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Full text of "A system of operative surgery: based upon the practice of surgeons in the United States, with a bibliographical index and historical record of many of their operations during a period of two hundred and thirty-four years (Volume 1)"

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PRESENTED BY 



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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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"/,l,„«*t ! 






' 






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