bistoury. Schiveiey's pattern.
Fig. 20. Small, blunt-pointed Hernia bistoury. " "
Fig. 21. Straight-pointed Hernia bistoury. " "
PRINCIPLES OBSERVED IN THE LIGATURE OF ARTERIES. 541
has designated as " the rule of the guiding points," is the follow-
ing:—
"Do not, at the commencement of the operation, occupy yourself
with looking for the artery, but seek the first marked point of
reference, then the second, then the third, if there be one, and so
on to the vessel."
Dr. Mott, of New York, whose experience in ligating the large
arteries has probably been greater than that of any other surgeon
in the United States, advises 1 that in every operation upon these
vessels, but little use should be made of the scalpel after the edge
of the muscle of reference is laid bare, the fingers, director, or handle
of the knife being capable of separating these parts quite as readily
as its edge, without at the same time exposing the surgeon to the
troublesome oozing which is apt to ensue on the division of the
minute vessels. By pursuing this plan, the main artery can also be
more distinctly seen.
The late Dr. Joseph Parrish, of Philadelphia, in connection with
Drs. Joseph Hartshorne and Thomas Hewson, also of Philadelphia,
was accustomed to employ a knife which was rounded at the end
(Plate XXXV., Fig. 1), for the purpose of dissecting about the
sheath of the vessel. 2
In order to hold the parts asunder, Dr. Mott employs curved
spatula? (Plate II., Pig. 10), and divides the sheath of the vessels
perpendicularly, and only upon the front of the artery, never dis-
secting or using the blade on the sides of the vessel, but introducing
the knife-handle, and separating the structure on each side, so as to
denude the artery only to such an extent as will permit the aneu-
rismal needle to pass. He has generally employed the Philadelphia
needle (Parrish, Hewson, and Hartshorne, Plate XXXV., Fig. 2),
and always introduces it so that its point will pass from the vein,
and not to it. This last rule is equally applicable to the introduc-
tion of any instrument which is intended to pass a ligature around
an artery.
In attempting the cure of aneurisms by the application of the
ligature, surgeons now generally resort to the method of Hunter,
in which the ligature is applied to the sound coats of the vessel at
some little distance above or on the cardiac side of the tumor, that
1 Mott's Velpeau, vol. i. p. 301.
2 Eclectic Repertory, vol. iii. p. 229, 1813.
542 OPERATIVE SURGERY.
of Brasdor, in which it was ligated on the distal side of the tumor,
being seldom employed. The latter operation is also applicable only
to cases in which no branch comes off from the artery between the
ligature and the sac (as is often the case), or in those where there is
no branch communicating with the sac itself, which is also often
met with. It is, however, especially applicable to aneurisms so seated
as not to leave sufficient space between the tumor and the main
trunk of the artery for the application of the Hunterian plan, e. g.
as in aneurism at or near the innominata, or at the root of the right
subclavian,; in these cases, Brasdor's operation is very useful. In
other cases, and they are by far the most numerous, the application
of the ligature can be most advantageously made by the plan pro-
posed by Hunter, that is, its application on the sound artery between
the tumor and the heart. This operation is, therefore, that which
will be hereafter followed in the description given of the treatment
of aneurisms by the ligature, except in the cases above mentioned
of their development at the root of the subclavian, or in the in-
nominata arteries.
CHAPTEE VIII.
ANEURISM OF THE CAROTID ARTERIES.
SECTION I.
ANATOMY OF THE BLOODVESSELS OF THE NECK.
The great points of reference in ligating the arteries of any por-
tion of the body are, as has been stated, the course of the muscles
of the part, after which the operator may seek for the adjacent bony
prominences, or be guided by the position of the nerves of the part.
In the arteries of the neck, such points may be readily found, and
a brief reference to the normal anatomical relations of each of them
will, therefore, prove sufficient for the general rules of operating
upon these vessels.
The Common Carotid Artery, arising from the innominata on the
right side, about the level of the top of the sternum, and from the
ANATOMY OF THE BLOODVESSELS OF THE NECK. 543
arch of the aorta on the left about one inch and a quarter below
the top of this bone, ascends the neck on the outer side of the
trachea and larynx as far as the inferior cornu of the os hyoides in
the male, though a little lower in the female. In the lower part of
the neck, the right artery inclines more outwardly than the left, the
latter ascending almost vertically.
In this course, each artery, together with the internal jugular
vein and par vagum nerve of each side, is inclosed in a firm sheath,
which is connected with the fascia of the neck, the vein being on
the external side of the artery, and swelling in front and above it,
whilst the nerve is situated between the two vessels or a little be-
hind them.
Directly above the sternum and clavicle, the vessels and nerve,
arranged as just described, are covered by the sterno-hyoid and
thyroid muscles, as well as by the sternal origin of the sterno-cleido-
mastoid. On a line with the lower part of the thyroid cartilage, the
artery is crossed obliquely by a ribbon-like muscle, the omo-hyoid.
Behind the vessels and outside of their sheath may be felt the trans-
verse processes of the cervical vertebras, covered by the longus colli
muscles, and upon these muscles, but exteriorly to the course of the
vessels, as well as behind them, is the great sympathetic nerve.
Along-side of the larynx, the carotid artery is very superficial, being
covered only by the skin, superficial fascia, and platysma-myodes,
though it is here also crossed by the omo-hyoid muscle. Having
reached the space between the os hyoides and the larynx, the com-
mon carotid divides into the internal and external carotids, the latter
being generally the smallest in children. No branches come off
from the common carotid in the normal condition of the parts,
though occasionally the inferior thyroid or the inferior pharyngeal
arteries may be in the way of any incisions upon the main trunk,
at the upper part of the neck.
The Internal Carotid in the adult is smaller than the externa],
and extends from the level of the larynx to the brain, being between
the external carotid and the vertebrae of the neck, in front of the
internal jugular vein, and having the par vagum nerve at its external
maro-in. Near the base of the lower jaw, it is crossed externally by
the digastric and stylo-hyoid muscles, and is immediately afterwards
concealed by the ramus of the jaw. 1
1 Horner's Anatomy.
544 OPERATIVE SURGERY.
"The External Carotid extends from the termination of the pri-
mitive carotid to the neck of the lower jaw. In the early part of its
course, it is in front of the internal carotid and between the pharynx
and sterno-mastoid muscle, where it is only covered by the skin,
superficial fascia, platysma-myodes, and its own sheath. Just above
this, it is crossed internally by the hypoglossal nerve, which sends
off the Descendens Noni branch, the latter nerve being found upon
the sheath as far as below the omo-hyoid muscle. Somewhat above
this nerve, the artery is crossed by the digastric and stylo-hyoid
muscles, and lies on the superior constrictor muscle of the pharynx
near the tonsil gland. About its middle, it is crossed internally by
the stylo-glossus and stylo-pharyngeus muscle, and then ascends
through the substance of the parotid gland to the neck of the jaw,
where it gives off the internal maxillary and temporal arteries."
" The Superior Thyroid Artery arises from the external carotid
about a line from its root, and the Lingual comes off about six to
twelve lines above this." 1 The anastomosis between the arteries of
the two sides, through all their branches, is also exceedingly free.
The course of the artery, from its origin to the level of the os
hyoides, may be designated by a line drawn from the mastoid pro-
cess to the inner edge of the clavicle, or by the course of the sterno-
mastoid muscle, when it can be recognized.
SECTION II.
LIGATURE OF THE CAROTID ARTERIES.
The ordinary position of an aneurismal tumor of the arteries in
the neck, rendering it a difficult matter to keep up a steady pressure
upon the main trunk, without also exposing the patient to the
dangers of congestion of the brain from the proximity of the jugu-
lar vein to the artery, has prevented any attempts to cure these
aneurisms by compression from being generally resorted to. The
ligature has therefore been employed, whenever direct surgical in-
terference was demanded.
The object of the applications of all ligatures to the carotid being
the same, to wit, to cut off the circulation through the main trunk
1 Horner's Anatomy, vol. ii. p. 207.
LIGATURE OF THE CAROTID ARTERIES. 545
of the vessel, it is unnecessary now to mention the complaints
which, in addition to aneurisms, may call for this operation, further
than to say that wounds, and erectile or other tumors, constitute
the greater number. Some of the various instruments employed
for passing the ligature around arteries may be seen by referring
to Plate XXXV., and are of course applicable to the carotid, as
well as elsewhere. But to a dexterous operator, the selection of an
aneurismal needle will prove a matter of but little moment, and any
of them may therefore be taken, the choice being guided mainly
by individual predilection.
History of the Ligature of the Carotid Artery. — In the
various accounts furnished by surgical writers of the history of the
ligature of the primitive carotid artery, it is generally stated that
the first application of it, as an operation, was made by Sir Astley
Cooper, in November, 1805, 1 the ligating of the vessel by Heber-
streit and Abernethy having been consequent on wounds of the
throat. It is, however, well known in the United States that two
years prior to the operation of Sir Astley Cooper, this important
vessel had been effectually ligated by Dr. Mason F. Cogswell, of
Hartford, Connecticut, who, in November, 1803, tied the carotid
during the removal of a scirrhous tumor of the neck. 2 In this case,
" the ligature separated from the artery on the 14th, and the patient
did well until the 20th, when he sunk in consequence of a slight
hemorrhage from a small vessel near the angle of the jaw, acting on
a system enfeebled by a long-standing disease." It may interest the
American student to know that this distinguished surgeon graduated
at Yale College, in 1780, and served in the United States army, dur-
ing part of the Kevolution, with his brother, Dr. James Cogswell,
commencing the civil practice of his profession in Hartford, in
1789. He died in 1830, in the 70th year of his age. 3 Since the first
four cases of ligature of this vessel, e. g. by Abernethy, for wound
from the horn of a cow in 1799; by Heberstreit, 1800, for the
extirpation of a scirrhous tumor ; by Cogswell, of Connecticut, for a
tumor, in November, 1803, and by Fleming in the same year, in a
case of suicide, it has also been tied successfully by Travers, in 1804,
for an aneurism in the orbit of the eye ; by Sir A % Cooper, in 1805,
for aneurism, the woman dying on the 19th day; and since then by
1 Velpeau, Op. Surg., Am. edit. vol. ii. p. 236.
2 Williams's Am. Med. Biog., p. 103.
a Ibid., p. 109.
35
546 OPERATIVE SURGERY.
very many surgeons in all sections of the globe. In the United
States, the ligature of this artery was successfully performed for
aneurism, by Dr. Wright Post, of New York, in 1817 ; by Dr. Mus-
sey, of New Hampshire, successfully, in 1822, and by Dr. Sykes, of
Delaware, successfully, in 1823. The ligature has also been placed
upon bothc arotids by Dr. McGill, of Maryland, in 1825, success-
fully; by Dr. Mussey, of New Hampshire, at two days' interval, in
1829 ; by Dr. Mott, of New York, unsuccessfully, in 1834, both ves-
sels being tied simultaneously ; and by Dr. J. Mason Warren, on
both vessels successfully (at an interval of five weeks) in 1846.
Keference to the Bibliographical Index, p. 91, will also show that
the single ligature has been very frequently practised by other
American surgeons, whose names are there given. Of these, few
have been so frequently called on to perform it as Dr. Mott, of New
York, he having, as I am recently informed, ligated the carotid
artery for the thirty-second time.
§ 1. — LIGATURE OF THE PRIMITIVE CAROTID.
Operation as practised by Dr. Mott, of New York 1 . — The
skin, superficial fascia, and platysma-myodes muscle being cau-
tiously divided on the inner edge of the sterno-cleido-mastoid
muscle, on a level with the larynx, separate the edges of the
wound with the fingers, and push the omo-hyoid muscle down-
wards. Then carefully picking up the deep fascia in the forceps,
nick it, and opening it on a director, seek for the descendens noni
nerve, where it lies upon the sheath of the vessel, and pushing it
to one side, cautiously open the sheath of the artery, and pass the
ligature around it by means of the Philadelphia needle (Plate
XXXV., Fig. 2), which Dr. Mott prefers to all others. Any small
vessels that may bleed during the incisions, should be promptly tied
in order to prevent the blood from obscuring the parts around the
main artery.
Operation of Velpeau. — The plan recommended by Velpeau, 2
and by him designated as the ordinary operation, from its being
pursued by nearly every surgeon, when circumstances admit it, is
substantially as follows : —
Operation. — The patient being placed upon the back, with the
1 New York Register of Med. and Pharmacy, vol. i. p. 93.
2 Med. Op^ratoire, tome i. p. 240.
LIGATURE OF THE PRIMITIVE CAROTID. 547
chest slightly raised, the neck a little stretched, and the face in-
clined to the side which is opposite to the tumor, the surgeon should
stand on the side of the aneurism, and feel for the anterior edge of
the sterno-mastoid muscle, or for the depression which shows its
border. Then placing upon it (as directed by Lisfranc). the four
fingers of his left hand, all brought to the same level, let him make
in this direction an incision about three inches in length, commencing
on a line with the cricoid cartilage, and terminating near the sternum,
if he desire to tie the artery in the omo-tracheal triangle, that is,
below the omo-hyoid muscle. But if the disease permits the artery
to be tied in the omo-hyoid triangle (above the muscle), the incision
should be carried a little higher up and not so low down. A second
cut of the scalpel should then divide the platysma-myodes muscle
and superficial fascia, and lay bare the fibres of the sterno-mastoid
muscle, when an assistant may draw the inner edge of the wound
towards the trachea, and the operator push its external edge out-
wards by means of the first and second fingers of his left hand.
The patient's head being then turned so as to relieve the extension
and inclination of the neck, and relax the parts, the fibro-cellular
layer, which extends from the sterno-hyoid and thyroid muscles to
the posterior surface of the sterno-mastoid (layer of deep cervical
fascia), should be divided by raising and nicking in it a little open-
ing, through which a director may be passed.
The omo-hyoid muscle, being now seen as a reddish ribbon, may
be divided upon the director, if it should be in the way of the ope-
rator, though generally this may be avoided by drawing it to one
side. Above and below the line of the muscle will now be seen the
yellow-looking sheath of the vessels, on the anterior surface of which
is the descendens noni nerve. The sheath being then picked up in
the forceps over the artery (not over the vein), and slightly nicked,
the director should be introduced and the sheath opened upon it
to the extent of an inch. If the jugular vein swells up in expira-
tion, so as to embarrass the operator, it should be compressed, as
advised by Mr. Hodgson, near the superior angle of the wound,
when it will soon empty itself and shrink.
When the sheath is opened, the artery, par vagum, and vein, in
the order mentioned, counting from the trachea, will be exposed ;
when the aneurismal needle should be introduced between the vein
and artery, so as to keep its point close to the artery, in order to
avoid the par vagum nerve, and being, by a slight rocking motion,
548 OPERATIVE SURGERY.
made to pass round the vessel, its point should be made to perforate
any cellular tissue that opposes its exit, by the pressure of the
fingers of the left hand.
After the ligature is withdrawn, the artery may then be very
slightly raised upon it, and tied by a double knot, both ends being
left attached in order to favor the escape of any suppuration that
may subsequently supervene. The wound should next be lightly
dressed, and the patient placed in bed in such a position as will
relax the parts, until the ligature separates, this happening some-
times in ten days, though often not till much later.
Remarks. — To avoid error in the first incisions, it has been ad-
vised to cut directly upon the belly of the sterno-mastoid muscle,
and then to draw the wound towards the trachea, instead of cutting
upon the inner edge of the muscle, as this, in the lower part of the
neck, is liable to throw the operator upon the tracheal muscles
instead of the sterno-cleido-mastoid. Mr. Chassaignac 1 has also
advised the surgeon, in case of difficulty, to feel for the tubercle or
projection made by the anterior branch of the transverse process of
the sixth cervical vertebra (carotid tubercle), which is in front and
a little inside the artery, if, in operating at the inferior third of the
vessel, he finds the parts so infiltrated as to prevent their being
recognized. I have tried this rule repeatedly upon the subject, and
seldom failed to find the artery simply by the touch.
§ 2. — EFFECTS RESULTING FROM LIGATURE OF THE CAROTID.
"Whei^the circulation is cut off from one side of the head by the
application of a ligature to the carotid artery, it is useful to know
by what means nature remedies this obstruction to the natural
course of the supply of blood intended for the head, and especially
for the brain, as well as its effects upon this organ. From the free
anastomosis found between the vessels supplying the head and upper
part of the neck, it might readily be surmised that their enlarge-
ment would be the chief means employed by nature to compensate
for the temporary loss occasioned by the operation, and such has
been accurately found to be the result. From a dissection made by
' Malgaigne, p. 165.
EFFECTS RESULTING FROM LIGATURE OF THE CAROTID. 549
Dr. Mott, 1 of New York, of a subject whose arteries were injected
after a death, consequent on a pulmonary affection, three months
and nineteen days subsequent to the operation, it appeared that the
carotid, which had been tied (right side), had been entirely obliterated
from the innominata to the angle of the jaw, leaving a firm ligament-
ous cord divided into two parts at the point where the ligature had
been applied. The vein and nerve were found to be perfectly na-
tural ; the right subclavian artery enlarged to a size equal to that of
the innominata ; the left carotid enlarged to twice its natural size,
and its branches increased in the same ratio. The branches arising
from the right subclavian artery were also enlarged. The inferior
thyroid was enlarged in the ramus thyroidea, and the thyroideas
ascendens were twice their natural size ; but the transversalis cervicis
and transversalis humeri, though arising from the same trunk, re-
tained their natural dimensions. The thyroidea ascendens was
found mounting up the neck in a zigzag direction, forming many
communications with the vertebral artery, and with the mastoid
branch of the occipital. The left carotid artery was also equal in
size to the innominata, and furnished the greatest part of the blood
to the right side, the superior thyroid, lingual, pharyngeal, and in-
ternal maxillary arteries, inosculating with those of the opposite
side, so as to have the appearance of continuous trunks. The men-
tal, inferior labial, coronary, and facial were also found to anasto-
mose freely with the same arteries from the right side. Although
no direct mention is made of the condition of the right vertebral
artery, there can be no doubt that it also participated in the enlarge-
ment seen in its parent subclavian, and thus materially aided the
supply of blood to the brain by means of the circle of Willis.
Notwithstanding the numerous facts cited to show that, in most
instances, no serious disturbance of the function of the brain ensues
upon ligature of the carotid, 2 yet the reverse has been noted, the
failures having been ascribed to some disorder or anomalous ar-
rangement of the arteries chiefly concerned in equalizing the circu-
lation after the operation. In a patient operated on by Mr. Key,
who died almost immediately, the left carotid was found to be nearly
obliterated at its origin from the aorta. In a case treated by Lan-
genbeck, the patient suddenly presented alarming symptoms, and
1 Amer. Journ. Med. Sciences, vol. viii. p. 45, 1831.
* Chelius, by South and Norris, vol. ii. p. 507.
550 OPERATIVE SURGERY.
PLATE XXXVI.
OPERATIONS UPON THE NECK.
Fig. 1. Ligature of the Carotid, Lingual, and Facial Arteries. C.
Ligature of primitive carotid. 1. Lowest point of incision. 2. Fascia
profunda. 3. Internal jugular vien. 4. Carotid artery raised on the
aneurismal needle. 5. Par vagum nerve. L. Ligature of Lingual Artery.
1. External incision. 2. Fascia. 3. Lingual artery. F. Ligature of
Facial Artery. 1. External incision. 2. Fascia. 3. Facial artery.
After Bernard and Iluette.
Fig. 2. Surgical Anatomy of the Subclavian and Axillary Arteries. 1.
Subclavian artery ; as it passes from beneath the clavicle, it becomes axil-
lary. 2. Axillary vein. 3. Brachial plexus of nerves. 4. Supra-scapu-
lar artery passing across the neck. 5. Omo-hyoid muscle. 6. Phrenic
nerve. 7. External jugular vein. 8. Clavicular portion of sterno-cleido-
mastoid. 9. Its sternal origin. 10. Clavicle sawed across. 11. Deltoid
muscle. 12. Cephalic vein. 13. Pectoralis minor muscle. 14. Section
Of pectoralis major muscle. Af ter Bernard and Huette.
Fig. 3. Origin of the Carotid and Subclavian Arteries and Branches of
the Subclavian. 1, 1. Aorta. 2. Innominata. 3. Primitive carotids. 4.
Right subclavian. 5. Left subclavian. 6. Scalenus anticus muscle. 7, 7.
Vertebral arteries. 8, 8. Thyroid axis. 9, 9. Posterior scapular arte-
ries. 10,10. Internal mammary. After Bernard and Iluette.
Fig. 4. Ligature of the Subclavian and Axillary Arteries. A. Liga-
ture of subclavian. 1. Incision in skin. 2. Deep fascia. 3. Omo-hyoid
muscle. 4. Brachial plexus. 5. Subclavian artery raised on the needle.
6. Scalenus anticus muscle. 7. Subclavian vein. B. Ligature of axillary
below the Clavicle. 1. Incision in skin. 2. Deep fascia. 3. Fibres of
pectoralis major cut across. 4. Axillary artery raised on the needle. 5.
Axillary Vein. After Bernard and Huette.
Fig. 5. Relative Position of the Subclavian Vessels. 1. Subclavian
artery. 2. Subclavian vein. 3. First rib. 4. Scalenus anticus muscle.
After Bernard and Iluette.
Fig. 6. A view of the operation of (Esophagotomy. 1,1. Incision in
skin. 2. Deep fascia. 3. Blunt hook drawing trachea inwards. 4. The
oesophagus. 5. Fingers of the surgeon drawing the bloodvessels out-
wards, so as to protect them during the incision in the oesophagus. 6.
Bistoury incising the oesophagus. 7. Sterno-cleido-mastoid muscle drawn
aside. 8. Internal jugular vein. 9. Primitive carotid artery.
After Bernard and Iluette.
.'.--
■J
■■/.
STATISTICS OF OPERATION OF LIGATING CAROTID ARTERY. 551
died thirty-four hours after the operation, in consequence, as is
siqjposed, of some abnormal condition of the arteria communicans.
Three patients in the hands of Molina, of Mayo, and of Sisco, suf-
fered more or less, in the sight and hearing of the side operated on.
A patient of Magendie, one of Baroven, one of Macauley, of Cooper,
of Vincent and others, suffered from hemiplegia of the opposite side
to that on which the artery was tied, thus indicating a lesion in the
side of the brain corresponding with the artery. 1 It is better, there-
fore, in all cases to watch the effect upon the patient after tying the
first knot before forming the second, so that, if requisite, the liga-
ture may be removed from the vessel.
Though the ligation of one carotid has occasionally created these
serious results, it has been successfully practised on both arteries,
at intervals varying from two to six weeks, by Drs. McGill, Mussey,
Mason Warren, Ellis, and Blackmail in the United States, 2 and by
several surgeons in Europe, and in these cases it is to be presumed
that the vertebral arteries were in good condition. In a case in
which both carotids were ligated simultaneously by Dr. Mott for
extensive disease of the parotid gland, the patient died in twenty-
four hours. 3
Death also ensued upon a ligature of the primitive carotid by
Dr. A. C. Post, of New York, one month after the operation, in
consequence of phlebitis of the corresponding vein, pus being also
found between the meninges of the brain. 4
§ 3. — STATISTICS OF THE OPERATION OF LIGATING THE CAROTID
ARTERY.
The attention of surgeons having been closely bestowed upon
the results of the application of a ligature to the carotid artery, we
are now able to form a tolerably correct estimate of the conse-
quences of this operation, and, without specifying the diseases which
required it, the following table will show the data from which an
opinion may be formed : —
1 Diet, de Medecine, tome vi., artiele Carotides.
2 See Bibliography.
3 Am. Journ. Med. Sciences, vol. xiv. p. 530, 1834.
* See Bibliography, p. 93.
09
50
9
10
11
5
2
22
8
1
(simultaneous li-
gature)
552 OPERATIVE SURGERY.
TABLE.
CURED. DIED. TNSIT- DOUBT-
OESsrvL. 1 1 i..
Of 137 cases reported by Velpeau 1 ... 82 40 13 2
Of 128 cases reported by Dr. Norris, of Phila-
delphia 2 (in reference to the cure of the
disease)
Of 21 cases reported by Dr. E. Crisp 3
Of 7 cases reported by Dr. Lente, of New York 4
Of 30 cases collected by myself, 5 from the ope-
rations of surgeons in the United States
Of 8 cases of the ligature of both carotids
Total of cases, 331 . . . . 194 112 22 2
From this table, it appears that in 331 cases the proportion of
cures is 30, more than one-half of those operated on.
Of the cases reported by Velpeau, 32 were by surgeons in the
United States, of which 27 were cured.
Of those reported by Norris, 38 were performed in the United
States, of which 28 were cured; and Lente and myself report only
those performed by American surgeons, being 45 in all (including
those of both carotids), of which 33 were cured.
Total of cases in the United States, 115; of which there were
cured, 88.
Total of those in Europe, 216; of which there were cured, 106;
showing a decided result in favor of the surgeons of the United
States, either in consequence of their subsequent treatment of the
case, or, what is more probable, the better constitution and habits
of the patients operated on.
§ 4. — LIGATURE OF THE LINGUAL AND FACIAL ARTERIES.
The ligature of the Lingual or Facial artery, though seldom
required, may occasionally be demanded for the relief of tumors
of the tongue or face, and may be accomplished as hereafter directed.
1 Med. Ope'ratoire, torn. 2 me , p. 232.
2 Am. Journ. Med. Sciences, vol. xiv. N. S. p. 13.
3 Lond. Med. Examiner, vol. ii. No. 3.
4 Transact. Amer. Med. Assoc, vol. iv. p. 326.
1 See Bibliographical Index, p. 91.
LIGATURE OF THE LINGUAL AND FACIAL ARTERIES. 553
Although rarely demanded during life, the ligation of these arteries
upon the subject, and especially the lingual, will be found to be a
good operative exercise, and worthy of repetition by the student.
I. LIGATURE OF THE LINGUAL ARTERY.
Anatomical Relations. — The Lingual artery, after arising from
the external carotid, will be found in the supra-hyoid region of the
neck. In the early part of its course, it is concealed by the digas-
tric and stylo-hyoid muscles; after which it penetrates the hyo-
glossus muscle, just above the cornu of the os hyoides, which is the
first point of reference, or between it and the middle constrictor of
the pharynx. It then ascends between the hyo-glossus and the
genio-hyo-glossus muscles, and, running forwards, lies between the
latter muscle and the sublingual gland, which is the second point of
reference. It may be ligated most readily at its nearest point to the
os hyoides (Plate XXXVI., Fig. 1).
Operation of Malgaigne. 1 — Feel for the greater cornu of the
os hyoides, and make an incision, one inch and a half long, and
parallel to the greater cornu, through the skin, fascia superficialis,
and platysma-myodes muscle, taking special care not to divide the
facial vein, which runs obliquely across the incision. After exposing
the submaxillary gland, which is readily recognized, push it up-
wards, and the bright tendon of the digastric muscle will be seen
showing through the cellular tissue, half a line above which will be
found the hypo-glossal nerve, which is to be drawn aside. Then,
at one line below it, raise the hyo-glossus muscle carefully, and
dividing it transversely, the artery will be found directly beneath,
unaccompanied by any vein or nerve. The first incision must not
be extended too much towards the sterno-mastoid muscle, lest it
involve the carotid region.
II. ligature of the facial artery.
Anatomical Relations. — The Facial artery arises from the
external carotid, a few lines above the lingual, and goes forward
1 Op. Surgery, Philad. edit. p. 155.
554: OPERATIVE SURGERY.
within the angle of the jaw and above the submaxillary gland, with
which it is closely connected, until it mounts over the base of the
inferior maxilla just in advance of the anterior edge of the inasseter
muscle. When compression of the artery upon the jaw will not
arrest the circulation on the side of the face, or when tumors about
the submaxillary gland demand it, the ligature of this artery may
be accomplished as follows (Plate XXXVI., Fig. 1): —
Operation. — Make an incision through the skin and fascia, an
inch and a quarter long, obliquely across the jaw-bone, from the
masseter muscle towards the angle of the mouth. Then, lacerating
the cellular tissue with the director, and pushing the accompanying
veins to each side, apply the ligature carefully around the artery,
so as not to include any nervous filaments.
CHAPTER IX.
LIGATURE of the INNOMINATA and subclavian arteries.
As a remedy for the relief of aneurismal tumors of the carotid,
or of the subclavian artery close to the clavicle, the ligation of the
innominata or of the subclavian within the scaleni muscles has
been practised. Before showing the plans that have been resorted
to for the accomplishment of this object, a brief reference must be
made to the relative position of the parts concerned.
SECTION I.
surgical anatomy of the innominata and subclavian
arteries.
The Aorta, in forming the arch which permits it to pass from the
heart downwards into the thorax, rises to within eight or twelve
lines of the superior edge of the sternum, and at this point gives off"
the Innominata and Left Carotid and Subclavian Arteries.
ANATOMICAL RELATIONS OF THE SUBCLAVIAN ARTERY. UOO
§ 1. — ANATOMICAL RELATIONS OF THE INNOMINATA.
The trunk of the Tnnominata artery, which is from an inch to an
inch and a half long, or rarely two inches, arises from the arch of
the aorta as just stated, and extends to near the level of the sterno-
clavicular articulation, where it gives off the right subclavian and
right carotid arteries. In this short course it passes obliquely from
below upwards, from within outwards, and from before backwards;
is very nearly in contact on its outer side with the top of the pleura;
rests against the front and right side of the trachea; is crossed on
its anterior face by the left transverse vein, and lower down by the
vena cava descendens, which is parallel to it, but more and more
distant as it approaches the heart. 1 It is covered by the skin, super-
ficial and deep cervical fascia?, by cellular tissue, by the origins of
the sterno-hyoid and thyroid muscles, and by a portion of the sterno-
clavicular articulation. (Plate XXXVIL, Fig. 3.)
§ 2. — ANATOMICAL RELATIONS OF THE SUBCLAVIAN ARTERY.
The Subclavian artery of the right side arises from the Innomi-
nata, and that of the left from the arch of the aorta. Each crosses
the first rib of their respective sides in the interval between the
scalenus anticus and medius muscles, and, passing between the sub-
clavius muscle and the rib, escapes from under the clavicle, and is
thence known as the Axillary artery. The right subclavian is
much shorter and more superficial than the left from its origin to
the scaleni muscles. Near these muscles, both arteries are covered
in front by the sternal end of the clavicle ; by the sterno-hyoid and
thyroid muscles, and by the subclavian vein of the corresponding
side. Behind them is the longus colli muscle; below them, the
pleura, the left artery being in contact with it for its whole length
in the thorax, and on their internal side is the primitive carotid
arterjr. Near the scalenus anticus, the right subclavian artery is
crossed by the par vagum nerve, whilst the phrenic nerve is found
in front of it, but on the internal edge of the scalenus muscle.
The Left Subclavian artery runs nearly vertically from its origin
to the interval in the scaleni muscles ; is nearly parallel with, but
1 Diet, de M6d., torn, xxviii.
556 OPERATIVE SURGERY.
behind the left primitive carotid ; has the phrenic nerve in the same
relative position as the artery on the right side, though the left par
vagum goes parallel with and in front of the artery for some distance
along its root. At the inner margin of the scaleni muscles, on both
sides, is found the thyroid axis or cluster of five branches. The
sympathetic nerve is generally behind the root of the artery on the
right side, whilst on the left, the thoracic duct is very near its pos-
terior face, and usually crosses it above before emptying into the
left subclavian vein.
Having become horizontal, the subclavian arteries present the
same relation on both sides, and lie directly on the first rib, the
insertion of the scalenus anticus muscle separating them from the
subclavian vein. All the nerves of the brachial plexus form a net-
work around the arteries resembling the plaiting of a whipcord.
Outside the scaleni muscles, the subclavian artery corresponds to
the supra-clavicular fossa, and rests upon the first intercostal space.
The subclavian vein, which covers the artery while descending
towards the clavicle, receives at this point the subscapular vein,
external jugular, and sometimes the acromial veins. The brachial
plexus accompanies the artery thus far, but soon afterwards passes
behind it. The artery is, therefore, generally found in a triangular
space formed by the omo-hyoid muscle on the outside, the scalenus
anticus on the inside, and the clavicle below. 1
SECTION II.
LIGATURE OF THE INNOMINATA ARTERY.
The difficulties attendant on the application of -a ligature to the
Arteria Innominata may be readily understood when reference is
had to its anatomical relations, as well as to the changes likely to
be created in the surrounding parts by the formation of such an
aneurism as would lead to its execution. This operation has been
performed ten times, 2 and in every instance resulted in death : to
wit, first by Dr. Valentine Mott, of New York; second, by Graefe, of
Berlin; third by Bland; fourth, by Dr. J. Wilmot Hall, of Balti-
more ; fifth, by Kuhl, of Leipsic ; sixth, by Lizars, of England ;
1 Horner's Anatomy, vol. ii. p 215.
2 Diet, de Med., torn, xxviii. p. 448.
LIGATURE OF THE INNOMINATA ARTERY. 557
seventh, by Arendt, of Russia ; eighth and ninth, by Bujalski, of
St. Petersburg ; and tenth, by Hutin, for a wound. 1
In order to obviate the numerous difficulties attendant on this
operation, various plans of proceeding have been recommended ;
but this account will be limited to the method of Dr. Mott, as it is
generally admitted to expose the parts as freely as is safe, and is
also sanctioned by the experience of Malgaigne and others, who
regard it as the best that can be employed, if the operation should
be again resorted to.
The appearance of the tumor, and the incisions required in the
operation, are shown in Plate XXXVII., Fig. 2, for a special draw-
ing of which I am indebted to the politeness of Dr. Mott, it being
believed by him to do justice to the appearance of the parts.
Operation of Dr. Mott, of New York, May 11, 1818. — The
patient being placed in a recumbent position upon a table of the
ordinary height, a little inclining to the left side, so that the light
might fall obliquely on the upper part of the thorax and neck, and
the surgeon seated on a bench of convenient height, an incision was
commenced upon the tumor just above the clavicle, and carried
close to this bone and the upper end of the sternum, so as to termi-
nate immediately over the trachea, the whole cut being about three
inches long. Another incision, about the same length, being then
made from the termination of this along the inner edge of the
sterno-mastoid muscle, the integuments were dissected back from
the platysma-myodes muscle, beginning at the lower angle of the
incision, when the flap was turned over upon the tumor and side of
the neck.
After cutting through the platysma-myodes, the sternal origin
of the sterno-mastoid muscle was cautiously divided in the direction
of the first incision, and also reflected over the tumor (Plate
XXX VII., Figs. 2 and 3), when the sterno-hyoid muscle was divided,
and then the sterno-thyroid, both being turned up on the opposite
side of the wound over the trachea, so as to expose the sheath of
the carotid artery. This sheath being now cautiously opened a
little above the sternum, the nerve and vein were drawn to the
outside, the artery drawn towards the trachea, and the subclavian
laid bare about a half inch from its origin, the handle of the scalpel
being mostly employed in order to avoid injuring these parts.
1 See Bibliography, p. 91.
558 OPERATIVE SURGERY.
Whilst separating the cellular substance from the artery with the
smooth handle of the scalpel, a branch of an artery was lacerated,
which yielded for a few minutes a smart hemorrhage. It was about
half an inch distant from the innominata, and about the size of a
crowquill; but the bleeding ceased upon a little pressure.
The bifurcation of the innominata being now in view, the dissec-
tion was mainly done with Dr. Parrish's knife (Plate XXXV., Fig,
1), care being taken to keep it directly over and along the upper
surface of the artery. After fairly denuding the vessel on its upper
surface, the cellular substance was very cautiously separated from
the sides of it by the handle of the scalpel, so as to avoid injuring
the pleura, and a round silk ligature being passed by means of the
Philadelphia needle (Plate XXXV., Fig. 2), the artery was tied
about half an inch below its bifurcation, the recurrent and phrenic
nerves being undisturbed.
In introducing one of the smallest blunt needles (Plate XXXV.,
Fig. 5) around the artery, the instrument was passed from without
inwards, so that the cellular substance and the pleura could be
pressed down with a part of the instrument, whilst the point was
very carefully insinuated under the artery from below upwards, so
as to appear on the opposite side of the artery. The hook (Plate
XXXV., Fig. 9) being then introduced into the eye of the needle,
the shank was unscrewed and the needle drawn through with the
utmost facility, leaving the ligature in situ, after which the knot
was gradually tightened.
The integuments being then closed tightly, the patient was put
to bed with a pulse beating sixty-nine, ten minutes after the opera-
tion.
This patient subsequently did so well that, on the fourteenth day,
the ligature separated. On the twentieth day he walked several
times across the yard, but on the twenty-third day was attacked
with hemorrhage from the wound, which recurred at intervals, till
on the twenty-sixth day after the operation, he died.'
Kemarks. — The want of success attending the performance of
this operation in so many able hands (it having resulted fatally in
every instance) has, at present, generally proscribed the operation
from the list of those that are justifiable in cases of aneurism.
The dissection of Dr. Mott's patient showed that a firm clot had
1 Mott, Yelpeau; also Eclect. Repertory, vol. ix., and other journals.
LIGATURE OF THE INNOMINATA ARTERY. 559
formed in the artery below the ligature, and that ulceration of the
opposite side of the artery was the source of the hemorrhage.
*Gra3fe's operation in 1822 apparently did well for sixty-eight days,
but then hemorrhage ensued upon the patient's exerting himself.
Blandin, in 1837, lost his patient by hemorrhage on the eighteenth
day. Hall lost his on the sixth day also by hemorrhage ; and the
patient of Mr. Lizars died in ten days of hemorrhage, the chest
containing twenty ounces of blood, the subclavian artery alone
being diseased. Judging from these results, Velpeau has therefore
expressed the decided opinion " that the operation ought not to be
attempted, at least for the cure of aneurism." 1
The little success that has followed this operation renders a
reference to the operations of Brasdor and Wardrop, or the appli-
cation of a ligature on the distal side of the tumor, essential to a
knowledge of the best method of treating aneurisms of this vessel,
and it should be deliberately considered before repeating the liga-
ture of the innominata. According to Mr. Wardrop's views, the
cure of an aneurism of the innominata by the application of a
ligature to either the subclavian or the common carotid artery, cor-
responds with the course taken by nature in effecting the cure, as
is shown in several preparations now in the Museum of the Eoyal
College of Surgeons. In addition to which, Mr. Wardrop has col-
lected eight cases of aneurism of this vessel thus operated on, in five
of which there was consolidation and diminution of the tumor, and
though in three others the operation failed, one lived a month, the
second died in a few hours, and the third was benefited for the time,
only dying on the increase of the tumor. This success, as compared
with that consequent on the ligation of the innominata itself, is cer-
tainly very great, and his method of treatment should, therefore,
receive that consideration which so serious an operation must cer-
tainly obtain in the mind of every judicious operator. In selecting
one of two vessels (either the subclavian or the carotid), Mr. Ward-
rop prefers the carotid ; as this vessel was found in his preparation
to be the one most frequently obstructed by the natural formation
of a clot.
•
1 Diet, de Me"d., tome xxviii. p. 474.
560 OPERATIVE SURGERY.
SECTION III.
LIGATURE OF THE SUBCLAVIAN ARTERY.
The ligature of the Subclavian Artery is an operation which dates
back only to the commencement of the present century, having been
first successfully performed by Mr. Keate, of England, in March,
1800; by Ramsden unsuccessfully in 1809 ; after which it was suc-
cessfully ligated in 1815, by Chamberlaine, and then by Dr. Wright
Post, of New York, in September, 181 7, 1 this being the first time
the operation was performed in the United States. Since this period,
it has been frequently attempted both in Europe and the United
States, being performed by Dr. Dudley, of Lexington, in 1826 ; by
Gibson, of Philadelphia, in 1828 ; by Wells, of Carolina, in 1828 ;
by Mott, of New York, in 1831; by the same surgeon within the
scaleni, in 1833 ; also by him upon the left subclavian, outside the
scaleni, in 1834; and by Kearny Rodgers, of New York, within the
scaleni muscles, in 1845, this being the first operation ever per-
formed at this point. By a reference to the Bibliographical Index, 2
it will also be seen that many other American surgeons have suc-
ceeded in ligating the artery at the usual place.
The ligature of the subclavian artery may be performed in any
portion of its course, though it is generally admitted to be accom-
panied by many difficulties, and to require perfect anatomical as
well as surgical skill, no matter what portion of it may be chosen.
Three different points have been selected for the application of
this ligature, the choice being usually directed by the necessities of
the case. These points are usually designated as the operation
upon the first rib; that between the scaleni, and that within the
muscles, the difficulties being greater in most of them, when it is
necessary to operate upon the artery of the left side. As the clearest
account of the operative proceedings, I have selected those fur-
nished by Malgaigne and Velpeau, adding to them a few of the steps
taken by the American surgeons whose cases are referred to in the
Bibliographical Index.
" To expose the artery on the first rib, it is necessary to divide
the skin, subcutaneous cellular tissue, superficial fascia, and pla-
1 Norris, Am. Journ. Med. Sciences, vol. x. N. S. p. 14.
2 See Bibliography, p. 95.
LIGATURE OF THE SUBCLAVIAN ARTERY. 561
tysma-myodes muscle; the fascia profunda colli, and a loose cellular
tissue full of venous branches and lymphatic ganglia, in which run
two important arteries, the trans versalis cervicis being placed some
lines above the subclavian and the superior scapula, running along
the posterior border of the clavicle. Sometimes the sterno-mastoid
muscle, from its wide origin along the clavicle, requires division,
whilst the external jugular vein, from running more outwards than
usual, requires to be avoided." 1
In the latter stages of the operation, the following test of the
position of the artery, which I have never known to fail, and which
was suggested originally by Dr. Jos. Parrish, of Philadelphia, 2 will
prove valuable, and that is, to notice the position of the tubercle or
prominence on the first rib into which the scalenus anticus muscle
is inserted, as the artery is invariably found on its outer side.
In the directions usually given by the French surgeons for the
ligature of this artery, much stress is laid by them upon the
importance of recognizing this prominence of the first rib as a
point of reference, and on the many occasions in which I heard
it referred to at Clamart, and the Ecole Pratique of Paris, in
1839, I supposed that the suggestion was due either to Lisfranc,
Velpeau, or Malgaigne, especially as the latter also mentioned
it in his Manual of Operative Surgery. Subsequent reading has,
however, induced me to think that this valuable direction ori-
ginated in the United States, with the late Dr. Jos. Parrish, of
Philadelphia, though, as I am unable to find any date in connec- •
tion with the accounts of the French surgeons, I cannot be positive
on the subject. A perusal of the paper of Dr. Parrish 3 will, how-
ever, show that he published the description of this important land-
mark to the position of the artery in the year 1813, four years after
Eamsden's operation, and this, I think, is the earliest notice taken
of an infallible rule for finding the artery.
The high estimate generally entertained of the accuracy of this
point of reference, renders it desirable to credit correctly the author
of the suggestion, and in claiming it for Dr. Parrish, there is every
reason to think that nothing more than justice is done to the me-
mory of a surgeon whose experience as an operator is well known
throughout the United States.
1 Malgaigne, Philad. edit. p. 148.
2 Eclectic Repertory, vol. iii. p. 240. Philad. 1813.
3 Eclectic Repertory, loc. citat.
36
562 OPERATIVE SURGERY.
§ 1. — LIGATURE OF THE SUBCLAVIAN ARTERY OX THE FIRST RIB.
Parrish's Eule for finding the Subclavian Artery. — The
depth at which the subclavian is placed rendering it very difficult
to recognize the position of the vessel by the sight alone, the sug-
gestion of Drs. Parrish, Hewson, and Hartshorne, referred to iu Dr.
Parrish's paper, will prove highly serviceable. It is as follows :
After dividing the external tissues, pass the finger down to the
superior edge of the first rib, and sliding it along this towards the
sternum, feel for the insertion of the scalenus anticus muscle. The
tubercle at this point is very perceptible to the touch, and the
artery will be found close iipon its outer side.
Ordinary Operation. — The patient lying down with the head
secured and the shoulder drawn downwards and slightly forwards
so as to depress the clavicle, make an incision immediately above
the bone parallel to its posterior border, commencing one inch
outside its sternal end, and extending to the insertion of the tra-
pezius muscle, and, after cautiously dividing the skin, draw the
external jugular vein, if it shows itself, inwards, by means of a
blunt-hook. Then, cutting across the superficial fascia and pla-
tysma-myodes muscle, cautiously open the fascia profunda colli,
and laying aside the knife tear the cellular tissue with the finger-
nail or point of the director. On carrying the forefinger into the
internal angle of the wound, feel, as directed by Dr. Parrish, for
the scalenus tubercle of the first rib, and, reaching it, the artery
will be felt pulsating on its external side. Then, whilst keeping
the finger upon this tubercle as a guide, pass the aneurismal needle
carefully under the vessel from its inner side, and bring it out ex-
ternally, holding the artery with the finger to prevent its slipping.
Then, placing a finger between it and the first fasciculus of the bra-
chial plexus of nerves, so as to preserve them from injury, facilitate
the passage of the needle by depressing the shoulder and turning
the patient's head to the opposite side. 1
Eemarks. — As this method of operating exposes the surgeon to
the risk of wounding the external jugular vein, Roux advises that
the incision should be made perpendicularly to the clavicle, and I
have found his mode of operating quite easy upon the subject.
1 Malgaigne.
LIGATURE OF ARTERY BETWEEN THE SCALENI MUSCLES. 563
A somewhat similar, but more accurate method of operating is
as follows: —
New Method. — Make an incision perpendicular to the clavicle
by dropping a line from the point where the anterior edge of the
trapezius and posterior margin of the sterno-mastoid muscle meet
(supra-clavicular fossa), so as to divide this triangular depression
into two triangles, and then dissect or lacerate the tissues until the
artery is distinctly felt.
Kemarks. — This mode of reaching the subclavian was suggested
many years since by the late Dr. Horner, of Philadelphia, and pro-
tects the surgeon not only from the risk of wounding the vein, but
also from injury of the transverse vessels, so often found near the
subclavian artery, should the transverse incision fall too near the
sternal end of the bone.
§ 2. — LIGATURE OF THE ARTERY BETWEEN THE SCALENI MUSCLES.
Operation of Dupuytren. — Make at the base of the neck a
transverse incision extending from the anterior edge of the trape-
zius to the inner border, or to a short distance upon the outer side
of the sterno-mastoid muscle, cutting through the different layers as
before mentioned. Having found the insertion of the scalenus
anticus, insinuate between its posterior surface and the front of the
artery a grooved director, and divide the muscle upon it, when the
retraction of the muscle will lay bare the artery, and enable the
needle to pass under it from without inwards. 1
Kemarks. — In this operation, caution has always been given re-
specting the position of the phrenic nerve, which, it will be recol-
lected, lies against the internal side of the scalenus anticus, and a
little anterior to it. But Mr. Malgaigne 2 also advises that attention
should be given to the internal mammary artery which runs outside
of this nerve, and is much exposed if the cut is made too near
the rib.
1 Velpeau. 2 Malgaigne, Philad. edit., p. 150.
564 OPERATIVE SURGERY.
§ 3.— LIGATURE OF THE SUBCLAVIAN" ARTERY WITHIN THE SCALENI
MUSCLES.
This operation, which was first performed by Mr. Colles, of Dub-
lin, who lost his patient on the eighth day, has since been repeated
several times in Europe and this country, Dr. Mott, of New York,
performing the second operation.
Operation of Dr. Mott ojst the Eight Subclavian Artery.' —
The patient being placed upon the table with the shoulders elevated,
the head thrown backwards, and the face and body inclined to the
left side, an incision was begun at the lower part of the outer edge
of the sternal origin of the sterno-mastoid muscle, and carried up-
wards about two inches. Another, commencing at the same point,
was then made along the upper surface of the clavicle for the same
extent. When the triangular flap of skin, with the corresponding
portion of the platysma, and its investments, was separately dis-
sected and turned aside, the clavicular portion of the mastoid muscle
was severed immediately upon its insertion, and reflected upon the
neck. This laying bare the deep-seated fascia, the latter was raised
with the forceps, and divided a little below the course of the omo-
hyoid muscle, on the outside of the deep jugular vein. On enlarging
this opening an inch downwards, the adipose and cellular tissues
were readily pushed aside, and the scalenus anticus muscle exposed
to view. The cellular substance being now separated with the
fingers and handle of the knife, the artery was exposed just within
the thyroid axis, the branches of which could be plainly seen. The
filamentous tissue being then raised from the artery with the forceps
and cautiously divided, the ligature was passed under the vessel
from below upwards by Dr. Parrish's needle, curved spatuloe being
employed to draw the deep jugular vein towards the trachea as well
as to separate the edges of the wound. Three small arteries were
tied, no vein required the ligature, but on the eighteenth day the
patient died of secondary hemorrhage.
1 Amer. Journ. Med. Sciences, vol. xii. p. 354, 1833.
LIGATURE OF LEFT SUBCLAVIAN WITHIN SCALENI MUSCLES. 565
§ 4. — LIGATURE OF THE LEFT SUBCLAVIAN ARTERY WITHIN THE
SCALENI MUSCLES.
Although the right subclavian artery has been occasionally
ligated on the cardiac side of the scaleni muscles, Dr. J. Kearny
Kodgers, of New York, was, I believe, the first surgeon who suc-
ceeded in tying the left subclavian within these muscles, such an
operation being regarded as impracticable prior to his case. It
was performed under the following circumstances : —
A German, 42 years of age, was admitted September 13, 1845,
into the New York Hospital, with an aneurismal tumor above the
clavicle, about the size of a small hen's egg, extending externally to
the outer third of the bone, and covered internally by the outer
edge of the sterno-mastoid muscle. A consultation having left the
decision of an operation to Dr. J. Kearny Eodgers, this gentleman
concluded, after mature reflection, that the operation was possible,
and therefore determined to try it.
Operation of Dr. J. Kearny Kodgers. 1 — The patient being
placed on a low bed, with his head and shoulders raised, and his
face turned to the right side, so that the light from the dome could
shine directly on the part to be operated on, an incision three
inches and a half long was made on the inner edge of the sterno-
mastoid so as to terminate at the sternum, and divide the integu-
ments and platysma-myodes. This was then met by another inci-
sion, which extended along the sternal extremity of the clavicle,
about two and a half inches, and divided a plexus of varicose veins
which were in the integuments covering the clavicle, and commu-
nicated with the subclavian vein. To check the free bleeding
which occurred from their cut extremities, it therefore became ne-
cessary to tie them.
The flap of integuments and platysma-myoides being now dis-
sected up, and the lower end of the sterno-cleido-mastoid laid bare,
a director was passed under this muscle, and the sternal as well as
half of the clavicular origin divided by a bistoury. This muscle
being now turned up, the sterno-hyoid and omo-hyoid muscles, as
well as the deep-seated jugular vein, were seen covered by the deep
cervical fascia.
i Am. Journ. of Med. Sciences, vol. xi. N. S. p. 541.
36*
566 OPERATIVE SURGERY.
PLATE XXXVII.
OPERATIONS PRACTISED AT THE LOWER PORTION OF THE NECK.
Fig. 1. A view of the operation for the Strangulation of a large Goitre
which was inducing strangulation, as performed by Liston. By a crucial
incision the skin has been dissected from the tumor, which is then caused
to slough off by strangulating it by means of ligatures carried through and
around its base by needles. This tumor sloughed off in eight days. 1.
Sterno-hyoid and thyroid muscles divided and turned down. 2. Upper
portion of the same. 3. Os hyoides. 4, 4. Enlarged veins on surface of
tumor. Af ' er Liston.
Fig. 2. A view of Mott's operation for Ligature of the Innominata. 1.
Aneurismal tumor of the Subclavian. 2. Skin and platysma-myoides
turned back. 3. Section of sternal origin of sterno-cleido-mastoid muscle.
4. Arteria innominata. Aftcr Mott -
Fig. 3. Yiew of the relative position of the parts concerned in this
operation. 1. Vertical incision. 2. Corresponding edge of skin. 3.
Flap everted. 4. Sterno-mastoid muscle. 5. Arteria innominata. 6.
Internal jugular vein. 7. Origin of subclavian artery. 8. Yertebral
artery drawn forwards. 9. Inferior thyroid artery. 10. Internal mam-
mary. 11. Transversalis cervicis artery.
After Bourgery and Jacob.
Fig. 4. A view of the position and arrangement of the Bloodvessels
and Nerves of the Neck, as shown by turning off the Clavicle. 1. Tra-
pezius muscle. 2. Sterno-cleido-mastoid. 3. Sterno-thyroid muscle and
thyroid gland. 4. Upper portion of sternum. 5. Omo-hyoid muscle.
6. One of the cervical ganglia of the sympathetic nerve. 7. First cervi-
cal plexus. 8. Right primitive carotid. 9. Subclavian vein. 10. Liga-
ture on subclavian artery. 11. Hook holding down internal jugular vein.
12. Hook holding par vagum nerve. 13. Branches of spinal accessory
nerve. 14. Section of second rib. 15. Phrenic nerve. 16. Aneurismal
tumor of the subclavian artery. After Auvert.
Fig. 5. Surgical anatomy of vessels just above the clavicle, as connected
with the ligature of the Subclavian Artery. 1. Incision in skin. 2. Sca-
lenus anticus muscle. 3. Omo-hyoid. 4. Subclavian vein. 5. External
jugular vein. 6. Transverse cervical. 7. Superficial artery. 8. Sub-
clavian artery outside the scalenus muscle. 9. Supra-clavicular nerves.
10. Roots of brachial plexus. 11. Phrenic nerve. After Auvert.
Fig. 6. Excision of the clavicle as performed by Dr. Warren. The
skin has been turned back by a crucial incision, and the bone being sawed
across near its humeral end, is represented as raised by a ligature so as to
favor its disarticulation. After Nature.
:
LIGATURE OF LEFT SUBCLAVIAN WITHIN SCALENI MUSCLES. 567
On turning up the sterno-mastoid, a portion of the aneurismal
sac was seen strongly pulsating and overlapping about half the
width of the scalenus, so as to form the outer half of the track
through which it was necessary that the operator should pass,
showing fearfully one of the dangers of the operation, but one
which Dr. Kodgers had anticipated. The deep fascia being then
divided by the handle of the scalpel and the fingers, the dissection
was continued in contact with the outer side of the deep jugular
vein to the inner edge of the scalenus anticus muscle, for the pur-
pose of reaching this muscle fully half an inch above the rib, in-
stead of at its insertion, in order to guard against any injury of the
thoracic duct. The phrenic nerve could now be distinctly felt run-
ning down on the anterior surface of the scalenus, and was of course
avoided, until, by pressing the finger downwards, the rib was dis-
covered, when after some little search the position of the artery was
recognized. By pressing the vessel against the rib, all pulsation in
the tumor ceased, whilst on removing the finger the pulsation re-
turned. In order to avoid any injury to the pleura and thoracic
duct in detaching the artery, Dr. Parrish's needle was employed
after that of Sir Philip Crampton had been tried,. the point of the
former being introduced under the artery, and directed upwards so
as to avoid the pleura. The needle being detached from the shaft
of the instrument, the ligature was drawn upwards so as to sur-
round the artery, and then tightened with the forefingers at the
bottom of the wound, all pulsation ceasing immediately in the tumor,
and also in the arteries of the extremity. Warmth was subse-
quently applied to the limb, and the usual treatment pursued. On
the thirteenth day, the patient, on changing his position from the
right side to his back, was attacked with hemorrhage, of which he
died two days subsequently, or fifteen days after the application of
the ligature. A post-mortem examination, after detailing other
points, established the inaccuracy of one fact, which had been pre-
viously urged as an argument against the operation, to wit, the
chances of hemorrhage from the want of sufficient adhesions in the
artery. In this case there was a perfect coagulum found in the
vessels, the hemorrhage had come from the distal end of the artery
in consequence of the free communication of the internal carotid at
the base of the brain with the vertebral, the latter vessel having
been given off from the subclavian just beyond the point where Dr.
Rodgers had applied his ligature. Decidedly the greatest danger in
568 OPERATIVE SURGERY.
the operation was thought by the operator to be the risk of wound-
ing the pleura and thoracic duct.
§ 5. — STATISTICS OF THE OPERATION OF LIGATING THE SUBCLAVIAN
ARTERY.
Of sixty-nine cases reported by Dr. Norris, of Philadelphia, 1
thirty-six recovered and thirty-three died, or a few more than ope-
half recovered. Of fifty-four cases, in which the affected side is
mentioned, thirty-one were on the right and twenty-three on the
left side.
Of the fifty cases reported by Velpeau 2 (several of which have
been also counted by Dr. Norris), twenty-three died and twenty-
seven were cured. Of the twenty-three cases in which the left
artery was tied, as reported by Dr. Norris, fifteen were cured and
eight died; but there is no mention made of any of these having
been performed on the left side within the scaleni muscles.
Of twenty-six cases of aneurism, reported by Mr. Crisp, 3 ten were
ligated successfully, one was cured by pressure, and five died after
the application of the ligature from hemorrhage.
Of eighteen cases of the ligature of the subclavian collected by
myself, 4 fourteen were cured and four died. Of seventeen per-
formed in the United States, and reported by Norris, eleven were
cured and six died. Of the thirty cases, therefore, in the United
States, twenty-one were cured and nine died.
On summing up these one hundred and fifty-eight cases, eighty-
three are mentioned as cured, out of the whole number reported in
the tables. It appears, therefore, that the successful cases have been
four more than one-half of those operated on, but that the ligature
within the scaleni muscles has been by far the most fatal of all, the
deaths ensuing chiefly from hemorrhage or from inflammation of
the pleura or pulmonary organs.
The anatomical relations of the pleura to these arteries sufficiently
explain this result.
' Am. Journ. Med. Science-, v. . s. N. S. J'. IK
2 Operat. Surgery, by Mott, vol. ii. p. '-'IV.
3 London Med. Examiner, No. 8, vol. ii. p. 209.
4 Bibliographical Index, p. 96k
LIGATION OF THE SUBCLAVIAN ARTERY. 569
§ 6. — ANATOMICAL PHENOMENA CONSEQUENT ON THE LIGATION OF
THE SUBCLAVIAN ARTERY.
After applying a ligature to a large artery, and thus for a time
cutting off the supply of blood from the extremity which it has
previously nourished, it becomes a matter of some interest to learn
in what manner nature can adapt herself to the change, and remedy
the evil that it might be supposed would ensue. The following
account, furnished in connection with the dissection of two of the
operations practised on the subclavian, will therefore it is thought
prove instructive to the student by exhibiting the anatomical
changes consequent on the obstruction caused by the ligation of
the main channel of this artery.
In the account of the autopsy, furnished by Dr. F. S. Ainsworth, 1
of Boston, of a patient on whom a ligature had been applied (four
years previously) to the left subclavian artery at the external border
of the scalenus anticus muscle, we find "that the injecting matter
which was thrown into the aorta of the subject passed readily into
all the vessels of the left arm and hand ; that the arteries and veins
of the neck, as well as the brachial plexus of nerves for the space
of three inches above the clavicle, were imbedded in a dense fibro-
cartilaginous substance, and that the subclavian artery was com-
pletely obliterated and reduced to a mere fibrous-looking cord at
the point where the ligature had been applied. Three-fourths of
an inch from this spot the vessel, however, nearly regained its
usual size, and continued throughout its whole course of the nor-
mal dimensions and distribution, the collateral circulation being
maintained by the intercostal branches of the internal mammary
through the thoracic branches of the thoracico-acromialis, and by a
large inosculation between the supra-scapular and a terminal branch
of the sub-scapular arteries. A communication was also traced be-
tween some small muscular branches of the transverse cervical and
the thoracico-acromialis. An irregularity which is not uncommon
was also noted in the transversalis cervicis artery, which was given
off from the thyroid axis in a common trunk with the posterior
scapular, and formed a large trunk, which, running parallel to the
clavicle, so as to correspond at first with the course of the subcla-
1 Am. Journ. Med. Sci., vol. xix. N. S. p. 84.
570 OPERATIVE SURGERY.
vian, might readily have been wounded or ligated in mistake for
the subclavian itself." From the information furnished by the dis-
section of another anomalous distribution in these vessels, Dr.
Ainsworth suggests that it may be well hereafter to secure both
extremities of the main artery so as to avoid the hemorrhage that
has sometimes ensued in the operation from the collateral circu-
lation.
In the report of the dissection of a patient operated on by Dr. J.
Mason "Warren 1 for the ligature of the left subclavian, one year pre-
vious, it was shown that the subclavian was of its original size as
far as the scalenus anticus, where it suddenly terminated, whilst
the vessels forming the thyroid axis were twice their natural size,
the internal mammary being enlarged and given off from the
thyroid. It was through this vessel, by means of the inosculation
of the intercostal arteries with the thoracic, and of the posterior
scapular with the sub-scapular, that the collateral circulation had
been accomplished.
1 Am. Journ. Med. Sci., vol. xxi. N. S. p. 53.
END OF VOL. I.
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