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THE LIBRARY

OF

THE UNIVERSITY

OF CALIFORNIA

PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID

A*S5^^^^^^0

^■-..*Si-i Y^'\^i^^>^.

-*^^l>*iiV^ V V\

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1

NEW ELEMENTS

OPERATIVE SURGERY;

WITH

An Atlas of neajrly Three Huxidred engravixigs,

BEPBESENTING

THE PRINCIPAL OPERATIVE PROCESSES, AND A GREAT NUMBER OF SURGICAL- INSTRUMENTS.

By ALF. a. L. M. VELPEAU.

Surgeon to the Hospital of la Pitie ; Fellow of the Faculty of Medicine of Paris;

Surgeon to the Dispensaries of the Philanthropic Society ; Professor of Midwifery, Anatomy, Pathologicu^l

and Operative Surgery ; Member of the Medical Society of Emulation of Paris ; Corresponding

Member of the Medical Societies of Tours, Louvian, &c. &c.

friTH AN APPENDIX OF NOTES,

By GRANVILLE SHARP PATTISON, M. D.

Professor of Anatomy in Jefferson Med. Col. Phila.

?!2^asi)ingtoit : PUBLISHED BY DUFF GREEN.

1835.

INDEX.

Preface. Introdtjctio^-. Elementary Operations. Chapter I. — Divisions Section I. — Cutting instruments Article 1. Manner of holding the bis- toury . _ - - § 1. First position. Bistoury held as

a knife, the edge downwards §2. Second position. Bistoury held

as a knife, the edge upwards §3. Third position. Bistoury held as a pen, the edge downwards, the point forwards §4. Fourth position. Bistoury held

as a pen, the point backwards § 5. Fifth position. Bistoury held

as a pen, the edge upwards § 6. Sixth position. Bistoury held as a drill-bow _ . .

Art. 2.-JHanner of holding the scis- sors - - - - Sect II. — Different kinds of incisions Art. 1. Simple Incisions

§ 1. Incision from without inwards § 2. Incision fr-om within outwards § 3. Upon a director § 4. With a fold of the integuments 4 5. Horizontally - - -

Art. 2. Compound incisions § 1. The V incision ^ 2, The oval incision § 3. The cross incision § 4. The T incision § 5. The elliptical incision § 6. The crescentic incision Art. 3. Incisions applied to abscesses, to collections of fluids § 1. Incision from within outwards 4 2. Incision from without inwards § 3. Complex incisions Art. 4. Incisions applied to the dis- section of tumors and of subcuta- neous cysts - . >

Page III

IX

1 1 1

1

2 o

13

§1. Form of the incision -

1. Straight incision

2. V incision . - -

3. Crucial incision

§ 2. Dissection of the Flaps

1. Concrete tumors

2. Cancers . . _

3. Cysts

Art 5. To cause the least possible pain - - - -

Sect. III. — Punctures

Chapter II. — Reunion

Art. 1. Suture ...

§ 1 . Interrupted suture § 2. The suture of Le Dran § 3. Furrier's suture § 4. Zigzag suture § 5. Twisted suture § 6. Quilled suture

CoKPLKX Operations.

Title I. — Operations upon the Blood- vessels J - . .

Chapter I. — Operation for aneurism in general - - - .

Sect. I. — Anatomical remarks

Sect. II. — Spontaneous cvu'e

Sect. III. — Curative methods

Art. 1. Method of Valsalva -

Art. 2. Refrigerants and styptics

Art. 3. Compression

§ 1. Mediate compression - § 2. Immediate compression

Art. 4. Cautery

Art. 5, Ligature - . .

§ 1. Nature and form of the ligature § 2. Permanent ligature - § 3. Precautionary ligatures § 4. Temporary ligature -

Operative processes - - -

§ 5. Two ligatures with immediate

division of the artery § 6. Ligature throiigli the artery - § 7. Mediate ligature § 8. Immediate ligature iii

'<.'-'

i:36Q>acr

IV

INDEX.

Page Art. 6. Methods of operation - 48 Relative value of the three princi- pal methods - - - 52 Art 7. Maiiual - - -55 § 1. Old method - - -55 §2. Method of Anel - - 56 §3. Results of the operation - 60 Art. 8, Of the suture - - 62 Art. 9. Torsion, Bruising - - 62 Art. 10. Acupuncture - - 63 Art. 10 {again). Changes occurring in vessels of a limb after the opera- tion for aneurism - - -65 Chapter II. — Operations for the parti- cular aneurisms - - 67 Sect. I. — Operations for diseases of the arteries of the inferior extre- mity - - - -67

A. Anterior tibial in the foot - 67 Art. 1. Anatomical remarks - 67 Art. 2. Surgical remarks - - 68 Art. 3. Manual - - - 68

B. Anterior tibial in the leg - 69 Art. 1. Anatomical remarks - 69 Art. 2. Surgical remarks - - 69 Art. 3. Manual . - - 70

C. Posterior tibial - - 71 Art. 1. Anatomical remarks - 71 Art. 2. Surgical remarks - - 72 Art. 3. Manual - - - 7o

D. Peroneal - - - 74

E. Popliteal - - -75 Art. 1. Anatomical remarks - 75 Art. 2. Surgical and historical re- marks - - - -75

Art 3. Manual - - - 78

Result of the operation - - 78

F. Femoral - - - 79 Art. 1. Anatomical remarks - 79 Art. 2. Surgical and historical re- marks - - - - 80

Art. 3. Manual - - - 83

§ 1. Inferior half - - - 83

§ 2. Superior half - - - 84

4 3. Results of the operation - 84

G. Ligature of the circumflexes or

of the profunda - - 85 H. External iliac - - - 85 Art. 1. Anatomical remarks - 85 Art. 2. Historical and surgical re- marks - - - - 86 Art. 3. Manual - - - 88 L Internal iliac - - - 91 Art. 1 . Anatomical remarks - 91 Art. 2. Surgical and historical re- marks - - - - 91 Art. 3. Manual - - - 92 K. Primitive iliac - - - 93 Art. 1. Anatomical remarks - 93 Art. 2. Surgical and historical re- marks - - - - 93

Art. 3. Manual ...

L. Abdominal aorta

Art. 1. Anatomical remarks

Art 2. Surgical and historical re- marks - . . .

Art. 3. Manual ...

Sect. II. — Arteries of the superior ex- tremity - . - ,

A. Arteries of the hand - Art. 1. Anatomical remarks Art. 2. Surgical remarks

Art. 3, Manual ...

B. Arteries of the fore-arm Art. 1. Anatomical remarks

Art. 2. Surgical and historical re- marks . - - . Art. 3. Manual ...

C. Artery of the elbow Art. 1. Anatomical remarks

Art. 2. Surgical and historical re- marks _ . _ _ Art. 3. Manual . . _

D. Brachial ... Art. 1. Anatomical remarks

Ai't. 2. Surgical and historical re- marks - - . - Art. 3. Manual - . -

E. Axillary - . _ Art. 1. Anatomical remarks

Art. 2. Surgical and historical re- marks - - . _ Art. 3. Manual ...

F. Subclavian . . , Art, 1. Anatomical remarks

Art. 2. Surgical remarks

Art. 3. Manual

Sect. III. — Arteries of the head

A. Temporal - - -

B. Facial - - - Sect IV. — Arteries of the neck

A. Primitive carotid Art. 1. Anatomical remarks

Art. 2. Surgical and historical re- marks . . - - Art. 3. Manual - - -

B. Internal and external carotids

C. Facial . - - -

D. Thyroids

E. Innominata _ - - Art. 1. Anatomical remarks

Art. 2. Surgical and liistorical re- marks _ . - - Art. 3. Modes of operation - Chap. III. — Naevi Materni, Erectile Tumors - - - - Chap. IV.— -Varix Title II. — Of Amputations Chap. I. — Amputations in general Sect. I. — Indications Art. 1. Gangrene - - - Art 2. Fractures - - -

Page 94 95 95

95 97

98 98 98 98 98 99 99

100 100 101 101

102 104 105 105

105 106 106 106

107 108 110 110 112 113 116 117 117 117 117 117

118 120 122 122 123 123 123

124 125

127 129 133 133 135 135 136

INDEX.

Art. 3. Luxations

Page 136

A. Flap method

.

203

Art. 4. Caries, Necrosis

137

B. Circular method

-

204

Art. 5. Cancerous affections

137

Art. 6. Arm

-

205

Art. 6. Aneurism

138

A. Circular method

-

206

Art. 7- Suppuration - - .

138

B. Flap method

-

20?

Art. 8. White swelling

139

Art. 7. The arm at the joint

-

Art. 9. Tetanus— Bite of a rabid ani-

§1. Manual -

-

208

mal - - - - .

139

A. Circular method -

-

208

Art. 10. Amputations of convenience

140

B. Flap method

-

209

Art. 11. Gunshot-wounds

141

C. Oval method

-

213

Sect. II. — Preliminary attentions

143

§2. Comparisonof the methods -

214

Art. 1. Counter-indications

143

Art, 8. The shoulder — ^Jiistory and

Art. 2. Time for the operation

144

indication

-

215

Art. 3. Point of amputation

147

Manual

-

215

Art. 4. Preparatives - - -

147

Sect. II. — The inferior extremity

215

Sect. Ill, — Methods of operation

150

Art. 1. Toes

215

A. Amputations in continuity

150

Art. 2. Metatarsus

216

Art. 1. Circular method

150

§ 1. In the continuity

216

§ 1, Manual - - - -

150

A. First metatai-sal bone

216

§2. Dressing - - - -

162

B. Second metatarsal bone

217

§ 3. Consecutive treatment

167

C. Extraction

218

§ 4. Accidents - - -

169

D. Collectively

218

Art. 2. Flap method -

175

§ 2. Disarticulation -

218

Art. 3. Oval method

176

Manual

219

B. Amputation in the contiguity

177

Art. 3. Amputation of a part

of the

Chap. II.— Amputations in particular

179

tarsus

-

224

Sect. 1.— The upper extremity

179

Art. 4. Comparison of the two par-

Art. 1. The fingers

180

tial amputations of the foot

-

227

§ 1. Partial amputation

181

Art. 5. Extraction of a part

of the

Manual . . . -

181

tarsus

-

227

Dressing and after treatment

183

Art 6. The whole foot

.

227

§ 2, Amputation of the whole finger

183

Art. 7. Amputation of the leg

-

228

Manual - - - -

184

Manual

-

230

§ 3. Amputation of the fingers col-

1. Process of Sabatier

-

233

lectively - - - -

186

2. « of Dr. Physic

.

233

Art. 2. Metacarpus - - -

387

3. " ofBaudenorB.

Bell .

233

§ 1. In the continuity

187

Dressing

-

233

Amputation of the metacarpus in

Flap operation

-

234

a body - - - -

188

1 . Process of Verduin

-

234

Amputation of a single bone

188

2. " of Hey -

-

234

§ 2. In the contiguity

189

3. " of Ravaton

.

234

A. Metacarpal of the thumb — Am-

4. " of y ermale

-

235

putation - - - -

189

5. " ofDupuytren

-

235

Extraction

191

6. « ofRoux -

.

235

B. Fifth metacarpal — Amputation

192

7. « of the Author

-

235

Extraction - ^ -

192

In the articulation -

-

236

C. Middle metacarpal — Amputa-

[Manual

-

239

tion - - - - -

193

1. Process of Hoin

239

Extraction - - -

194

2. « ofLeveille

239

E. Disarticulation of several or of

3. « ofBlandin

239

all the metacarpal bones collec-

4. « of Smith

240

tively - - - -

194

5. « of Rossi

240

1. Anatomical remarks

194

Dressing

240

2. Manual - - - .

195

Art. 9. The thigh

241

Art. 3. The wrist

196

§ 1. In the continuity

241

A. Circular method

197

Anatomical remarks

241

B. Flap method

198

Manual -

242

Art. 4. The forearm -

199

Circular method

242

A. Circidar method -

200

Position of assistants

242

B. Flap method - w -

201

Flap operation -

243

Art. 5. The elbow

203

1. Process of Vermale

244

INDEX.

2. Process of Langcnbeck

In the contig-aity

History and value

Anatomical I'cmarks § 1. Manual — Circular method

Eng"lish process -

Flap operation -

1. Process of Labonette -

2. « of Blandate

3. "of Manee

4. « of Ashmead

5. « of Delpech

6. " of M. Larry

7. " of Blandin

8. « of Lisfranc

9. " of Dupuytren -

10. «« of Beclard

11. « of Guthrie C. Oval operation

1. Process of M. Cornuar -

2. « ofLecoIletan -

§ 2. Relative value of various me- tliods . . - .

Title III. — Excision of the Bones Chapter I. — In the continuity

1. Recent fractures

2. Wounds from fire-arms -

3. Old non-consolidated fractures Method of operating Org-anic lesions -

\rt. 1. The ribs

Operation Art. 2. The sternum Art. 3. Lower inferior jaw

History and value

Operation

After operation - Art. 4. Superior maxillary bone ('hapt. II. — Excision of the joints Sect. I. — Thoracic members Art. 1. The hand -

Operation Art. 2. The wrist -

1. Operation. First method

2. M. Dubled's method -

3. Moreau and Roux's method Art. 3. The elbow -

1. Operation. Park's method

2. Moreau's method

3. Dupuytren's method

4. Author's method Art. 4. Radius

Art. 5. The shoulder

Operation. (1st White's) method 2. Moreau's methods Mancas's "

Sabatier's Bent's Morel's Lyme's Remarks

Page

244 245 245 247 248 248 248 249 249 249 249 250 250 250 251 251 251 251 251 252 252

252 254 254 254 255 255 255 256 257 257 257 258 258 259 262 262 265 267 267 267 267 267 268 268 269 269 269 269 270 271 272 272 273 273 273 273 273 273 273

Art. 6. The clavicle - - - 275

1. Acromial extremity - - 275 Extirpation - - - 276

Sect. II. — Abdominal members - 277

Art. 1. Tibio-torsal articulation - 278

Operation. 1. Moreau's method - 278

2. Roux's method - - - 278 Value - - . - 278

Art. 2. Knee - - - 279

Operation. 1. Park's method - 279

2. Moreau's method - - 279

3. MM. Sanson and Begin's method 280

4. Lyme's method - - 280 Remarks - . . 280

Art. 3. Head of the femur - - 281 Artificial articulation - - 281 Title IV. — Trepanning - - 282 Chapt. L — The cranium - - 282 Parts that admit of it - - 284 Apparatus, operation, and 1st step 285 2d step - - - - 286 3d step and remarks - - 287 Dressing - - - 288 Chapt. II. — Thorax, pelvis, and extre- mities - - - . 290 Scapula, spine, and long bones - 292 Special Operations - - . 293 Operations on the head - - 293 Chapt. I. — The cranium - - 293 Method of operating - - 293 Osseous tumors .. - . 294 Encephalocele ... 294 Lupia .... 294 Operation - - - 294 Hydrocephalus - - - 295 Chapt. II.— The face - - 295 Sect. II. — The nose - - . 295 Taleacotian operation - - 295

1. Tagliacozzi's method - - 297 h. M. GrsePs « - - 297

2. Indian - - 298 a. By means of cutaneous flap

from the rump - - 298

h. By transplantation - - 298

c. With the skin of the forehead- 299

3. French method - . 300 Relative value - - - 300

Art. 2. Other operations on the nose 301

Excision of tumors - - . 391

New operations ... 302

Occlusion of nosti'ils - - 302

Rhinoraphia - - - 302

Appabatus of Vision - - 303

Art. 1. Lachrymal passages - - 303

§ 1. Anatomical remarks - - 303

§ 2. Obstruction, tumor - - 304

Anel's method - - - 305

Injections - - - 305

Catheterism - - - 305

Laforest's method - - 305

§ 3. Fistula - - - 306

INDEX.

Vll

Page

Page

Dilatation of the natural passages

307

Orbital cavity

.

.

329

Mej can's method

-

-

307

Art. 4. Globe of the eye

-

-

331

Pallucce's «

-

-

307

§ 1. Foreign bodies

-

-

331

Caboni's *'

.

308

§ 2. Pterygium

-

-

331

Guerin's «

.

.

308

§ 3. Cataract

-

.

332

Care's «

-

-

308

1. History

-

-

332

Dilatation through an

'iccidental

2. Conditions

-

-

332

opening

-

-

309

3. Ages -

-

-

334

Monro's method -

.

-

309

4. Simple or double

-

-

334

Ponteau's «*

.

-

309

5. Preparations

-

-

336

Lecat's «

.

.

309

6. Seasons

-

_

336

Desault's «

-

-

310

Methods of operating

-

-

337

B oyer's modification

-

-

310

Depression

-

-

337

Pamard's method

-

-

310

1. Preliminary attentions

-

•

337

Jurine's "

-

-

310

Apparatus — Instruments

-

337

Foumier's "

-

-

311

2. Operation

-

-

338

Jourdan's "

.

.

311

Ordinary method

.

.

338

Scarpa's «

-

.

311

Process of Petit and Ferrein

.

341

Ware's «

.

-

312

« the author's

.

-

342

Permanent canula

-

-

312

Hyalonyxis

-

-

342

Cautery -

-

.

314

Scleroticotomy -

-

-

34:^

Superior operation

-

-

315

Retroversion or reclinat

ion

-

343

Process of Harveng

-

-

315

Cutting or breaking up

3f the lens

343

Process of Deslande

.

_

315

The lens passed to the anterior

Inferior operation -

.

.

315

chamber

.

.

344

Process of Bermond

-

-

315

Ceratonyxis

.

.

344.

Process of Gensoul

-

-

315

Simple puncture of the

cornea

.

346

FonMATION OF A NEW CANAL

.

.

316

In children

-

.

346

Process of Woolhouse

-

-

317

Consecutive treatment

-

_

347

« of St. Yves

-

»

317

Extraction

-

.

348

« of Dionis

-

-

317

Operation

-

-

349

« of Monro

-

-

317

1. Scleroticotomy

-

-

350

« of Hunter

-

..

317

2, Ceratotomy

_

-

350

« of Scarpa

-

-

318

Inferior keratotomy

-

-

351

« of Nicod

-

-

318

First second and third step

_

352

« of Picot

.

_

318

Process of Guerin and Dumont

_

357

Art. 2. Eyelids

-

-

320

Superior keratotomy

-

-

357

§ 1. Ectropion

-

.

320

Dressing

-

-

358

Process of Antylus

-

-

321

Comparative examination of the

« of Walther

.

.

322

two methods

.

.

359

« of Key

-

-

322

§ 4. Artificial pupil

-

_

363

Blepharoplastic operation

.

322

Methods of operating

-

_

363

§ 2. Trichiasis, Entropion

and Ble-

1. Coretomia or the method by

n-

pharoptosis

-

-

323

cision

.

.

364

Excision

- ■

-

323

Process of Cheselden

_

.

364

Extraction and cauterization

of

« of Sharp

_

_

364

the cilia

.

.

323

« of Odhelius

.

_

364

Eversion of eyehds

.

-

324

« ofjanin

.

.

364

Excision of the edge of the palpe-

" of Guerin

_

_

365

bral - .

-

.

325

" of Maunoir

.

_

365

Crampton's method

-

-

325

" of Adams

.

_

366

Guthrie's «

-

.

325

" of Author

_

.

366

Saunder's «

.

.

325

2. Coredialysis

.

.

367

Vacca-Berlinghieri's method

.

325

Process of Scarpa

.

_

367

§ 3. Tumors

.

.

326

" of Couleon

-

-

367

First process

.

-

326

" of Assalini

-

.

367

Second process

.

-

327

" of Langenbeck

.

S67

Modified cauterization

-

.

327

" of Reisinger

,

-

367

Cancerous tumors

.

_

327

" of Lusardi

.

_

368

4 4. Anchyloblepharon and symble-

" of Donegana

-

-

368

pharon

-

-

328

3. Corectomia

-

-

369

Vlll

INDEX.

Tage

Process of Demours

. 369

Process of Couleon and Gibson

. 369

"* of Beer

• 369

«* ofWalther

369

" of Dr. Physic

370

Relative value of the various me-

thods . - . -

370

§ 5. Puncture — ^incision

372

1. Onyx - . - -

372

2. Hydrophthalmia

372

Operation . . .

373

3. Hypopyon - - .

374

4. Empyesis . - .

374

§ 6. Recision

575

Operation _ - .

375

§ 7. Extirpation -

376

Operation. 1. Process of Bartisch

377

2. Process of F.deHilden

377

3. « ofHeistei- -

378

4. " of Louis

378

First stage

378

Second stage

378

. Third stage and dressing

379

Remarks

380

Artificial eyes

380

Sect. III.— Mouth

381

Art. 1. The lips

381

§ 1. Harelip

381

Cheiloraphy

382

A. Simple harelip

382

a. History ...

382

b. Operative process

385

c. Remarks - . .

387

B. Complicated hai-elip

390

C. Age proper for the operation

391

§2. Excision of the lip

393

4 3: Eversion. Mucous enlarge-

ments - . - .

394

§ 4. Hypertrophy

395

§ 5. Chciloplasm -

396

Manual - - - .

396

1. Ancient process

396

2. Process of Chopart

397

3. « of M. Roux of St. Max-

imin ....

397

4. Process of Professor Roux

398

5. M. Lisfranc's modification

399

§ 6. Genoplasm

400

1. Indian method -

400

2. French «...

401

a. Process of M. Roux, of St.

Maximin ...

401

b. Process of M. Gensoul

401

c. " of Professor Roux

401

§ 7. Abnormal coarctation

402

Art. 2. Salivary apparatus -

404

§ 1. Fistulae

404

A. Of the parotid gland or its ex-

cretory ducts

404

B. Of the duct of steno

405

C. Of the submaxillary gland

409

Page

§ 2. Ranula or frog^s tongue . 410

§ 3. Salivary tumors foreign to the

excretory canal . . 413

Art. 3. The tongue - - - 414

§ 1. Filet - . - 414

§ 2, Aiichyloglossis - - 416

§ 3. Excision ... 417

Art. 4. Isthmus of tlie fauces . 420

§ 1. Excision of the whole or a part

of the tonsils ... 420 § 2. Abscess — Incision of the tonsils 425 §3. Excision of the Uvula - 425

§4. Staphyloraphy - - 427

A. History - . - 428

B. Manual . . - 431

C. Modifications - - - 433 Sect. IV. — Olfactory apparatus - 434 Art. 1. Nasal fossa - - . 434

§ 1. Hemorrhage — plugging . 434

§ 2. Polypi . - - 435

a. First process of Levret - 441

b. Second « « - 441

c. Brasdor's process - - 441

d. Desault's « - 442

e. Process of M. Boyer - 443 /. « of M.Dubois - 443 g. « of M. Rigaud - 443 h. " of M. Felix Hatin - 444

Art. 2. Maxillary sinus - - 445

§ 1. Perforation - - - 445

§ 2. Foreign bodies — polypi - 448

§3. Frontal sinus — perforation - 450

Sect, v.— The face - - 450

Art. 1. Osseous cysts - - 450

Art. 2. Section of the facial nerves - 451

Sect. Vl. — Auditory apparatus - 455

Art. 1. External ear - - 455

§ 1. Otoraphy - - - 455

§ 2. Otoplasmus - - - 455

§ 3. Perforation. Dilation of the

auditory canal ... 456

§ 4. Foreign bodies - - 457

§ 5. Polypi - - - 459

Art. 2. Internal ear - - - 461

§ L Perforation of the membrana

tympani ... 461

§ 2. Perforation of the mastoid cells 462

§ 3. Catheterism of the Eustacliian

tube .... 464

Title IL— Operations on the Trunk - 467

Chap. I.— The neck - - 467

Sect. I. — Lateral and superior regions 467

Art. 1. Parotid gland - - 467

Art. 2. Submaxillary gland - - 473

Sect. II. — Anterior region - - 474

Art. 1. Thyroid body - - 474

Art. 2. Air passages - - 479

§ 1. Bronchotomy - - 479

A. Surgical and anatomical remarks 484

1. Tracheotomy - - - 489

2. Thyroid laryngotomy - - 490

INDEX.

IX

Page

3. Laryngo tracheotomy - - 490

4. Thyro-hyoid laryng-otomy - 490 § 2. Bronchoplasmus - - 491 §3. Catheterism - - - 491

Art. 3. Alimentary passages - 491

§ 1. Catheterism - - - 491

§ 2. Foreign bodies - - 494

Chap. II.— The chest - - 499

Sect. I.— Tumors - - - 499

Art. 1. Extirpation of the mamma - 499 Art. 2. Extirpation of tumors in the

axilla - - - - 505 Sect. I[.— Effusions - - 506 Art. 1. Empliysema - - 506 Art. 2. Wound of the intercostal ar- tery - - - - 513 Art. 3. Paracentesis of the pericardium 515 Chap. III.—Abdomen - - 518 Sect. I. — Effusions and cysts - 518 Art. 1. Paracentesis - - 518 Art 2. Humoral tumors of the liver 526 Art. 3. Cysts and tumors in the inte- rior of the abdomen - - 527 Sect. II.— Hernia - - - 530 A. Hernias in general - - 530 Art. 1. Radical cure - - 530 § 1. Topical applications, compres- sion, position - - - 530 ^ 2. Various operations - - 531 § 3. Possibility of obtaining a per- manent cure, and whether it ought to be attempted - - 536 § 4. Inguinal hernia - . 538 Art. 2. Strangulated hernia - 539 § 1. Anatomical remarks - *541

a. Sac - - - - 541

b. Aponeuroses - - 544

c. Herniary openings - - 544 §2. Seat of strangulation - 545

Internal Strangulation - - 549

§ 3. Indications . - - 550

§ 4. Herniotomy or celotomy - 561

A. Enterocele - - - 561

B. Epiplocele - - -575

C. Dressings . - - 579

D. Treatment - - - 581 § 5. Gastrotomy - - - 583 § 6. Hernia with gangrene - 585 § 7. Enteroraphy - - 588

Suture on a foreign body - 589 Suture witli invagination - 591 Raybard's process - - 591 Suture with contact of serous sur- faces - - - 592 Process of M. Jobert - - 592 '* of M. Denaus - - 592 « of M. Lembert - - 593 Ulceration - _ . 594 § 8. Preternatural anus - . 596

A. Suture - - - 596

B. Compression - - - 597

B

Page

C. Enterotomy or the process of M.

Dupuytren - - _ 595

Sect. II. — Particular hernias - 603

Art. 1 . Inguinal hernia - - 603

§ 1. Anatomical remarks - 603

§ 2. Surgical remarks - - 607

Infantile hernia - - 609

§ 3. Composition - - 611

§ 4. Operation - - 613

Art. 2. Crural hernia - - 618

§ 1. Anatomical remarks - 618

§ 2. Operation - - 622

Art. 3. Umbilical hernia - - 626

§ 1. Anatomical remarks - 626

§ 2. Operation - - 628

Art. 4. Ventral hernias - - 631

Chap. IV. — The sexual organs - 633

Sect. I. — The sexual organs of fie

male - - . - 633

Art. 1. Scrotum - - - 633

§ 1. Anatomical remarks - 633

§ 2. Hydrocele - - 635

Operation - - . 636

§ 3. Ectomia scroti - - 648

§ 4. Castration - - - 651

Method of Maunoir - - 652

« ofZeller - - 657

Art. 2. Copulative organ - - 659

§ 1. Phymosis - - 659

§ 2. Paraphymosis - - 662

§ 3. Strangulation of the penis - 664

i 4. Sectio freni - - 664

§ 5. Adhesions of the prepuce to

the glans _ , - 665

§ 6. Destruction of the prepuce 665

§ 7. Amputation of the penis - 666 Sect. II. — The sexual organs of the

female - - _ 669

Art. 1. Imperforation of the vulva - 669

Art. 2. Puncture of the uterus - 671

Art. 3. Inverslo uteri vaginse - 673 Art. 4. Reduction of the uteinis and

vagina - - - 673

Art. 5. Pessaries - - 674

Art. 6. Foreign bodies - - 678

Art. 7. Foreign bodies in the uterus 679

Art. 8. Uterine polypi - - 680

1. Tearing out - - - 682

2. Ligature - . . 683 Method of operation - - 683 Remarks - - - 685

3. Excision - . . 686 Method of operation - - 687

Art. 9. Cancer of the cervix uteri - 690

Anatomical remarks .- - 692

Amputation - . - 693

Method of operation - - 695

Art. 10. Extirpation of the matrix - 697

1. The uterus displaced - 699 The method of operation - 700

2. The uterus not displaced - 701

INDEX.

Art. 11. Veslco-va^nal fistula

1. Sutures

Method of operation

" of M. Lewziski Catheters, crotchet forceps, &c. Method of M. Dupuytren

" ofLaugier

2. Caxiterization

Art. 12. Recto-vaginal fistula

Suture -

Art. 13. Dystokia — difficult delivery Symi)hyseotomy Method of operation Uterotomia abdominalis. Caesa- rian operation Metliod of operation Art. 14. Vag-inal uterotomy Chap. V. — The urinary apparatus - Sect. I. — The operation of cutting for stone - . . -

A. Stone in man

Diajrnosis . _ -

So'Mding

Ind -ations . - .

Art. 1. Stone by the perineum (the appar.M is minor) §1. A latomipal remarks 4 2. M thods of operation

1. Th ; lateral method (cystotomy pro] r) ... o. 1 rocedure of Antyllus and P.

^.^inetus ...

b. F rocedure of Brother Jacques

c. " of Raw

d. " ofCheselden c. " of Foubert /. « of Thomas

2. Median cutting. Apparatus ma- jor - - - - a. r rocedure of Mariano

h. " of Vacca Berling-

hicri - _ .

3. Oblifjue, or lateralized cutting a. V ; ')cedure of Franco or d'Hu-

nai It h. Procedure of Garengeot

c. " ofCheselden

d. " ofBoudou c. ** ofLeDran / « ofLecat

f«« ofMoreau

« of F. Come

i. '* ofGuerin

j. « of Hawkins

k. ** of Thomson

/. ** of M. Boycr

4. Transversal, bi-lateral or bi- oblique cutting

a. Procedure of Chaussier

b. « ofBeclard

c. " of Dupuytren

Page 707 707 708 710 710 711 711 712 715 716 718 718 719

722 727 729 731

731 731 732 732

737

738 738 743

744

744 745 746 746 746 747

747 748

749 750

750 751 751 752 752 752 753 753 754 756 757 758

759 760 761 761

d. Procedure of Senn 5. Quadri-lateral cutting § 3. Recapitulation of the methods of

operation in the different species

of perineal cutting

Apparatus

Staff

Forceps ...

Position of patient and assistants

Introduction and placing of the staff

Cutting at two distinct intervals Art. 2. Recto-vesical cutting (poste- rior or inferior) § 1. Anatomical remarks § 2. Method of operation Art. 3. Hypogastric cutting § 1. Anatomical remarks § 2. Examination of methods 1. Method of Rousset

of Douglas

of Cheselden

of Morand

of Le Dran, Winslow

of Baud ens

of Tanchou ^ of Verniere

2." « of Franco 3. « of Brother Come

§ 3. Method of operation

B. Cutting for stone in the female Art. 1. Anatomical remarks

Art. 2. Examination of the methods § 1. Old procedures

a. Lateralized method or lateral cutting

b. Method of Celsus and Lisfranc

c. Vesico-vaginal cutting Method of operation

§ 2. Urethral methods

a. Method by dilatation

b. Urethrotomy Art. 3. Estimate

C. Relative value of the different ways of cutting for stone in the

male . _ ,

D. Nephrotomy

E. Stones stopped outside of the bladder . _ .

1. Stones in tlie ureter

2. " in the thickness of the vaginal septum

3. Stones in the pro.state

4. " in the Urethra

5. " between the glands and prepuce ...

Sect. II.— Lithotrity Art. 1. Historical

Art. 2. Examination of the methods § 1. Rectilinear method a. Perforation

INDEX.

XI

b. Excavation

c. Concentric friction

d. Crushing'

e. Of the four ways of producing trituration

§ 2. Curvilinear method § 3. Accessory apparatus

a. Position of the patient

b. Injections

c. Introduction of forceps

d. Finding the stone

e. Open the forceps

/. Find and seize the stone again

g. Apply the drill-bow

Art. 5. Remarks on some points in the

operation, and accidents in lithotrity

Art. 6. A comparison of cutting for

stone and lithotrity Sect III.— The urethra Art. 1. Catheterism

§1. Anatomical remarks § 2. Examination of methods and instruments

Position of the surgeon and patient Difficulties in the operation Flexible catheters The master-turn Catheterism in the female Art. 2. Stricture

§ 1. Forced catheterism

§ 2. Injections

§ 3. Incisions and scarifications of

the part strictured § 4. Concentric or external incisions

Page

Page

825

§5. Dilation -

859

825

§ 6. Cauterization

864

826

i 7. Abnormal dilation of the ure-

thra

870

827

Sect. IV.— Puncturing the bladder

871

828

Art. 1. Perineal puncture

871

830

Art. 2. Puncture through the rectum

872

831

Art. 3. Puncture above the pubis -

874

831

Art. 4. Mutual advantages and incon-

832

veniences of the species of puncture

875

832

Sect, v.— Fistulx urinaria^

877

832

Chap. VI. — Defecator organ

880

832

Sect. I. — Vices of structure

880

833

Art. 1. Imperforation

§ 1. Re-establishment of a natural

880

835

anus _ - .

881

§ 2. Establishment

883

839

Art. 2. Stricture

885

842

§1. Dilation

885

842

§ 2. Incision

887

842

§ 3. Cauterization

887

Sect. 2. Acquired lesions

887

845

Art. 1. Foreign bodies in the anus

887

846

Art. 2. Polypi

889

847

Art, 3. Hemorrhoidal tumors

889

849

Art 4. Prolapsus

891

851

Art. 5. Fissures

895

852

Art. 6. Fistula

896

853

§ 1. Anatomical remarks

897

853

§ 2. Examination of methods

900

855

A. Ligature

900

B. Operation, properly so called

901

856

Art. 7. Cancers

909

858

Metliod of operation

910

PREFACE.

In introducing a new treatise on operative surgery, my object is to meet a want long felt by those engaged in the practice of that branch of medical science. The work announced in 1813, by M. Roux, has not been completed. The additions of MM. Sanson and Begin, to the inimitable work of Sabatier,, cannot, notwithstanding their importance, supply the place of a book of this character. The diagnostic and symptomatological details of almost every disease requiring surgical aid, in which the author has indulged, have enlarged his work, by encroaching on pathology to the injury of operative surgery. The only object of M. Richerand, in publishing his nosographie, was to pre- sent concise views of surgical science. M. Boyer, in confining his descrip- tions to his own views of practice, has omitted many methods which should be presented to the public. Besides, his work is not a special treatise on the subject, and the eleven volumes which compose it, do not afford the student a text book in the schools. A number of neglected operations, and others in- vented since the time of Sabatier, and already known to the learned world, have not yet found a place in our classic works. Rhinoplasm, chieloplasm, blapharoplasm, otoplasm, bronchoplasm, staphyloraphy, torsion, puncture of the arteries, lithotrity, cauterization of the urethra, amputation of the womb, extirpation of the ovaria and of the anus, are among these operations. Indeed, a review of the whole subject of operative surgery had become necessary from the progress it has made and the changes it has undergone during the last thirty years. My pursuits for the last ten years led me to the investigation of the subject, and convinced me of the deficiency alluded to ; and I should have attempted to remove the evil sooner, but I feared the task was beyond my abilities. At first I conceived the idea of furnishing a simple manual ; but I soon perceived that this course would increase the evil tendency of our young students, to content themselves with every possible abridgment. The re- searches which the undertaking required, have convinced me, under existing circumstances, that in order to be useful to the faculty and the world, a trea- tise must be full and complete, and not a mere manual.

Several volumes had been written when the journals announced the forthcom- ing work of M. Lisfranc. I then thought of arresting my labors ; being pursuad- ed that from long experience in the dissecting room, and hospitals, this emi-

xiii

XIV PREFACE.

nent surgeon would accomplish all that was wanting. Five or six years have now passed away, and he has not fulfilled the expectations of an impatient public. Feaiing that his numerous occupations would long deprive us of his able and interesting researches, I have determined to prosecute my original design. Another motive also induced me to postpone this work. Depending solely on the experience of the anatomical colleges, my opinions then could have been but of little value. Operations on the dead body could not be adopted, until they had passed the ordeal of the hospitals. My situation at that time, did not entitle me to the privilege of invoking my personal expe- rience. But a practice of four years in the hospital of " perfectionnement," two years superintendence of the hospital of St, Anthony ; and the direction of La Pitie since 1830, have enabled me to apply for the benetit of the living, the experience acquired from frequent operations on the dead. I hope I may be permitted to express an opinion on the propriety, either relative or absolute, of the different methods of operating, which ought to be examined in a work of this kind. Having witnessed the public practice of our great masters till within a few years, there are few operations which I have not seen performed. I have thus been enabled to compare the relative advantage of many of them, and to judge understandingly on the reasons which they advanced in support of the process they pursued, or against those measures which they condemned. Writing for the sole interest of truth and science, I have examined the labors of all without distinction of country, of school or of person ; reserving the privilege of weighing their merits impartially, of drawing those deduc- tions which naturally flowed from them, and in fine, of pointing out whatever seemed to me either useful or injurious. Under this point of view, the pre- sent epoch presents difficulties which can only be felt by those who wish to produce an impartial history. Cotemporaries are rarely just to each other. Animosity is too often transferred from the individual to the institution which he may direct. Instead of being published by their authors, the improvements and inventions, due for the most part to the great practitioners occupying the domain of science, are only known by tradition, or by the efforts of candidates impelled to defend the pretensions of their chief; it is indispensable in making a conscientious critique, to investigate carefully true sources of information. No work having yet been executed in this spirit — the surgical history of the nineteenth century being yet in embryo — I have found it necessary to consult a multitude of periodicals, private memoirs, and monographs of every de- scription. A work of such great extent, in which all, should in some degree assume the character of mathematical demonstration — treating of dates, of inventions, of proceedings which gave origin to much discussion, of numerous controversies of which the end and object of all have been presented in so many different lights, interpreted in such a variety of versions, requires an attention, a care, a literary labor, and an extent of research of which it is difficult to form an idea without making the experiment. In executing this work, I have derived great assistance from the General Archives of Medi- cine, from the Universal Bulletin of Medical Sciences, and from the Medical Gazette of Paris, which laterally has permitted nothing of interest to escape the attention of its readers. The pages of the Lancet have sometimes afforded me supplies. I can say the same of the Review, of the Medical Transactions, of the Universal weekly Journal of Medicine, besides

PREFACE. Xt

every Journal, whether French or foreign, have been put in requisition. La Bibliotheque Chirurgicale of Languenbeck, the Journal of Graefe and Walthen, the Manual of M. Chelius, and the Treatise of Zang, have been very- useful to me as regards the state of science in Germany ; and for the same object, I have consulted the Medico-Chirurgical Review, the London Medi- cal and Surgical Journal and the Lancet in England, where the classic works are generally so inferior. In Philadelphia, the IMorth American Journal of Sciences, &c., the Quarterly Journal &c., Dorsey's Abridgment, Sterlings Appendix to my Treatise on Anatomy, are the sources I have had recourse to in the United States. From the Annales Universelles of Milan, by M. Omodei, and the Journal of M. Strambio, alone, I have been able to gather information in relation to the medical affairs of Italy. The collections of Thesis at Paris, Montpelier, and Strasburg, although too generally neglected, have afforded me much valuable information. They contain a crowd of suggestions, of propositions to which no attention was paid, of methods which have since been advanced by different authors, and appropriated as original, because the real author had retired and become forgotten in some distant province, where he had not the means of reclaiming the honor of his discovery. In fine, that nothing essential should be omitted, I have often addressed medical men themselves, particularly those whose researches had not been published, or those which had been written out by a third person. Thus, in order to be in- formed about certain operations of M. Dupuytren, I have inquired of M. Mark, his private student. By this means I learned that the disc-very of the lachrymal duct originated in 1810, with the professor of the Ho^«l-Dieu, operating on an invalid who had been afflicted for many years ; that he had removed the inferior maxillary bone twenty times, and that the buperior maxillary had been removed by him in 1813 ; that his process for am utating at the shoulder joint dates in 1802; that he has tied the carotid four times successfully since 1814; that it was in 1805, and not in 1810, he arplied a ligature to the femoral artery for a fracture of the leg; that his first operation for stone was {hypogastrique) at the Hotel-Dieu ; and that he had atiempted lithotrity eight times.

It is unnecessary to mention here the aid derived from MM. Rou c, Rich- erand, J. Cloquet, &c. having recorded it in the body of the work. The same may be said of MM. Lauth of Strasburg, Ashmead of Philadelphia. Deleau, G. Pelletan, Berard, Blandin, Pravaz, Leroy, Maingault, and many p -vincial surgeons, to whom I am equally indebted. I learned also, from M. . louline of Bordeaux, the success attributed to refrigeration in the treatment ;f aneu- rism ; and nothing is more certain, than that all, or nearly all, the success was due to the concurrent means not mentioned in the report. I would have asked similar aid from M. Lisfranc, my colleague in the hospital la Pitie, but knowing it was his intention to publish his own course of operative surgery, I thought it would seem indiscreet, or that the request wt>uld be disagreeable to him. Though very desirous of profiting by his labor- I have concluded to derive my information from publications in the per )dicals, either in his own name, or in that of his students ; in the Thesis sus<:r led for fifteen years by the faculty, and in the Manual of M. Coster. In ord r not to mutilate his ideas, I have used them with great reserve, hoping hereafter to be able to present them in his own language.

XVI PREFACE.

In relation to the doctrine which is foreign to modern practice, I have anxiou :ly endeavored to trace it to its source ; and this investigation has shown me ho\ Sabatier himself and particularly Mr. Cooper have been so often led into err ;)r, in giving the ideas of those authors whom they had consulted. Where I couh; not attain my object from the scarcity of the works, or the foreign langua e in which they were printed, I had recourse to the authority of Spring e confirmed by Le Clerc, Freind, Dajardin, or of Peyrilhe, and what is still more valuable, that of M. Deizeimeris, who, besides, on many occasions, procun il me facilities and information which I could not obtain elsewhere, and am >ng these I ought to mention the Historical Dictionary, with the praise, too, wi'ch a book concientiously written justly merits.

I have scarcely mentioned a fractional part of the titles of the books and entire .y omitted the papers I have consulted. It seems to me that the opposite course, the advantages of which I would be the first to acknowledge, would liave, i'l compiling a dogmatical treatise, a sufficient portion of inconveniences. In the first place it would cramp the style ; 2, multiply its pages to an iuordiiite degree; 3, burden the memory; and 4, encourage that imitative learnin ;, which is now unfortunately too extensive in the French schools. In abs ining from quoting the names of authors, I would have fallen into an unf rtunate extreme, though most of our elementary books are composed in this , 'ay. It is true the author finds the advantage of permitting the un- learne(. to remain ignorant of the authorship of what he relates, and igno- rance « ^ historical research will prevent detection ; but it seems to me nothing can be more injurious to the true interests of science. Students seeing no name i the text, attribute to the author in hand ideas that have been pro- mulga (I for ages, or recorded by twenty different writers ; and thus become unjust A^ithout being aware of the fact. Hence that credulity so skillfully worke. upon for years, and more so than ever, at present, by the inventors of new m 'thods : hence that academic mystification and that mode of fabricating discov ries by numerous practitioners who are as liable to be mistaken astheir pupils In attaching to each subject t discuss the principal authority connected with it 1 acquit myself of blame by rendering rigorous justice. I have thought that n y opinion would thus acquire an irresistible influence, and ultimately that I should find my advantage in telling my readers in a single word, wheth r the inventions they were examining were of a recent date, or had been 1 )ng known to others. To those who reproach me with leaving it impos.- ble to verify my quotations with precision, I would say, that in re- cordin ^ the opinions of others, I have, in general, given them as I compre- hende 1 them, without rendering others accountable for my interpretration. Belie\ ng that I am addressing myself to students, I wish to let them under- stand • hat there is such a thing as history, and to impress upon them a taste for sci intific literature.

The compilation of this work is another point which requires some explana- tions.

In performing surgical operations the importance of anatomical knowledge has never been questioned ; nevertheless as it was impossible to embrace all collate ral knowledge in a work on operative surgery, I have confined myself to that which is indispensable, and have chosen a form which seemed best adapted to an abridgment. Hence it is neither on the anatomy of the regions nor no surgical anatomy, so called, that I have written, I have simply re-

PREFACE. XVii

counted in each operation, the points which were absolutely necessary — those not essential I have passed unnoticed.

Sabatier, in other respects so perfect, who demonstrated science with such clearness and precision, was, nevertheless, defective from his poverty in de- scriptive details ; and can neither satisfy those who confine their studies to the closet, nor those who practice in the anatomical schools. I have endeavored to avoid this evil without loosing sight of the opposite inconvenience; well aware how fatiguing from their dryness, and perplexing from their multipli- city, are these interminable details which we find in many of the recent publications. In fine, to satisfy all on this point, I have given to each case, as far as the limits of the work would permit, the particulars, both practical and mechanical, under the head of manuel operation^ absolutely useful in performing an operation either on the living or the dead. The history, exami- nation, discussion, appreciation of method, accidents, consequences and in- dications, forming the subjects of so many distinct heads, will be a great advantage to those who do not wish to read the whole article. I have used these divisions only in complicated operations ; omitting them where the sub- ject can be conveniently described in a few pages, unwilling either to treat solely of the operative process, or to write a book on surgical pathology ; like Sabatier, I have confined myself to the discussion of the indications, omitting, without special necessity, whatever relates to the pathology, signs or general treatment of disease. The comparison of methods, and of the results which tjiey have furnished, form another question hitherto too much neglected but of such unquestionable utility as to demand all possible attention.

If, in the course of my historical research, I have commented on operative processes long since forgotten or justly proscribed ; if I have recorded a crowd of recent inventions of no intrinsic merit, and useless to the cause of science 5 it is because, on the one hand, there is no process so singular but it may again be revived by some new inventor, and, on the other, it is necessary to lay before the student not only what he should adopt, but also what he should reject in relation to the cotemporaneous history of data and opinions which he will daily hear unjustly praised or condemned. Though I have, in this double relation, endeavored to follow the course pursued by men of talents, and to present with precision and impartiality, the actual condition of science ; though I have neglected nothing in order to procure the best information concerning modern improvements, still I fear that many useful points have been overlooked. Upon this subject, as well as upon all others, I will cheer- fully bow to the criticism of the learned.

The engravings are not as numerous as the nature of the subject seems to render necessary; but the price of the work being already sufficiently high, I thought it ought not to be increased. All have been taken from nature with the greatest care, reduced in size, and marked with neatness and precision. I have chosen such views as will exhibit at a single glance, the whole opera- tion. The object being to supersede long graphic details, I have paid less attention to richness and splendor than precision and clearness of design. The execution has been confined to one of our most distinguished artists, M. Chazal, well known for his talents in this line. The instruments which could not be found in the Hall of the Faculty, were procured for me by MM.Char- riere and Sirhenry, two of the most eminent surgical instrument makers of C

XVlll PREFACE.

Paris. I cannot express too much gratitude for their kindness ; and also for the politeness of the curators of the museum de L'Ecole, the MM. Thillaye. At one time I decided to collect the plates into an atlas, and to annex an ex- planatory text for the use of the amphitheatres ; and I thought it also possible that I should make this subservient to another work on the same subject. The drawings of M. Maingault on amputations, of M. Syme on resection or opera- tion at the joints, of MM. Froriep, Manec on ligature of the arteries, of M. DemoursandM.Weller on theeye,of M.Bretoneau and M. Bui Hard on trache- otomy, of Scarpa on hernia, of MM. Anderson, Houston, Segalas, &c., on the genito urinary organs, though more or less perfect in their kind, have been but of little use to me. Among others, those of M. Manec did not make their appearance till after the execution of my own, and besides being desirous of presenting the objects in a new light, it was absolutely necessary that I should have recourse to the dead subject. Lithotrity, staphyloraphy, &c., did not present the same difficulties. And I have so freely used the lithography of MM. Leroy, Civiale, Heurteloup, Tanchou, Tavernier, Roux and Schwerdt, that I have often copied them exactly.

INTRODUCTION.

Definition. — In medicine the term operation may be defined an action whose object is the amelioration of the organic condition of man. It is synon- ymous with surgery ; but custom has given it a meaning, if not definite, at least much more limited. At present surgery is translated by surgical pathology, or rather pathological surgery, and embraces all diseases in the treatment of which topical applications form the principal remedies ; while operative sur- gery is confined to the therapeutics, which require the hand either alone or armed with instruments. One is a true science scarcely different from medi- cal pathology ; the other leans more towards the arts. The first can only be advantageously pursued by those who are endowed with great aptitude for intellectual exertion ; on the contrary, the hand is the indispensable and characteristic agent in the second. But it is impossible to draw an exact line of demarcation between them ; as we see them constantly encroaching on each other in works purporting to be devoted to each.

If operative surgery is allowed to embrace rules for the application of cata- plasms, plasters, ointments, leeches, cupping-glasses, blisters, moxas, acu- puncturation, cauterization, seton, bleeding, &c. we cannot see why the reduction of fractures and luxations, the study of splints and bandages should be excluded. On the contrary case it is not less arbitrary in its point of separation. Catheterism in general, the extraction of a foreign body either from the ear or between the eyelids, the cutting of the frenum linguae, require no more knowledge or address, than venesection or opening of an abscess. The manner of dividing this science is merely a matter of courtesy, which every man may construe according to his own views.

In omitting all that relates to dressings, treatment of wounds, &c. in order to speak of operations, I have had no other motive than the necessity of fol- lewing a path already pointed out by custom. These branches of surgery having become the subject of special books which no student can dispense with, by reproducing them I would have labored unprofitnbly, as the details which my limits would have admitted could not supersede the special trea- tises of MM. Legouas, Bourgery, and Gerdy on petty surgery and bandages.

Classification > — The necessity of dividing operations into a certain number of classes has been felt at all times. The ancient classification laid down by

xix

XX INTRODUCTION.

Celsus who referred all to Dissresis, Synthesis, JExseresis^ or Prothesis, and which prevailed during so many ages in nearly all the schools of Europe, can no longer be maintained. In creating eight classes to supply their place Fer- rein is still less successful. The reunion, the separation of tissues accident- ally united, the dilatation and the re-establishment of natural canals, the closing or obliteration of useless channels, the extraction of certain liquids, amputations, extraction of foreign bodies, and reductions which he arranges in so many different heads, form a division in effect the least natural that could be imagined. DiarthrosiSy to remove deformities was added to the four primitive orders since the time of Dionis. Dilatation and compression to which M. Roux allows a separate place, and prothesis rejected by Ferrein, ap- pear unworthy and but imperfectly fill the outline. The exploration of the bladder, eustachian tube, and the lachrymal ducts, the injection of these dif- ferent passages and simple torsion of the vessels for example, though important operations, would find no place under any of the above divisions.

The efforts of Lassus and M. Rossi, to obviate the effects alluded to, have been unsuccessful ; and the plan adopted lastly by Sabatier is attended with so much trouble and inconvenience that no one will think of recurring to it. Indeed, of what incoherences are we not made sensible when we see in treat- ing of the eye, for instance : fistula of the corneoy hypopion, hydropthalmia, staphyloma, scirrhus, procidentia of the iris, foreign bodies, cataract, and arti- ficial pvpil, &c, scattered here and there to the middle of three volumes and forming as many distinct divisions ? By this arrangement it would be almost impossible to know where to find an article until we had previously waded through an interminable index. In order to ascertain how to open the ante- rior chamber of the eye, for instance, we would be compelled to consult by turns the second, third, or fourth volume, according as it treated on the ex- traction of pus, a foreign body, or the crystaline lens. In this point of view the essay of Delpech is still more defective. Indeed, the method developed by M. Richerand though one of the most advantageous for study, having genius equally for its foundation, is not entirely exempt from the defects so justly attributed to Sabatier. Hence it results that the topographical order recommended by J. Fabricius, and followed by M. Boyer, notwithstanding the repeated criticism, more or less just, to which it has been subjected, is still in operative surgery the best, and, perhaps, the only course that can at present be of any assistance to the reader. This is the only plan which conveys the same ideas to every one. By its aid all will know where to find trepan, cataract, empyema, lithotomy; whilst by following Sabatier or Delpech after first inquiring whether such operations belonged rather to wounds and foreign bodies, or to fractures and styptics, then to find in what order these different heads had been classed in relation to each other. The pathology and cause of disease, which render such divisions necessary, are too imperfectly known or too variable to serve as a permanent foundation for the classification of operations. In proceeding exclusively on the base of functional apparatus, or the organic system, we depart from fixed rules it is true, but then we are obliged to collocate the most incongruous subjects, (salivary fistula, abdominal hernia, polypus of the rectum, &c.) or to separate others, (foreign bodies in the trachea and oesophagus, tracheotomy, oesophagotomy, &c.) which have the greatest analogy.

INTRODUCTION. '* XXI

We may present operations here under two general points of view : 1st, as independent and classed according to their analogy or difference; 2d, as therapeutic resources subject to the same divisions as the diseases which re- quire them. In practice the first is applicable only to a few, such as trepan- ning, amputation, ligature of the artery and suture. Incisions, extractions, and special operations cannot properly be included. The second would be still more difficult to generalize ; for if cataract, fistula lachrymalis, hare-lip, &c., may be taken as the heads of chapters in operative surgery, why not compound fractures, caries of the joints, gangrene, and gun-shot wounds, &c. Seeing, from the difficulties against which all authors have in vain contended, that it would be impossible to form a systematic classification, I have con- cluded to adopt the plan least embarrassing to the students, though perhaps least rational and less methodical. It is the only one, at least with some slight modifications, that can be followed in the anatomical schools. Hence I have undertaken to demonstrate, that the numerous operations of which the human body is susceptible, may be exhibited without exception, on one sub- ject. The desire of attaining this object, induced me to introduce ligature of the arteries before amputations ; and to describe them from the extremity to the trunk, without order or analogy. The operation of aneurism does not in effect interfere with the process necessary to exhibit amputation ; while ampu- tation would render it impossible to demonstrate the rules for the application of ligatures on the vessels. If, instead of passing in review, the amputation of the joints, the fingers, the hand, the wrist, the forearm, the elbow, the arm, and shoulder, I had treated first of coniimcous and then of contiguous ampu- tations, one subject could not have afforded the means of exhibiting all. Be- sides, it seemed to me better to proceed with the trunk from the head to the pelvis ; showing first the operation, then the diseases, then the organs or parts subject to them, as the guide and standard. The only object in adopting this method was to facilitate the study of the subject, and to aid as much as pos- sible the memory of the reader ; it is cheerfully submitted to the criticism of men of science.

Among operations all the data is given in advance, but no rules could meet the difficulties of some operations. The first, generally termed regular operations, are fortunately the most numerous and important. Under this class may be ranged amputations, operations for aneurism by the method of Anel, of harelip, of lithotomy, &c. The second comprehend tumors either can- cerous or otherwise, which devel ope themselves on the scull, the face, the neck, the axilla, the abdomen, and which require extirpation. There exists a third class, which, in some degree, holds a middle rank ; such as cancer of the breast, sarcocele, fistula in ano, hernia, re-sections* themselves, and the operation of aneurism by the ancient method. We know well the parts to be divided when operating for strangulated inguinal hernia; though we are often ignorant of the pathological condition of the parts reduced. Thus operations naturally divide themselves into three classes. In thejirst, the instrument acts on parts entirely healthy or little deranged by disease ; in the second, it bears on points the anatomical relations of which have been changed, or for the removal of a tumor whose limits, if not naturally fixed, it is impossible at first to determine ; and in the ilurd, it is applied to affections the limits of which are easily esta-

* Re-section, indicates the cutting- off the articular extremity of the long bones ; or the ends of bones which do not unite after fracture. Tr.

XXU INTRODUCTION.

blished — surrounded by points fixed and known; but the varieties of wlii chare too numerous for established rules of operating in one, to apply exactly to others Process on the dead Body. — The convenience of this division essentially practical, is thoroughly confirmed by experiments on the dead body. It is possible, indeed, to exhibit completely the removal of members, ligatures of the arteries, in a word, all operations that can be performed on the organs in their normal state ; viz. on all of theirs/ class, nothing of the kind, however, could take place in sarcoma of the face, maxillary sinus, amputation of the superior maxillary, of the parotid gland, of the thyroid gland, the cyst of the ovaria or the interior of the abdomen — in fine all of the second class. Every student knows also that the knowledge acquired in the amphitheatres* of ligature of the polypus, amputation of the neck of the uterus, operation for fistula in ano orperineo, and of hernia particularly, is very imperfect, and but feeble aid when called on to operate on the living patient. He would strangely deceive himself were he to believe himself perfectly master of all operations, merely from repeatedly witnessing the performance of them in the dissecting room. No one can be a skilful surgeon without having a long time practised these operations. They impart an aptitude, a steadiness, an address that the most precise anatomical knowledge can never supply. But this is not all even for operations of ih^ first class. If the eye is more flabby, more loose, less trans- parent in the dead body, no idea of its mobility, of the tendency of thevitrous humor to escape, of the eyelids to contract and of the tears which constantly flow during life. When a limb is amputated, the tissues being more firm and tense are more easily cut before than after death ; but in the latter case there is no retraction of the muscles, no blood to disturb or annoy, and no difficulty in ascertaining whether certain hemorrhage proceeds more from the veins than the arteries. vSometimes, when an artery is deeply seated, it cannot be dis- covered without dividing vascular ramifications, the blood from which so con- ceals the parts as to render the distinction more or less embarrassing; whilst on the dead body nothing analogous is to be met. The palpitation of the ves- sels, which at the first glance would seem to afford precise information, is so uncertain, so vague in regard to wounds, that very little advantage can be de- rived from that source. In tracheotomy and a^sophagotomy, is it possible to simulate the least portion of the embarrassment which arises from the plexus of veins and the numerous arteries of the neck ? In passing to the two other classes we must add their special, to these general difliicuities. We never operate for fistula lachrymalis unless the angle of the eye is pasted up, ulcer- ated, or more or less altered. It is the same more frequently in the nasal fossa, when we are about to extract polypi. The motions of the throat, the desire to vomit, the mucous or blood, the lassitude into which the patient each moment falls, when we operate for hypertrophy of the amygdalas, bifurcation of the veil of the palate, are never met with in operating on the dead body. Caries and necrosis, which render excision of the joint absolutely necessary, always change essentially the surrounding soft parts. Whence it follows that there is no point of comparison between the process we are compelled to adopt on the living patient, and the freedom of our experiment on the dead subject. In each case, however, we know the number and situation of the tissues or organs to be divided — the part to be raised or separated ; but suppose a mor- bid mass of considerable volume becomes developed in the perineum, what

• The Lecture Room.

INTBODUCTION. XXlll

assistance would the surgeon derive from tlie experiments of the dissecting room ? What I have said in relation to the perineum applies to the groin, the axilla, the neck and every other part of the bod j. Without neglecting it, how- ever, we ought to be careful and not attach too much importance to this species of experience. Experiments on living animals though infinitel j more important under this point of view, do not possess every advantage. In the first place their formations being rarely alike, the results obtained by reasoning from the analoo:y are generally defective. Hence, in order to study an operation with the necessary care and judgment, it ought to be practised on the dead body, and also on the living animal ; two sources of knowledge which mutually aid without being able to supersede each othei".

Operative surgery is then definitely bounded— Jirst, on anatomy ; second, on cadaverous experience ; third, on vivisection ; fourth, on pathological ana- tomy ; and Jifth, on the habit of operating on the living man.

Methods. — As there are few operations which cannot be performed in dif- ferent ways, I have thought proper thus early to explain, by an appropriate word, the ensemble of which each method is composed. The terms, method, process, mode^ have been indiscriminately used, and though nearly synonymous. these three words are used still in a variety of circumstances. It has been attempted, however, by M. Roux particularly to give each a distinct meaning. The expression inethod, for example, is taken in a much more extensive sense than the two others. Thus we say method, and not process or mode, in speak- ing of extracting or covching the cateract; while in performing lithotomy with the goro;et, use the term process and not method as indicated by the modified operation adopted by M. Boyer. Ligature of the polypus is a method, but ii2;ature of the polypus, according to the practice of such and such authors, is 0. process. In fine, we understand, generally, by the term method, some funda- mental principle sufficiently extensive to be divided and variously modified ; while the word process is more restrained, and is only used to designate the diminution of some peculiar method. Nothing could more clearly prove the propriety of these distinctions, than the operations for aneurism, for amputa- tion, hydrocele, and lithotomy. To apply a ligature to the artery without touching the tumor is called a method ; but place it higher or lower, and it is called IX process. To open an abscess is denominated a method; the manner ofopeninji; it is a ;)roce55. To resume — 7?ie^/iOfZ embraces the entire subject; process relates to each of its modes of application. In common parlance, therefore, it is necessary to adhere to these purely arbitrary terms ; and not to use, as is frequently done in works more carefully written, the words pro- cess, mode of operating in the place of method, and vice versa. Fistula lachry- malis, among others, proves it completely; the term method being applied indiscrimimitely to the process of Dupuytren, Desault, and Boyer. Hydro- cele, hernia, and lithotomy are equally liable to the same remark. Process, the method of cauterization and of injection ; method, the process of dilata- tion and solution; process, the method of Frere Come are daily used. This subject is one, however, of secondary importance; and in such a discussion every one may reject or adopt these conventional terms, without being held to account for it.

1st. Before the Operation* — The first object which demands the solicitude of the surgeon before performing an operation, is its indications. It is on

XXIV INTRODUCTION.

this point that the most extensive and most precise medical knowledge is in- dispensably necessary. After having satisfied himself that the cure can only be effected by an operation, he should still be convinced of its utility, and also that the patient incurred less danger in submitting to it, than in laboring under the disease. Hence, it is only by the aid of a diagnosis, enlightened by the clearest and most precise knowledge of pathological anatomy — of a prognosis drawn from what the soundest judgment may apprehend of the progress or of the probable issue of the organic derangements, and of an appreciation as exact as possible of the power and value of the ordinary therapeutic agents that the first problem can be solved. And, besides, none of its relations ap- pears to me to be considered in a proper point of view. I wish to speak of the choice to be made between the operation and the other therapeutic agents which we may wish to substitute for it. Thus because the lachrymal tumor, has lately been considered not within the domain of operative surgery, hav- ing yielded sometimes to regimen and antiphlogistics — that certain tumors of the breast having been dissipated by compression, it would be, in my opinion, highly improper to conclude that all this treatment should precede in order to render recourse to the knife unnecessary. Indeed, it does not concern us to know if cancer, or any tumor whatever, can be removed by the action of such and such medicines or by the knife ; but which, in the last resort, offers the .'greatest advantages. I grant that the frequent application of leeches, emol- lient cataplasms, abstinence, &c., cure a number of tu^^iors and even fistula laclirymalis; but is it hence to be concluded that the treatment, whose suc- cess is not even uniform, and requires to be continued several months, ought to be substituted for a metallic tube in the nasal canal — a matter which is effected in a second, removing in two days a disease of ten years standing, and restoring the patient to health in a great majority of cases ? That leech- ing and regimen may triumph over some masses apparently scirrhous or can- cerous I will not deny ; but if these tumors remain movable and are favorably situated who will assert that the bistoury will not remove them with much more certainty and rapidity ? and by affecting less seriously the general phy- siological condition of the system, diminish the sum total of human suffering. What has been said in relation to cancer and fistula lachrymalis applies to a number of other diseases ; forming the foundation of a remark that the sur- geon ought never to lose sight of. If it is cruel to use the knife on those who might be cured in a more gentle manner, it would still be less conform- able to the interests of humanity to compromise the future health of the patient under the vain pretext of averting a little present pain.

Nearly all the preparations to which patients were formerly subjected pre- vious to operations have been abandoned by the moderns. Still there are some which should be observed when the disease will permit delay. The choice of season is not certainly a matter of indifference ; ceteris paribus, spring and autumn ought to be preferred to winter and the heat of summer; not because the temperature is more mild, but because the system is then better able to resist general morbific variations. Thus it is rational and pru- dent to postpone operations for the stone, cataract, the removal of large tumors, and all operations which deeply affect the vital functions, till temperate sea- sons; unless from some peculiarity of the patient, we have reason to pursue another course. But too much importance is not to be attached to this pre-

INTRODUCTION. XXV

caution ; there is no time of itself capable of destroying the success of an operation ; and the question of season is only an affair of better or lessfavor- abU. No doubt the appearance of an epidemic should be a powerful reason for temporizing ; and that the morbific conditions of the moment should be regarded. In choosing the morning rather than the evening, the operator has the advantage of finding his patient less fatigued, and he is better able to watch his wants immediately after the operation ; but, besides this, there is nothing that renders the morning indispensable, and the most plausible mo- tive is that the forenoon is generally more convenient for all. As regards urgent operations, they must be performed when exigency requires, without reference to the seasons or hour ; and hence, authors have been led to establish a time of choice and a time of necessity.

The moral precautions vary, and ought necessarily to vary, with the indivi- duals. The first is, to inspire the patient with unlimited confidence in the surgeon, and all that confidence is acquired in a thousand different ways. The second is to convince the patient that the operation is the only means of arresting his suf!*erings, and to disabuse his mind if he exaggerates the danger. To resume it is necessary to do every thing, within the limits of truth, that may induce the patient to desire the operation, if not with pleasure, at least with resignation. There are two sorts of individuals to be encouraged on this point. One is of extreme timidity, frightened at the idea of the slightest stroke of the scalpel ; whom it is necessary to deceive as to the severity and acuteness of the pain, and also to the dangers to which he is exposed. Tlie others tliink that in public establishments the operation will be performed nolens volens, and therefore never speak to the surgeon but with a disturbed air ; and they remain under this delusion until the operator is able to remove the error. Experience has discovered two other species of patients which require to be well watched. In the first class we place those who doubt not their risk, and who wishing to exhibit a bravado courage, submit themselves, in spite of every one, to the knife of the operator, and pride themselves in sup- porting the operation without complaint. The second class composes the naturally timid or very susceptible, but who after long hesitation, have become convinced that the operation is absolutely necessary, and collecting all their courage, force themselves to withhold the scream, to resist the most natural sufferings, and to stifle even the slightest complaint. To the first it is necessary to manifest great seriousness on the subject which they appear to treat so lightly and to decide after much reflection. An effort should be made to convince the second that an affected courage never supplies the place of real bravery ; also, that it is as dangerous to stifle complaints as it is to exaggerate them ; that in suppressing them they do violence to nature, which require that the cries of each suffering organ should be expressed freely and without the least restraint. Besides, nothing augers so badly as these forced resolutions and bragging of calmness or resignation. It seems as if nature is weakened by this turning, as it were, on herself, instead of preparing to parry the attacks. The fact is, that operations performed under such circum- stances, terminate, generally, less favorably than others.

Internal Injuries. — It would be unprofitable to enter into an investigation of the preparations in relation to injuries of this description, as it would tend to complicate the principal diseases here spoken of. We never attempt any D

XXVI INTRODUCTION.

operation, so long as the patient labors under any formidable functional dis- ease, lest it should prove the means of terminating all the troubles of the human economj. Besides, such injuries should be met as thej arise, before or after having decided on an operation. The manner of recognizing and treating them, having been necessarily laid down in books on pathology, it would only be to abuse the patience of the reader to introduce them in a work on operative surgery. The preparations are such as would be demanded by the condition of the patient, in other respects in good health. Upon this point authors are far from agreeing. Some prescribe scarcely a day's regi- men, while others do not operate till after having used ptisans, purgatives, revulsives, bleeding or a diet of the greatest rigor — in a word, of the most minute precautions for one or two weeks. Hence, the difficulty of establish- ing a general rule for all cases. It is in treating on the particular operation, that this question ought to be touched. At present, I will merely remark, that every operation sufficiently important to require a rigid diet for several days afterwards, in order to control general re-action and imperceptibly to cjjange the habits of the patient, require an antiphlogistic regimen, so far as not to debilitate the patient ; that the soups and ptisans should be slightly diluted and cooling; and that one or two bleedings either by the lancet or leeches be resorted to. If the patient be robust, a purgative, or at least laxative drinks should be given, in order that the transition be not too sudden and that there remain no germ of morbid derangement in the system, except what follows the operation itself. The preceding considerations ought to apply to local prejmrations. The only thing necessary to be noticed here, is that whatever supports the action of the instruments, the bandages or other dressings ought to be carefully scraped and cleaned.

Place of Operation. — In hospitals, it is customary to remove the patient to the amphitheatre, in order that his companions in misfortune may not witness either his cries or the mutilation he undergoes. This place instituted for the purpose, besides being very commodious, has no other inconvenience than that it is more difficult to warm than an ordinary chamber; and it is the only one which could enable the assistants to witness fully the skill of the operator. It is only used, however, for the capital operations and a few others. Hydro- cele, lithotomy, hernia, cataract, fistula lachrymalis and trepan, can, and ought to, be frequently operated on in the hall or even where the patient lies. It is only for lithotomy, amputations and the dissection of certain tumors, that the amphitheatre is indispensably necessary. When the bed room of any patient is not suitable for the operation, we should select some other place more roomy, better lighted, and well ventilated. Here the assistants should be as lew as possible, because those who are not actually employed, cause embar- rassment almost always, by their indiscreet or ill-timed expressions, by change of countenance, by vitiating the air of the chamber, or by restraint on the patient or operator. The interest of students and of science require the attendance of assistance in hospitals ; but here every thing being public, the patients know beforehand what they have to submit to, and resign them- selves to it without difficulty.

The assistants deserve the greatest attention, their number cannot be fixed ; one being absolutely necessary, the others merely useful. In private practice as few as possible are admitted ; while in public institutions all are employed

INTRODUCTION. XXVll

to wliom the operation affords the least advantage. In country practice there

is often a great want of assistants. Some of them may not have finished their medical studies ; and to those are confided the duties which require only strength, coolness, a little address or intelligence. It is necessary, also, that each should be well acquainted with the duty he has to perform. The sur- geon should be careful in making his selection in regard to the ability, saga- city, stature and strength of those he entrusts ; and as far as possible to take his assistants from the students accustomed to his practice, who can divine his tiioughts at the least sign, and who have at heart the success of the opera- tion, and the triumph of his labors.

The appareil or apparatus, is another point that should not be overlooked. The materials which compose it are naturally divided into three orders. The first, such as the garotte, tourniquet, pads, compresses, &c, are intended to prevent accidents during the operation ; the second embraces all that is neces- sary to perform it, and the third relates entirely to the dressings. There should be in readiness, a sufficient number of flexible wax candles, rather than lighted candles, in the event of the natural light not being sufficient; 2d, a chaffing dish full of coals and cauteries; 3d, a little wine, vinegar, cologne and brandy in separate vessels ; 4th, tepid and cold water, basins and sponges ; 5th, the means of suspending temporarily the flow of blood in the parts about to undergo the operation ; 6th, several compresses, lint, ordi- nary bandages, napkins to dress the patient or protect certain organs. The second series comprehend the different instruments; such as bistouries, knives, needles, scissors, saws, ligatures, nippers, pincers, &c, which are placed on a waiter or table in the order in which they are to be used. The fillets, pledgets, compresses, bandages and other dressings, are disposed on another table so as to be at hand without confusion, when they are required for use. Being about to recur to these details in treating of many operations, such as amputations and aneurism among others, where their utility will be more fully developed, it is unnecessary at present to enlarge on their advantages.

2d. During the Operation — The situation of the patient, of the surgeon and his assistants, necessarily governed by the character of the operation, the diseased organ and the taste of the operator, cannot be indicated more advan- tageously than by describing each article. The same may be said of the hemostatic means, either provisional or definite, of whatever is intended to moderate pain, of the resources besides which have been mentioned under the article " amputation."

3. After the Operation. — It is also important that care should be taken to prevent syncope, convulsive movements or spasms, and in fact every attack which may follow the operation. Being obliged to pass in review these vari- ous chapters, so that the dressings, the question of knowing if the operation will unite by the first intention, the accidents to which operations are princi- pally exposed, and also the elementary points in the removal of members, and of aneurism, it would be a waste of time to describe them here. I shall, however, not stop to discuss the propriety of the ancient adage " cito tuto et jiiciinde,'^ which formerly re-echoed throughout the schools.* To say that an

*This adag-e belongs to Ascepiades and not Celsus to whom it has been attributed. Hip- pocrates and Galen say : Celerite^ jucundcy prompter et eleganter which amounts to tlie

MVlll INTRODUCTION.

operation should be conducted with promptitude, ability, and address, is a truism which there is no occasion to repeat in our day : the most important part is not to sacrifice one of these advantages to the other ; to look imme- diately to the mind, and to show for example, that promptitude is neither pre- cipitation nor swiftness ; but in surgery that safety and care should reign paramount.

Phlebitcs or purulent Absorption. — The division of tissues by the hand of the operator creates sometimes such a series of symptoms, which in latter times has so much occupied the minds of scientific men, that it is impossible to avoid entering upon its discussion more fully. The progress of disease in similar cases is besides extremely variable ; sometimes it commences with a violent trembling that may continue for many hours, sometimes by spasms, and, in certain cases, simply by a coldness of the extremities. The skin becomes pale, takes a yell()>4^ish tint, somewhat livid, and soon after an aspect more or less ghastly. To the difierence of intermittent fevers produced from low grounds, marshy places which have more than one trait of analogy, this first period is rarely followed by a free re-action. If perspiration succeeds, it is unequal, often clammy or heavy; after being renewed once or oftener undei- the shape of paroxysms, these symptoms are generally followed by remarkable adynamia and mortification. The eyes are sunk and covered with greyish rheum, the conjunctiva becomes yellow, as well as the compass of the lips, and the whole face remains more or less dull. The tongue which is habitually moist, without being very large or pointed, as is the casein intes- tinal affections, does not become, furred until at an advanced period of the dis- ease ; the teeth and the lips become fuliginous. The pulse assumes a frequency and hardness without being quick ; and becomes by degrees more and more small and feeble. Distention of the abdomen, sometimes diarrhea, (seldom delirium although nearly always stupor) scarcely ever fail to exhibit themselves.

To these are to be added the indefinite symptoms of visceral inflammation; it appears occasionally as a livid redness of the cheek, which maybe remarked for a moment, at the same time accompained by a slight cough or pain in the breast, and difficulty of respiration ; sometimes as a jaundice, more or less developed, with pain and derangement in the hepatic region or in the right shoulder ; likewise, with what is more rare, a desire to vomit; with a par- ticular redness of the lips and the borders of the tongue, which then becomes dry, as in cases of follicular ulceration of the intestines or of typhoid fevers ; as well, in fine, as by acute suffering in some part of the members of the body — the great joints for example. Thirst, is not generally very great ; the breath, often fetid, exhales sometimes the true odor of pus ; the process of cicatrization is immediately suspended in the wound, the borders of which become pale the same as the rest of the surface. However thick or creamy it might have been, the suppuration becomes all at once greyish, clotted, or resembling ill conditioned serous matter. It is not rare to see it stop sud- denly. The soft parts shrink up with iht same rapidity, and assume the most cadaverous aspects. The muscles, bones, &c., fall asunder, as if the cellular tissue which unites them in the normal state had been destroyed; after a while a bloody oozing ensues, which becomes more and more fluid until it terminates, when the malady has lasted a long time, by resembling the washings of meat, and produces hemorrhages which nothing can arrest. In

INTRODUCTION. XXIX

fine, Ihe subject dies exhausted on the twelfth, thirteenth, or fourteenth day.*

Pathological Anatomy. — Upon the opening of dead bodies, lesions of different sorts are found, although susceptible of being all traced to the same cause ; these are often the seats of multiplied abscesses, in the proper tissue of the viscera, or collections more or less abundant of greyish cream colored serosity, rather than flakes floating in the serous cavities. Among others the large articulations, such as the shoulder, the hip, the knee, are equally filled with pus, which is supplied frequently, either by the state of the parts or by infiltration, particularly when there is a sufficient quantity of lax cellular tissue. The arteries are almost empty, and the blood which they contain is in general very fluid ; that of the veins, which is more abundant, is still more evidently altered. The clots which are found here and there, are a mixture of black, yellow, white and green, and have a granulated texture, which escapes in cutting or even in pressing them under the fingers. They contain sometimes globules of pus, obvious to the naked eye. It is not even rare to meet with the true purulent foci in small clots of blood. All the parts of the venous system have offered specimens of this de- scription; as, for instance, the iliac and uterine veins, the vena-cava inferior below the liver, and at its entrance into the right auiicle, the vena-cava supe- rior, the different cavities of the heart, &c. Many of these concretions are yet soft and evidently of recent origin, others, on the contrary, are so dry and brittle that it is impossible to deny them a certain age. Not one of them has, in a majority of cases, a pathological relation to the state of vessels in the re- gion in which it is found. It is entirely different, in the case of wounds, where nothing is more common than to see the veins inflamed, in full suppuration, either interiorly or exteriorly, and that to an extent extremely variable, but of such a description, however, that the two vense-cavas remain in almost ever J instance unaffected.

The small abscesses of which I have spoken in the commencement, have been observed in all the organs. A subject which I had occasion to examine at Tours, in 1808, presented them by dozens in the brain and in the tissues of the heart. A young man who died at the Clinique of the faculty, in 1825, from the effect of amputation of the great toe, exhibited them even in the spleen and in the kidneys. The lungs and the liver, are not less subject to them. It is there that at all times it has been known to exist when no trace whatever could be found elsewhere. Their characters are so well marked, that it is difficult to confound them with the results of ordinary inflammation. Besides, they are seldom developed singly, but much oftener a large number exist in the same part. The surface of the organs appears to be more congenial to them, than deep seated parts ; and it is rare that they acquire any great size. In this point of view they vary from the size of a pin's head, to that of a walnut or of a small egg. By pressing upon them they can be distinguished as so many large tubercles reaching across the pulmonary apparatus, the periphery of which seems quite superficial. In the liver they are enveloped in a blackish or livid couche, sometimes several lines in thickness. In this organ they are situated most commonly near the centre, and are generally of

* In the text it is the twelfth, thirtieth, or fortieth day. Tr.

XXX IKTRODUCTION.

a larger size than in the other parenchymae. The matter of which they are formed is also more irregular. Although generally very fluid, blue, and flaky, or of a milky whiteness near the centre, they are very often grumous or even hard especially near the circumference. In the lungs we may wit- ness the various phases of this affection still better. At some points may be discovered slight stains resembling ecchymosis. In others we see these stains or blotches inclosing a drop of pus. Again, no ecchymosis exists, and nothing but grumous pus is to be found. Still further we meet with others either concrete like the caseous tubercles of lymphatic ganglions, or liquid as in the liver. The substance of some seems to be confounded with the neighboring tissues. Others are as if encysted. Then the walls of the sac are villous and of a lilac color. At some lines distance from them the organ recovers all the attributes of its normal state. They are almost always separated by inter- val completely healthy. Frequently it appears after evacuating the matter and removing the cyst as if the organ had never been diseased, or as if the places of the disease had been formed mechanically by a separation of the tissues.

The eftusion in the serous cavities is also very remarkable. The pleura is generally its seat although it may also take place in the pericardium, perito- neum, arachnoid membrane, &c. In a few days it becomes very abundant. Without scarcely any alteration the membrane after being emptied, remains covered with a greater or less thickness of true pus, and the residue of the liquid, of an ashy or earthy appearance, is far from resembling the flaky or lactescent serosity which is found as a sequence of recent pleurisy. The state of the tissues in the articulations is astonishing. Neither the cartilages, ihe capsules, the ligaments, the cellular envelope, nor any thing, in a word, presents the least trace of inflammation, and after removal of the pus a sim- ple lavation has been sufficient more than once to cause doubt whether or not the articulation had been diseased. It may even happen that the cartilages may be partially destroyed, the synovial membrane and the ligaments pierced without the contiguous parts losing any of their mobility or natural color. The same may be said of the sub-cutaneous and other deposites in the extre- flriities. In other cases these- deposits are surrounded by ecchymosis and more or less evident traces of inflammation.

Although some patients die with all these varieties at once, imbibing pus as it were like a sponge, the greatest number exhibit only a part of them. Some- times they are tubercle-like as in the lungs or liver, without any efiusion. Sometimes collection in the pleura exists alone; in another case this may be found in the extremities, within or without the articulations ; in many cases it will be found no where, and then we must seek the cause of death in the more or less serious alteration of the blood in the vessels themselves.

Etiology. — Every solution of continuity that suppurates, may produce the alterations that we have just spoken of: trepaning, a simple incision, the sec- tion of a varix, an ordinary venesection, as well as the amputation of the neck of the womb, the excision of hemorrhoidal tumors, or the amputation of a member. Nor is this a discovery of the present day. Pare mentioned it, and Pigrai says, that in a certain year almost all that died of wounds of the head had abscesses of the liver. Morgagni describes these affections with some detail, Quesnay, Col. de Villars formally mentions them. J. L. Petit

INTRODUCTION. XXXI

gives a very correct idea of them, and many modern surgeons have noticed them in their lectures or their writings, but they had not then fixed the at- tention of the profession so strongly to their importance as they now do. In saying that the pus was transported from the wound to the organ in which it was found deposited, the ancients merely reiterated their usual humoral hy- pothesis and proved nothing To believe as MM. Boyer, Roux, and Dupuy- tren did, that so many disorders result from simple idiopathic inflammation, caused itself by the sympathetic (retentisment) of the wounded part upon the viscera, or by the anterior existence of tubercles or other organic lesion un* appreciable until then, was not likely to excite a very lively interest in the question. Struck, at the commencement of my medical studies with the fre- quence and importance of these aifections I soon made them the object of my special attention. Believing from a fact observed in the hospital of Tours in 1818, that I had discovered the true etiology, and confirmed in this opinion by what I afterwards met either in Tours or Paris, I took the liberty of publishing it in my public lectures in 1821 and 1822, and in my Tliesis de Reception in 1823. I then maintained that these numerous purulent depo- sites owed their existence not to any separate idiopathic phlegmasia, but to an alteration of the blood, to the passage of pus into the circulation and its trans- port into these organs, whether it came from the wound or was secreted by the neighboring veins. It required some boldness to advance such idea then whilst solidism reigned triumphant over our schools, from which the partisans of the physiological doctrine thought they had for ever banished humoralism. These ideas were therefore badly received generally. Yet my own convic- tion and the facts that came daily to their support did not permit me to abandon them. My sojourn at the hospital de Perfectionnement furnished me numerous. occasions to submit them to new proofs, to call them to the atten- tion of the students, and to show in what manner they might enlarge the field of general pathology. The two memoirs that I published in 1826 in the Re- view upon this subject, and that which I had already said in the same journal in treating of the alteration of the fluids ; that which I had advanced at the same time, or soon after, in the Archives and La Clinique des Hospitaux, and the discussions that I caused in the Academy finally had its effect, and I soon had the satisfaction to see that Marechal and Raymond of Marseilles, in their ex- cellent thesis (1828) and M. Legallois in a memoir at the same time had arrived at the same conclusions that I did. Whilst M. Dance in a work stiU more complete, was removing the last vestiges of objection, opinions supported by' facts of the same kind were taught at London by MM. Rose and Arnott. M. Blandin, who in a thesis a little later than mine (1824) had adopted the hy- pothesis of sympathetic reaction and pure simple inflammation — MM. Tonnelc and M. Rochoux have ranged themselves under the same flag although their tkeoretical views are not exactly alike. In fine, the pathological meeting which took place at the Faculte de Medicine in the spring of 1831, having called in MM. Berard, Blandin, Sanson, and myself, to examine the question c(f metastatic suppurations following traumatic lesions, has in a manner forced us to show the present state of opinion upon this subject, and to provfe that there can be no further difference of opinion upon the principle with which I set out, viz. that metastatic abscesses caused by great operations are the result of an alteration of the blood.

XXXll INTRODUCTION.

There is still, however, a problem to solve. Marechal, Legallois, and Rochoux, found in the absorption of the pus of the wound a sufficient expla- nation of all the observed phenomena. Dance, Arnott, and Blandin on the contrary thought that an inflammation of the veins always preceded the gene- ral infection, and that the pus which entered into the circulation was always the immediate product of phlebetis, which M. Blandin located in the veinules of the soft parts, the medullary canal, or the spongy tissue of the divided bone, when the primitive branches offered no traces of the affection. Instead of j admitting a transport without decomposition, a true metastatic deposite, the latter authors think also that the blood, profoundly altered by its intimate intermixture with the pathological secretion, and becoming more irritating than common, is simply permitted to escape here and there ; and being depo- sited in the tissues, by their irritation become the centre of so many points of suppuration. This opinion differs from mine only in this, that it gives a cause as the constant one, which I think exists only in certain cases. Nor can I comprehend how any one can expect to make use of the labors and opinions of MM. Dance and Blandin to combat mine. In fact, so far from denying phlebetis in such cases, I expressly said in 1826, (Rev. Med. tom. 4j "the veins of the diseased member are full of a very fluid greyish pus, and inflamed from point to point, but only as far as the entrance of the great saphena into the crural." Again, I added, '* the phlebetis was not sufficiently extensive ; if it were even primitive to play an important part as inflammation. In turn- ing our attention towards the fluids, on the contrary, every thing explains it- self in the clearest manner," &c. In May 1827, I asserted (C Unique des Hopit,) that " in this frightful affection authors have paid attention only to one cause of danger; the facility with which the inflammation is propagated from the wounded point towards the principal veinous trunks ; whilst the pus secreted by the walls of the vessels continually mingles with the blood which it alters and decomposes, and thereby produces all the danger of the disease." Finally, in speaking of the same fact in the Archives (August 1827,) I said, ** here the disease was incontestably a phlebetis ; but it is to the inflammation of the vein that we must attribute all the symptoms. I think not: the pus continually entering the heart and distributed to every organ with the blood has produced the general affection," &c. As to the formation of the purulent collections, this is my theory which I gave in 1826, (Rev. Med., tom. 4.) " It is possible to explain the formation of these collections by two processes; 1st, the blood more or less changed from its natural condition, may commence by deranging the general organism, and terminate by the formation of a local phlegmasia of a peculiar species ; or, 2d, the inflammation at first developed under the influence of ordinary causes compels pus in a manner to be depo- sited at the point of the greatest irritation. It appears to me demonstrated that the inflammation when it follows the deposition is then only secondary, and that it is produced by an extravasated portion of foreign matter, which forms the point, and that this is at least a phlegmasia altogether sui gene- ris,'' &c.

Thus, in my opinion, the question may be reduced under two heads ; 1st, the mixture of pus with the blood as the cause of the observed visceral altera- tions; 2d, the origin of the pus whether in the blood or in the organs. The first, of which I was the first to venture on the demonstration of its truth, [%

INTRODUCTION. XDdSL

now generally admitted as incontestable. For the other I have not felt the same interest it is true. The object of my efforts being to prove that the pus could circulate with the blood, and infect the system like a poison, I cared little at the moment about proving whether it penetrated into the veins by ab- sorption or was simply formed on the inflamed surface of these canals, pro- vided it was admitted to be transported a certain distance from the point of departure. The preceding quotations, however, are sufficient to show that I had not altogether neglected these secondary questions. The effect of phle- betis upon the composition of the blood are so evident that it appeared to me superfluous to enter into any detail for their exhibition. The same cannot be said of absorption, as many yet refuse to admit it ; it is, therefore, after leaving this part of the question, that a real difference seems to exist between M. Dance and myself. According to this author, the phlebetis is the first and almost only cause of these metastatic /od, and the veins alone secrete the pus that alters the blood. On the contrary, I said at first, as I believe now, that the inflammation of the veins so often met with, whether cause or effect, were not indispensable; that the pus and other morbid matters of the trau- matic surface enters sometimes into the circulation, either by lymphatic absorp- tion, by imbibition, or by the orifices of the veins remaining patulent at the amputated surface. The proof of its truth, in my opinion, is, that I have frequently found abundance of pus in the midst of the viscera although the veins plunging into the exterior lesion were scarcely phlogosed, and without any trace of phlebetis at any other point of their whole course. And since the possibility of this has been denied, I have proven it upon thirteen sub- jects ; among others, in a woman who died in consequence of a serious trau- matic lesion of the foot at the hospital Saint Antoine in 1829, who was opened in presence of M. Dezeimeris, an avowed partizan of M. Dance's ideas ; and again, upon one of the wounded heroes of July, who died on the twentieth day of an amputation of the thigh in 1830, at la Pitie, in which I exhibited tlie total absence of phlebetis to M. Berard, who had also adopted the hypothesis of veinous phlegmasia as the first cause of metastatic abscesses.

As to the mechanism of these abscesses themselves, I said that the pus tra- versing the tissues might be deposited naturally, or by its presence irritate sevei-al points of the viscera, and thus form so many phlegmasia! and puru- lent foci. M. Dance rejects the first of these two modes, and seems even to deny its possibility. With all the reasoning and objections that he produces, I cannot submit to his opinion. If he thinks that the blood, rendered more fluid and altered by the pus, begins always by producing a small echymosis, and soon after a true inflammation, before producing an abscess — ^a mechanism that I have pointed out myself for the majority of cases — then he has not seen, as I have, these foci, not larger than a hemp seed, in the head, the spleen, the kidneys, the lungs, and the liver, and around which the most atten- tive and minute examination, did not enable me to discover the least lesion of the organic elements ; nor those purulent collections that I have so frequently met with in the cellular tissues or certain articulations, and which after eva- cuation and lavation, leaves not the least trace of their existence. If the little veins around each purulent focus are sometimes inflamed it is certainly erro- neous to say that they are always so, and we may admit the capillary phlebetis pointed out by M. Cruveilher as happening in similar cases. Moreover, if we E

XXXIV INTRODUCTION.

admit the deposition of one molecule of morbid matter, we cannot refuse to admit that there may be a great number. The pus mingled with the blood is a heterogeneous matter, which tends continually to escape by one way or another. Whilst it is inclosed in the large vessels, and the circulation has lost nothing of its activity it injures nothing; but in the capillary system where the movement of the fluids are only a sort of oscillation, where are produced nutrition, the various secretions, a thousand new combinations, compositions, and decompositions, must not its elements make some efforts to agglomerate, to reunite, and cease to flow with the other fluids ? This chemi- cal aggregation made, will it not constitute a centre of attraction for other similar molecules ? Is any thing else necessary to determine the seat of an ab- scess ? There is nothing in this more difficult to comprehend than in the formation of bile, urine, saliva, or mucus. These are natural secretions and exhalations ; that on the contrary, is a pathologic secretion or exhalation. This is all the difference.

Prognostic. — Let the matter be explained as it may, these metastatic collections, are the effect of serious operations, and always produced by the passage of a certain quantity of pus into the general circulation ; and thereby justifying an extremely unfavorable prognostication. The name tuberculous that I first gave these collections, related to their form, and I am astonished tliat any person should have attributed to me the idea of comparing them to tfie tubercles of the lungs under any other aspect. The silent and often rapid march of these lesions rarely permits us to detect them in their origin, and when at last the fact of their existence is no longer doubtful, they are gene- rally beyond the reach of art. As soon as the surgeon discovers the existence of violent chills with alteration in the expression of the face, a continued fever, whether attended or not by pains in certain parts of the body, or whe- ther following or not following a diarrhea, in a patient recently operated upon, or who is suffering from an extensive suppuration of any kind, attended with traumatic lesion, he may expect the most serious consequences and fear that death will be the inevitable termination. Yet, if such phenomena exist 'only for two or three days, and at the end of this time a general sweat or some other critical evacuation extinguishes the fever and calms the above men- tioned organic derangements, he will have some cause to hope. I have seen persons recover after having had the true shiverings as well as other symptoms of a purulent infection. The examples are rare, it is true, but they have occur- red, and the surgeon should not forget them.

The mode of treatment is yet unsettled. Sanguinary evacuations either by phlebotomy, leeching, or cupping, is only applicable in the onset of the disease, and in robust and plethoric cases, unless there be some pain or well determined local inflammation j I have seen them used and pushed as far as possible in a number of cases without discovering any sensible advantages. Those who have suffered from hemorrhage either of the wound or the mucous surfaces were not more fortunate. Purgatives administered early, have ap- peared to luc to succeed sometimes. Vesication either of the thighs, legs, or painful parts of the chest or abdomen, deserves to be remembered. Nor is tiie sulphate of quinine without some utility when there arc any intermissions and the stomach not too irritable. Tartrite of antimony, in large doses, first recommended by Laennec, and since by M. Sanson, did not prevent the death

INTRODUCTION. XTTt

of three patients on whom I tried it. As to the preparations of opium, cam- phor, ether, ammonia, and other diffusible and exciting substances, they have ' always appeared to me to increase the symptoms, and hasten the fatal ter- mination.

Finally, when the derangements above indicated manifest themselves, every exertion should be made to attract the fluids towards the wound. If it be an amputation, it should be first enveloped night and morning in a large linseed cataplasm, applied naked to the skin. At the same time, one or more blisters are to be applied to the legs, and a light warm infusion of linden or elder pre- scribed as a drink. A bleeding to the extent of eight or* ten ounces if the pulse has sufficient force, or the patient be not already too weak. If the wound be very pale and the tissues have lost their consistency, it will be ne- cessary at each dressing to make use of a lotion strongly charged with cinchona, and then cover it with a pledget of storax or of balsam d'Arcceus, mixed with cerate. A blister to the stump, scarification, and leeching, if there be at the onset any swelling, inflammation, or external evidence of phlebetis, will be indicated. Compression by means of a roller from the origin of the m.ember towards the solution of continuity should also be tried if the disease has not affected the system and is still local. After these Seidlitz water may be administered as a purgative if the tongue con- tinue soft and not red. The stimulant emetic should only be used after- wards, when stupor, swelling of the abdomen, and a fuliginous state of the mouth have made their appearance. Cinchona, either in decoction or substance, is only to be used in well marked adynamia. Gum, and rice water should be combined withitwhen diarrhea exists, or when the digestive tube seems disposed to revolt against it. The sulphate of quinine in a dose of five or eight grains at the termination of each paroxysm will answer better if there be intermission and sweat. The drinks must be varied according to the predominating symp- toms and the taste of the patient. Such as lemonade, decoction of tamarinds, &c., rf the thirst be great, or light bitter aromatic infusions in the contrary case. The decoctions of rice, barley, ratany, the white decoction, disascor- dium, gum kino catechu, or extract of ratany are no longer to be dispensed with when the alvine evacuations are frequent and threatening to the patient. In a word, the whole of this treatment being exactly the same as that for phlebetis, and the absorption of pus in general can only be incompletely ex- posed here. The details must be sought in the treatises on pathology. I have only felt it necessary to give a summary, such as was indispensable to excite the solicitude of the surgeon, and premonish him against the dangers of a false security in the therepeutics whose eflficacy is still so uncertain.

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OPERATIVE SURGERY.

ELEMENTARY OPERATIONS.

The greater number of operations are made up of several separate steps, each of which often constitutes in itself a distinct operation. Throughout operative surgery are found, incisions, dilatations, extractions, and reunions, whether separate or variously combined. As dilatation and extraction require in each of the particular operations in which they are practised different instruments or processes, it would be superfluous to examine them here as general indications. But, there are few operations which do not be^in by a division, or do not end in a reunion. I have thought it best therefore to begin by saying a few words of diarjesis and syntheses.

CHAPTER I.

DIVISIONS.

SECTION I.

Cutting Instruments.

Laying aside laceration, pulling out, and rupture, which nevertheless are also divisions, diaeresis requires no other agents than the bistoury, the scissors, and certain instruments designed to answer particular indications.

ARTICLE I.

Manner of Holding the Bistoury,

The bistoury is of itself worth all the rest of the surgeon's armory. If it were absolutely necessary, it could supply the place of all other cutting instruments. To use it skillfully then, is an art which the surgeon should make it his first endeavor to acquire. There are three principal ways of holding the instrument; first as a table knife, secondly as you would hold sl

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h

pen, and thirdly as a drill -bow. Each of these modes presents varieties which I intend briefly to point out, giving to each the name of position.

FIRST POSITION.

Bistoury held as a Knife, the Edge downwards.

In this, which is the most frequent position, the handle of the instrument enclosed in the palm of the hand, and retained there by the ring and little fingers, is pressed on either side by the thumb and middle finger, at the junction of the blade with the handle, whilst the fore-finger rests upon the back of the blade: thus held, it presents the utmost firmness and security, and it can be guided in every possible direction ; if it is necessary to employ much force, to cut into solid tissue, to cut out large flaps or vast and indu- rated tumors, or to pair off" some dense excrescence, nothing would be easier than to bring the middle and index fingers before the others, upon the side of tlie handle, and to hold the instrument in full grasp.

SECOND POSITION.

Bistoury held as a Knife, the Edge upwards.

Instead of being held towards the tissues, as in the preceding position, the edge of the bistoury should be sometimes turned in the contrary direction. In that case, the front and not the back part of the handle is pressed against the palm of the hand, and the thumb with the fore-finger presses the sides, while the middle is beneath the handle with the third and little fingers. Thus, turned upwards, or in the direction of the back of the hand, it is in the best position for cutting from within outwards, in certain cases where more force than celerity is required in the movement.

THIRD POSITION.

Bistoury held as a Pen, the Edge downwards and the Point forwards.

In this position the handle of the bistoury passes from the back of the hand on the radial side of the first metacarpal bone, to be held as in the fii-st position by the thumb and the first two fingers. The remaining fingers are left free to find some point of rest near the part to be divided.

FOURTH POSITION.

Bistoury held as a Pen, the Point backwards.

If the edge of the instrument be turned towards the tissue, and the point directed forwards, it will be found to be held exactly in the same manner as a pen, and this is the characteristic of the preceding position.

Manner of Holding the Bistoury.

But, in the fourth position, the middle finger is pushed forwards on one side of the blade, and then flexed, turning the point of the instrument by this

OPERATIVE SURGERY. • 3

motion towards the body or wrist of the operator, so that its edge looks towards the palm of the hand, from which it is separated by a triangular space varying in the dimensions of its posterior base. The greater part of delicate incisions and dissections require the first mode ; the second is more applicable when it is necessary to pierce some deep part, and cut outwards from the puncture.

FIFTH POSITION.

Bistoury held as a Pen, the Edge upwards.

To dissect or to cut forwards, in order to enlarge certain openings which are deeply situated, we are often obliged to change the position of the edge of the bistoury, and turn it in the same direction with the dorsel aspect of the hand, and to present the back towards the palmar side ; and except that it is necessary to substitute the index for the middle finger, the instrument may be held with the point either forwards or towards the wrist of the operator, as the fingers may be flexed or extended, and as it may be desirable to carry a continued incision, or merely to divide attachments.

SIXTH POSITION.

Bistoury held as a Drill-bow.

The sixth position holds in some sort a middle place between the first and the second. As in the one, the handle of the instr^iment rests on the interior of the hand, and as in the other, it is held only by the ends of the fingers. This mode differs nevertheless from both in the fact, that with regard to the axis of the fore-arm, the bistoury is held in a horizontal plane, and that the pulp of the extended fingers supports it on one side, whilst the thumb is applied upon the other. The three varieties of this position are easily distinguished. In the first, the edge of the bistoury looks downwards. In the second variety, which approaches nearer to the second position^ it is turned upwards, and in the third, it is turned to the riglit or the left, while, instead of holding the handle by its flat faces, the finders and the thumb press against the back and front. The first of these positions, giving facility to light and delicate strokes, is particularly indicated in scarifications, such as of inflam- matory erysipelas, where we have decided to operate by incisions, and also for laying open large subcutaneous abscesses. Recourse is rarely had to the second position, unless for the purpose of cutting small lamellae, guiding the bistoury along the groove of a director. The utility of the third position also, is only acknowledged in a small number of cases, when, for fear of wounding some subjacent organs, it is thought necessary to cut horizontally' by successive laminae, as in the operation of planing.

Manner of holding the Scissors.

The manner of holding the scissors is familiar to all. It is not necessary for me to point it out. I will only say, that instead of the index or middle finger, the fourth or little finger and the thumb should hold the rings of the instrument ; the two first fingers being placed before, either about the handles, or upon one of the flat faces, add to the firmness and precision of the move- ments. The use of knives, or of particular bistouries, will not be described except in connexion witli the operations which require them.

4 NEW ELEMENTS OF

SECTION II.

Different Kinds of Incisions.

All incisions are made in one or other of two general modes, the definition of which will serve as a principle of classification. The first class of incisions consists of those which are made from the skin towards the deep parts, and is called from without inwards; the other class, are those which are made from the midst of the or2;ans towards the exterior, and are called incisions from within outwards. The choice of the first or second of these modes must be decided by a variety of circumstances, whicii will in their proper order be developed in the sequel, and which will, in the discussion of the opening of abscesses, be in a great measure recapitulated. Whichever method is adopted, incision is practiced: first, towards the operator; secondly, from the operator ; thirdly, from left to righty when the handle or point of the bistoury is directed either immediately across, or obliquely backwards and outwards M'ith the right hand, the fingers bent, and the wrist or fore-arm previously extended ; fourthly, from right to left, if with the same conditions, the left hand is used. The direction from left to right being the most natural, is of course the most usually followed, so that the others might strictly be ranked amongst the exceptions, and are at least not so frequently indispensable. A single or simple mch'ion , is that which is made in the same direction throughout, and which can be terminated by a single stroke of the bistoury. It is nearly always made to the right; and, by repetition and combination varied in a thousand ways, gives rise to those complex and multiplied incisions, whose forms, heretofore so various, are now reduced to the V, the T, the -f, the ellipse, the oval, the crescent, and the L.

Art. 1. — Simple Incisions.

Direction. — Tn the absence of special indication, the incision should be parallel ; first, to the greatest diameter of the part ; secondly, to the direction of the arteries, the large veins, or the principal nerves ; thirdly, to the direc- tion of the fleshy fibres, the muscular masses of the tendons ; fourthly, to the natural folds of the teguments ; or, fifthly, to the great axis of the tumor.

On the dorsal and plantar surfaces, and on the sides of the foot, about the knee, before, behind, and on the outside of the thigh, it is made in a direction parallel to the axis of the limb, because the vessels, the nerves, the muscles, and the tendons there have mostly that direction. Behind the ankles it is made somewhat concave forwards, because in this part the same organs are necessarily somewhat cui-ved in order to reach the sole of the foot; on the inner side of the thigh it should be oblique, to correspond with the course of the muscles of the leg, of the saphena vein, or of the femoral artery; in the groin it is never made in the direction of the great furrow of that part, except when they are intended to go no deeper than the subcutaneous cellular tissue.

On the breech the muscles serve as guides, and the same is true on the sides of abdomen, while before and behmd this cavity, the incision should follow the axis of the body ; the chest requires the observation of the same rules, except towards the arm -pit, where it is better to follow the axis of the trunk than the fibres of the serratus. In the hand, reference should be had to the wrinkles of the palm, and in the bend of the arm, to the arrangement

OPERATIVE SURGERY. 5

of the veins, muscles, or arteries, rather than to the axis of the limb. About the neck incisions should correspond in direction with the muscles, the vessels, or the axis of the part, as the circumstances of each case may require ; and it is seldom or never right to cut directly across, except in the bottom of the fossa, above the collar bone. On the cranium they should be parallel to the muscles, or the principal arteries. About the eye-lids they should be made in a semilunar curve, concave towards the eye, to correspond with the muscles, the wrinkles, and the arteries: it is much the same with the lips. They should be straight on the nose, and oblique in this or that direction upon the other parts of the face, according to the wrinkles on which they fall, or to the vessels or the muscles over which they are to pass. Lastly, on the ear the projections of that organ should regulate the direction of the incision. ' The nature, the comparative depth, and the form of the disease are the only circumstances which can justify an infringement of these rules.

Stretching the Skin. — There are several ways of fixing the skin in order to make a simple incision.

1st. With the cubital side of the left hand, the thumb acting in the opposite direction.

2d. By graspino; the part underneath with the whole hand.

3d. With the extremity of the four fingers placed in a line parallel to that in which the bistoury is to pass.

4th. By taking up a fold of the integuments.

5th. Causing the tissues to be stretched by assistants in order to keep both hands free.

6th. In drawing on one side whilst the assistant pulls the integuments towards the other.

With the thumb and little finger the part must be accurately supported, and the tension is seldom equal on every point, unless we use the assistance of the index and even that of the two other fingers. To grasp the organ is a method which can only be applied to limbs, or to certain tumors which are verv prominent or pendulous.

With the ends of the fingers the skin is firfhly fixed, and the nails give support to the instrument, but the tension is incomplete, and is only made on one side. To take up a fold of the integuments is only proper in a few cases, and is not always practicable. The hands of assistants or of one assistant are never so safe as that of the operator himself, and should never be put in requi- sition, except in cutting around, or on the surface of tumors, and large masses of flesh ; the first mode is therefore the best, and it is for the surgeon to decide under what circumstances it will be necessary to resort to either of the others.

§ 1. Incisions from Without Inwards,

To cut from without inwards, the bistoury maybe held in the first, third, or sixth position, according to the degree of force to be emploved, the situation of the disease, or the extent to which the incision is to be carried. The convex bistoury which, all things being equal,cuts better and with less pain, has neverthe- less the inconvenience of leaving, more commonly than other kinds of bistoury, portions at the two extremities of the incision imperfectly divided, and is ill adapted to operations somewhat delicate, which pass deeper than the skin, and to incisions made upon excavated surfaces, and require that tlie instrument should act principally witli the point. The straight bistoury, tliough less rapid in the commencement of the incision, is nevertheless afterwards incomparably

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in the commencement of the incision, is nevertheless afterwards incomparably more convenient, and could strictly be substituted for the other in ^very case.

In the first position the convex bistoury is rested with the most prominent point of tlie blade on the middle of the space supported by the thumb and fore-finger, and then drawn from left to right, as far as the point where the incision is to terminate, so as to divide the entire thickness of the skin at the lirst sweep, and even deeper still if no important organ be situated beneath. In order to leave as small a trace as possible imperfectly divided, care should be taken to apply the instrument with firmness in the beginning, and to raise the wrist in terminating the incision. Held in the third position the bistoury will cut more with the extremity than with the prominence of the blade, and will be less likely to wound or injure the parts beneath, or to leave long traces at the ends of the incision, but it loses much of its lightness and of its other advantages. In the sixth, it cuts like a razor, dividing with case the finest :ind softest layers, as well as the thickest and most tense, but its stroke wants firmness, and seems like cutting upon air.

The straight bistoury, held in the first position, pressed like the other, and drawn and witlidrawn in the same manner, acts principally with the point. Jt does not penetrate so well, but cuts more equally and leaves scarcely a trace not fully divided. In the third position, the point should be sunk, by puncture, to the intended depth of tlie incision, the hand being raised for !hat purpose : in continuing the incision, the wrist should be brought down by degrees, but again elevated at the end of the operation, so that the edge may be at that point perpendicular to the surface cut. The whole process begins v^itli a motion like that of a scale-beam descending-, and ends with a corre- sponding motion upwards. In this position, the little finger, placed on the right of the incision, serves as a support for the hand, and gives steadiness and security to the successive stages of the operation.

Lastly, when held in the sixth position, the straight bistoury acts in the same way as the convex when held in the same manner ; with this difference, that it does not penetrate so t[uickly nor so well.

§ 2. Incisions from Within Outwards.

An incision of this class is sometimes made without the aid of a conductor, at other times with ; sometimes with the bistoury, and sometimes with the scissors ; sometimes in a part yet undivided, and sometimes through a previous division.

WithmU the conductor, with the bistoury — without a previous division, inci- sions are made either towards or from the operator. When the incision is made, the instrument is held in the second position and entered by puncture, after which the wrist is quickly raised, so that the bistoury may' divide the tissues from its heel to the point, acting as a lever of the second kind ; or else we raise the point by depressing the hand, so as to pierce the skin a second time, and finish by drawing the bistoury towards the operator with the edge upwards, so as to divide the parts between the points or the entry and exit of the instrument, causinj^ it to move as a lever of the third class. When the incision is made in a direction towards the operator, the instrument is held in the fourth position, with the ring-finger fixed on the side of the blade at such a distance from the point as properly to limit its progress. It is then entered b}^ puncture, and wlien it has penetrated to a sufficient depth, it is rapidly brought to a perpendicular position, acting like a lever of the second class.

OPERATIVE SURGERY.

§ 3. Upon a Director.

When there exists a previous opening, the instrument is passed through that, either towards or from the operator, without a conductor, when this can be easily done ; otherwise laid flat on the fore finger, or guided by a grooved director, if the finger would occupy too much space. After this is done, the operation is performed as mentioned above. The director is held in tlie left hand, like a scale-beam or a lever of the first class, of which the fore-finger placed beneath forms the fulcrum, the thumb upon the plate the power, and the layers which the point tends to elevate the resistance. To glide along the groove with ease, the bistoury must then be held in the second, fourth, or sixth position, with the edge upwards. Those which have no cul de sac, present no obstacle to the point of the instrument, which then can be passed directly onwards until it emerge by piercing the skin ; but where there is a cul de sac, the bistoury must be raised as a lever of the second grade. The narrower the bistoury the more easily it advances. The convex bistoury is not adapted to such cases, because its extremity is too lar^e, and its point, depressed too far behind, easily comes against the groove of the director.

After having placed the director, another method maybe used; feel for the end of that instrument through the skin, and, having ascertained the point under which it projects, cut upon it by a slight transverse incision, so as to make a counter opening. The point of the instrument, guided by the groove of the conductor, is then slipped towards the handle, or^from right to left ; or even, without making a previous incision, the point of the bistoury held in the fourth position, may, by puncture, be brought in contact with the director near its beak, and carried in the fourth position rapidly along the groove towards the body of the operator.

In using the scissors you introduce one branch upon the finger, or upon a director, leaving the other on the outside, and then cut from you as briskly as possible all that you design to divide.

§ 4. With a Fold of the Integuments,

With timorous or refractory subjects, if the skin is very unsteady or waver- ing, or if it is desirable not to penetrate beyond it, it is sometimes necessary to take up a fold of it before cutting. This fold, which varies according to the extent to which the incision is to be carried, should be held on one side by an assistant placed in front, and on the other by the operator. It is then divided from its free edge towards its base, as in the incision from without inwards, or by puncture in the contrary direction ; that is, passing through from the confined towards the free edge as in making an incision from within outwards. The pressure made upon the integuments in folding them up, deadens their sensibility, and consequently renders the pain less acute. Besides, as the bistoury only pierces the parts like an arrow, there is no risk of failure or embarrassment from the movements of the patient. The objection to this mode of practising incisions is, that there is rather less certainty of giving exactly the suitable extent than in those above described.

§ 5. Horizontally,

The horizontal incision is that which is most rarely practised, and only when it 16 desirable to cut out successively over some one point the various laminae

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concealing an organ, which is to be avoided. The bistoury is then held in tlie sixth position, with the edge on one side; the left hand armed with fine pincers, lifts up successive layers of tissue, while the right hand shaves oft' the portions thus raised with the bistoury held horizontally below the beak of the forceps.

This kind of incision is almost exclusively reserved for herniotomy, but is yet occasionally used in some other operations, such as those for aneurism.

Art. 2. — Compound Incisions,

Complex incisions, being but a combination of simple ones, are necessarily subject to the same rules of practice, and may in the same manner be executed, from without inwards, or from within outwards, and with or without a director.

1. The V incision is composed of two straight incisions, which, starting from the same point, terminate at a greater or less distance apart, according tc the extent of the triangular space which is to be included between them. The angle should, in the absence of particular counter-indications, be turned towards the lowest part, and the incisions should be made towards and not from that point. The reason of this rule, which at the first glance seems inconsistent with the aim proposed, is, notwithstanding, easily comprehended. If the bistoury were applied to the extremity of the first incision, in order to execute the second, it would press upon or weigh down the edge now deprived of support before it could cut, occasioning more pain than is necessary, and producing a contused and irregular incision. If the convex bistoury were used, there would be the additional inconvenience of making a scratch beyond the external border of the first incision, or leaving the second imperfect near the angle. In beginning at the base of the triangle, no inconvenience of this kind will be sustained. The skin maybe as easily held tense tor the second incision, as for tlwi fii'st. Tiie bistoury itself stretches it in some measui e in approachin;^ the apex of the triangle, which it isolates and completes without difficulty, if the surgeon take the precaution of raising the wrist in finishing. To detach the flap of integuments, which has been limited by such an incision,, it must be seized at the point with the pincers, for which it is well to sub- stitute the fore-finger and thumb, as soon as it is practicable. The right hand provided with the straight or convex bistoury (no matter which), is held in the third position when you intend to cut towards yourself, or by bending the fingers; in the fifth position, on the contrary, if you intend to cut from youy or by the extension of the fingers ; dissect up the flap by free sweeps from below upwards, or from the apex to the base, taking care to raise with ita layer of cellular tissue as thick as possible. Formerly the V incision was thought indispensable in the operation of trepanning the temple ; at the present day it is absolutely required nowhere, but is occasionally wsed in the removal of certain tumors, and in certain disarticulations.

2. The oval incision, which will be discussed under the article of Ampu- tations, differs from the incision V in this, that it continues from one branch of that incision to the other, passing round the base of the flap, which is thus completely isolated.

3. The cross incision consists, as its name indicates, of two simple incision» which cross each other at right angles. Only the second of these incisions, needs to be described. It is commenced at the left side of the first division -with the same precautions as in all other straight incisions ; but, instead of being carried across without interruption, it is terminated with an elevation of the wrist at the point where it touches the first incision, of which it cuts only the left lip. To complete it the operator changes the position of the bistoury^

OPERATIVE SURGERY. if

unless he prefers to take it in the other hand, and repeats on the right the operation which he has just performed on the left. In short, it is an incision made in two separate steps, of which the two portions, having a common termination, meet in the middle of the first incision ; and which does not allow the instrument to roll or fold under its edge the second lip of the first incision, as it would almost inevitably do in passing from the left to the right, so as to complete the incision at a single stroke.

The dissection of the four triangles which result from this double division, is but a repetition of that which has been already mentioned in speaking of the V incision.

4. The T incision difters from the crucial incision in but one point, that is, instead of passing on both sides the second incision stops upon the first, forming with it only two right angles ; so that it consists of two cuts, instead of the three, which form the crucial incision. For the rest, the same precautions are to be taken in the division of the tissues and in the dissection of the flaps, and the manner of holding the bistoury is the same in both cases. The crucial incision, and the T incision, being mere modifications of each other, are indicated whenever a straight incision is insufficient to expose the tissues which it is intended to isolate or remove. The relative value of either should be determined by the size of the part to be exposed.

The bistoury, carried flat between the integuments and the tissues beneath, and there turned so as to cut from within outwards, or otherwise, conducted along the groove of a director, would convert a simple straight incision into a complex one, as securely as if it were directed upon the skin cutting from without inwards. This method is indeed sometimes preferred.

The elliptical incision, which becomes in almost every case necessary in the operation on a subcutaneous tumor where it is thought proper to remove a portion of the integuments, is formed by the union of two curved incisions, with the concavity of each presented, towards the othei*. To trace out the direction with ink has no other inconvenience than that of being useless, except in certain rare cases, where, by the least deviation of the bistouj^, great hazard would be incurred. This is a case where the hand of an assistant is of advantage to hold the skin on one side, whilst the surgeoa stretches it upon the other. The rule demands that the lower incision should be first made, so. that the bleeding which might be occasioned by the operatioa^ should not interfere with the performance of the other. It is made by cutting from left to right, or towards the operator, while the assistant raises- the tumor, and the operator stretches with the left hand the integuments beneath. This arrangement is reversed in making the second incision ; for here the surgeon himself usually draws towards him or depresses with the ends of his fingers the mass to be excised, while the assistant stretches the skin above, taking care at the same time that this tension is exerted at one time in a transverse and at others in a longitudinal direction, in such a manner that the instrument, carried to the left extremity, or to the upper part of the inferior incision, can make the incision as neatly in the beginning as in the middle of its progress, and will have no folds of skin rolling before it towards the end.. It should not be forgotten, moreover^ tliat this upper incision being^ carried above a depressed part, needs but a slight degree of curvature during, the passage of the knife to become deeply concave immediately afterwards, when the parts are left to assume their natural posltioui

Crescentic incision, — Some persons have thought of late, that a double curved incision, with both parts convex in the same direction,, could be, in 2

10 NEW ELEMENTS OF

certain cases, advantageously substituted for an elliptical incision. The crescentic portion which it circumscribes, leaves a wound with a loss of substance, the convex edge of which may be dissected and turned over on its base, so that it can be afterwards applied to the concavity of the other edge, and over the bottom of the hollow left by the operation. Might it not be adopted for the extirpation of extensive tumors where it is possible to preserve nearly all the skin, and where a straight incision would not suffi- ciently expose the disease? It would afford the same advantages as an elliptical incision, without opposing so strongly an immediate reunion. — The dissection of the flap described by a simple semilunar incision, where no skin is to be removed, may be performed in the manner above described under the T, the V, and the crucial incisions, for which this is frequently substituted. In conclusion, I will add, that by dissecting up the lips of any incision whatever, from the subjacent parts to the extent of an inch or more, according to the wants or situation of the wound, you are often able to cover extensive losses of substances, since the integuments thus raised may be stretched to an astonishing extent, and permit us to bring into contact the borders of an assemblage of wounds which would have been thought incapable of meeting.

The L incision, which is used in exposing some large arteries, as the carotid and subclavian, need not be here described.

Art. 3. — Incisions applied to Abscess — to Collections of Fluids.

It may be boldly asserted that the bistoury is the sovereign remedy for abscesses, whether hot or cold, diffused or circumscribed, vast or incon- siderable. The pain which it produces is nothing in comparison to the acci- dents which it prevents ; and I can scarcely comprehend why it is that its use is so often abstained from, merely because fluctuation continues obscure in the sequel of phlegmonous inflammations. Since it is a very eflfective means in the treatment of subcutaneous inflammations themselves, suppose even that the sac is not opened, what evil can result from its application ? It is a perfectly simple wound, winch relieves engorgements, and presents no obstacle to the disappearance of the original malady ; but, on the contrary, favors, in almost every case, its progress towards recovery. After having witnessed the ravages secretly committed by the presence of pus, either infiltrated or effused into the organs by the absorption of this fluid, or by its migrations through long tracts of cellular tissue, it is impossible to hesitate between such dangers and the fear of making a useless incision.

Every kind of straight incision is applicable to abscess, the further treatment of which I shall not here discuss. The large abscess lancet, which was formerly thought so indispensable, has entirely fallen into disuse for this half century past. The common lancet, which sometimes takes its place, is insufficient, except for a very few cases ; as where the skin is very thin, and the abscess very superficial or small ; and even then the bistoury should be preferred, if there were not certain beings occasionally to be found who are terrified at the very name of ** bistoury," but who would submit without reluctance to the stab of a lancet.

§ 1. Incision from Within Outwards.

There is no circumscribed abscess which cannot be opened from within outwards. The operation is rapid, and gives but little pain ; the instrument

OPERATIVE SURGERY. 11

penetrates by puncture ; its point plays in the interior of the sac, and its edge being raised so as to cut from heel to point, stretches the cutaneous covering as fast as it divides it, instead of pressing it down. In a case of this kind, the straight bistoury is the only one that should be used. It is never held in the fifth position, except to cut from you at the bottom of some cavity, as for instance, in certain abscesses in the hollow of the cheek. But it is very frequently used in the second position. When it is thus held, it affords all necessary force and ease ; it penetrates with great facility in a direction from the operator with any degree of obliquity that may be. desired, and nothing is more simple than to sway it as a lever of the second class, by raising the wrist at the proper moment for terminating the incision. The fourth position is still more convenient; the support which is given to the hand by means of the ring and little fingers, is an advantage which the second does not present in the same degree. The puncture is made towards the surgeon with the hand and fingers flexed ; it is only necessary to extend these at the same time that the handle of the bistoury is drawn back to assimilate it to a lever of the second class, as, in the previous case, to make the incision from heel to point, and to divide the outer wall of the abscess through its whole extent with equal firmness and celerity. This is the position which incurs the least risk from inconsiderate movements or refractory behavior in the patient, and I have been long in the habit of using this in preference to the others, where there was no special indication to the contrary. The puncture being made, the remainder of the incision takes place almost spontaneously. Upon occa- sion, this position will be as convenient as the second for transpiercing through and through a hard or superficial sac, as it is sometimes proper to do in cases of furunculus or anthrax, and of some prominent abscesses on the limbs, covered by an extenuated portion of skin. The best bistoury in such a case, and indeed generally for opening abscesses from within outwards, is one'with a narrow blade accurately grooved and perfectly keen. It is held more or less obliquely, according as the deeper wall of the abscess is more or less distant from the surface ; if this were touched, and cut with the point of the instrument, the inconvenience, in ordinary cases, would scarcely merit attention ; but the danger would be so great, when the abscess lies before one of the larger arteries or an important viscus, that the mere idea of such an accident is dreadful. It is a precaution, then, of prudence, if not of necessity, at once, as soon as the cessation of resistance or any other circumstance gives notice that the instrument has entered the cavity of the abscess, to turn it into a position more nearly parallel to the axis of the limb or of the diseased part, and to prolong the incision only by raising and withdrawing the bistoury. In practising this mode of incision, the stretching of the parts with the left hand, whilst the right hand operates with the bistoury, although useful is not always necessary. If the collection is large, superficial, or situated at a great distance from any delicate part, you may even dispense with the support of the fingers, and depend solely upon the movements of the hand, as if you were swaying it in the air. After a little practice in the use of the instruments, one of the fingers detached from the others, and placed upon the side of the blade, secures you against the danger of pushing the point of the bistoury to too great a depth, and takes the place, in the greater number of cases, of every other precaution.

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§ 2. Incision from Without Inwards.

The diffused abscess, the deep abscess, and those which develop themselves around the articulations, upon the passage of vessels, and upon the surface of organs, which it would be dangerous to touch or pierce, usually require that the opening should be made from without inwards. The first require large incisions, either with the straight bistoury in the first or in the third position, or the convex bistoury held in the same manner. With the straight bistoury in the first position, the incision is made by applying the whole length of the edge upon the skin, as for deep scarifications, and it is drawn backwards, and at the same time pressed so as to cut rapidly from heel to point. In the third position the point is at first plunged directly into the sac, and the incision is then continued by bringing down the heel and the rest of the edge, the point remaining stationary. The bistoury becomes thus a lever of the second class, but working from above after the manner of a straw-cutter. With the convex bistoury, held in the first position, you cut quick and deep; it suits generally better than any other such a purpose as this, and is particularly well adapted by its form to cases in which it is necessary to make several incisions at some distance apart, over the surface of a purulent collection. The second class of abscesses divides itself naturally into two orders: — 1st. Those which are covered over with a thick and dense layer, and do not lie upon any organ which it is important to avoid. 2dly. Those which lie so deep that their precise seat cannot be ascertained, or which it is not prudent to expose at a single stroke. There is no objection to attacking the first kind by puncture and a depression of the handle, using the straight bistoury held in the third position ; for example, on the eminences of the hand, on the pahnar surface of the fingers, on the external sides of the limbs, on the breech, on the cranium, and in the posterior region of the trunk.

The incision by puncture is not applicable to the second class of abscesses. If these are to be opened with the straight bistoury, it must be drawn with the edge towards the abscess in the first or third position, and divide, by successive strokes, the parts which conceal the matter, while the fore-fingei* of the left hand is, from time to time, applied to the bottom of the wound to ascertain the fluctuation or the probable depth of the abscess. This is the proper mode of operating for abscesses formed under aponeuroses, between the crural muscles and the thigh-bone, in the hollow of the ham, about the humerus, in the thickness of the abdominal parietes, or of the muscular covering of the chest, or on the forepart of the neck.

Unless we proceed with the same caution in the neighborhood of the joints, we shall run the risk of opening the subjacent capsules and the synovial membrane, and of exposing bony surfaces to the air, whilst these incisions, made through successive layers, do not prevent you from entering the capsule at last, where this is deemed indispensable. If the abscess is extensive, and its external wall sufficiently extenuated, the convex bistoury is preferable, because it makes a cleaner incision, and gives less pain. When its seat is less clearly indicated, we have recourse to the straight bistoury, which is better adapted to the more delicate operations.

The same principles will guide us in cutting about an artery, an aneurism, or a hernia, near the pleura or the peritoneum; because then tlie operator is sure that he shall not pass the interior wall of the sac before meetin«5 with the pus, and that he may interrupt the operation when he chooses, to feel the pulsations of arteries, and to ascertain with the finger upon what tissue he is working:

OPERATIVE SURGERY. IS

whereas in operation by puncture, there is nothing to guarantee the safety of the concealed organ when once the bistoury has begun its progress. How many times has the instrument been plunged, in opening an abscess, into an aneurism, or a large healthy artery, or a hernia, and that too by celebrated practitioners, simply for want'^of paying proper attention to these indications !

One of the principal faults to be found with incisions from without inwards is that of pressing upon the abscess in opening it. It is no sooner opened for some few lines, than this pressure forces out the pus, lessens the tension of the partitions, and renders it almost impossible to continue the incision at the same stroke; this, however, should only be understood of slow or gradual incisions. Those which can be made briskly with the whole edge of a straight bistoury, or what is better, of a convex bistoury held in the first or sixth position (as"^in collections of great extent, situated immediately beneath the skin), have not the same inconvenience, and are in fact the least painful of all.

With a Director. — To enlarge the opening of an abscess, the finger or the grooved director serves as a guide to the instrument, and the bistoury or the scissors are directed in the manner already laid down in speaking generally of incisions from within outwards, with the aid of a director and a previous opening.

§ 3. Complex Incisions.

The same rules will govern the operator if, instead of a simple incision, he wishes to open an abscess by an incision in the shape of a V, a T, or a cross. Modifications like these, which are more frequently useful than the greater part of practitioners seem to admit, are of very great advantage in cases of subcutaneous collections with alteration of the skin. The first opening being made upw^ards, and to the left for instance, the director finds itself a passage under the skin to the right ; a second incision is then made in the latter direction, and the abscess, laid open, presents a V incision. When the cul de sac is on one side, an incision in T is made, and in collections where it is desirable to lay the bottom entirely open, the crucial incision finds a place. Thus we see that, except elliptical or semicircular incisions, every description of division can be called in in the treatment of purulent collections, but yet that the simple incision is almost uniformly the only one required.

Art, 4. — Incisions applied to the Dissection of Tumors and of Subcutaneous

Cysts*

In the excision of cysts and tumors, contrary to what has just been said of the treatment of abscess, the complex excision is most commonly indicated. When the whole of the skin should be preserved however, a simple incision will often suffice. Vascillating or very movable tumors covered with sound and flexible skin, do not always require a complex incision. The testicle, the breast, and several degenerate ganglia, are often extracted by a simple straight incision, although they may have acquired a very considerable size.

§ 1. Form of the Incision.

1st. The straight incision should pass from a half-inch to an inch, or even more than that, beyond the limits of the tumor at either end, and penetrate

14 NEW ELEMENTS OF

the entire thickness of the adipose layer. There are then several methods of continuing the operation. One of those most frequently adopted is, to seize with the forceps or the first fingers of the left hand, each of the lips of the wound, and to dissect them, one after the other, from the wound outwards, with tlie rio-ht hand, whilst an assistant draws the tumor in the opposite direction, with his fingers, a crotchet, or a hook. Others prefer, where the parts are sufficiently loose and flexible, to press with the thumb and fingers of one hand through the skin, upon the sides of the body to be extirpated, as deeply as possible, as if to expel it through the wound, whilst with the other hand, the adhesions of the cellular tissue are cut perpendicularly, in proportion as the borders of the incision separate or withdraw themselves backwards. If the tumor is pendulous you attain the same end by grasping it below with the whole palm or the hand. By this method the pain is generally less, the operation at once prompt, easy, and sure, but unfortunately is not in every case appli- cable. Some find it more convenient to hold the tumor themselves, and to cause the lips of the incision to be drawn back by an assistant, whilst they dissect and detach it from its bed. Indeed this is the best way to operate in almost every case as soon as its anterior face has been exposed. In adopting any other course for the purpose of separating it from the deeper tissues, the surgeon exposes himself to the danger of penetrating too far, or else of not removing all the diseased parts. He can in this point of view rely only upon the testimony of the fingers, which have however the inestimable adivantage of being able to feel arterial pulsations if they present themselves, and to confine their movements without difficulty as well as to adapt them to the action of the other hand.

2d. V Incision. — It is an erroneous idea that the elliptical and crescentic incisions are the only ones which permit the actual abstraction of substance from the integumenti The V incision has more than once fulfilled the same indication. By cutting several Vs or triangular flaps, continuous at their bases upon the surface of voluminous tumors, there may be raised with the diseased mass a star of integuments, which does not afterwards hinder the covering of all the bloody surface with the remaining triangular portions. M. Delpech and M. Clot, have had recourse to a similar device in the extirpation of elephantiastic tumors, of which they have given the first notices, and I have seen M. Roux operate in this way for the removal of a fungous hematodes from before the knee.

3d. The T incision or a crucial incision, is only used where the skin, of which it is not desirable to remove any part, is not flexible enough to allow a straight incision properly to expose the tumor. It is also indicated in certain cases, conjointly with the elliptical or crescentic incision 5 for example, when the base of a cyst extends so far beyond the flap of integuments which has just been circumscribed that it appears difficult to raise alternately the lips of the wound, or where it is desirable that the flaps should not be very large. In this case all that is to be done is to divide transversely one of the ed^es of the ellipse or crescent for the T incision, or both of them successively tor the cross.

§2. Dissection of the Flaps,

Whatever may be the then form or extent, these different incisions give rise to flaps which it is necessary to raise from the apex to the base. This is usually the most delicate part of the operation, and is not executed by precisely the same rules for tne exposure of all kinds of tumors.

OPERATIVE SURGERY. 15

1. Concrete Tumors. — Whenever it is necessary to operate for the removal of adipose tumor, or any other solid mass free from malignity, the edge of the bistoury should be more inclined towards the tumor, or the deep parts, than towards the skin, since the thicker the flap is left by raising with it the cellular or adipose mass which lines it internally, the more life it retains and the more it is disposed to attach itself to the layers beneath. If inclined in the opposite direction, the instrument would leave the skin entirely naked, might even pierce it, and render its preservation or restoration impossible, while even, if we should proceed too far inwards, I cannot see what evil could arise from it.

2. Cancers. — Carcinomatous tumors deserve a little more attention. Tlie skin should not, indeed, be denuded, but it is necessary at the same time to avoid turning over with it the least trace of the morbid tissue.

S. Cysts. — The removal of encysted tumors, of sacs filled with matter wholly or only partially liquid, which it is desirable to remove without opening them, require still more care ; the sides of the cyst are sometimes so thin that the least pressure with the edge of the bistoury divides them ', the bag is quickly emptied, and the tissues can no longer be held tense; the operation which, without this accident, would have been one of the most easy and simple, becomes immediately most laborious, and even in some instances insusceptible of completion. It is necessary then, although we endeavor to preserve the cellular tissue in exposing a cyst, to turn the edge of the instru- ment a little more towards the integuments than in the direction of tiie tumor, whenever the parietes of the cyst are superficial enough, or appear thin enough to be easily pierced.

For the rest it is well to remark, that certain cysts do not require so much caution, and that the operation may be confined to cutting through the whole anterior wall by a simple incision, by a T, or by a crucial incision, as in the case of abscess. To this class belong deep and adherent hydated tumors, or those of which it is desirable either to cauterise the interior of the cavity or to expose it to the air, in order to occasion suppuration. We shall see hereafter that the same may be said of the encysted tumors of the cranium and some others.

4. Abdominal cysts, and collections of liquids which border upon the great cavities of the trunk, and the adherence of which to the serous membrane of the walls of those cavities is not fully ascertained, often justify a mode of incision mucli boasted of by some practitioners in modern tijnes. It is a simple incision, straight or curved, carried through, layer after layer, by successive strokes with a straight bistoury held in the first or second posiiion with the edge towards the cavity. If the cyst is in the abdomen, the mcision is carried by degrees as far as the peritoneum, which is opened over the tumor if it is found not to be adherent, and which is left untouched if it appears to be incorporated with the parietes of the morbid sac, and these very much extenuated.

The operation here terminates for the time, the seton-cord is placed length- wise in the wound, so as to keep the lips separate, and is renewed as often as may be necessary for a certain number of days. Constrained by the pressure of the divided tissues, the cyst inclines to slip between the lips of the incision, approaches the exterior, and often finishes by bursting, or by opening spon- taneously, sometimes the next day, but more frequently at the expiration of several days.

If it was unattached, this incision would occasion an adhesive inflammation, which would immediately unite the anterior partition to the laminae which

16 NEW ELEMENTS OF

cover it ; puncture or incision could then be practised without the least danger of an eftusion into the abdomen.

Art» 5. — To cause the least possible Pain,

not at surgery, are

To avoid giving pain in making incisions, is a chimera which is this time pursued by any one. Cutting and pain, in operative surge ^ two words which always suggest each other in the mind of the invalid, and the association of which it is always necessary and proper to recognize. The efforts of the surgeon should then be confined to rendering the pain of the incision as light as possible, without endangering in any degree the success of his operations.

The pretensions of several foreign writers, German surgeons among others, and of the editors of the work of Sabatier, who think that they have attained this end by never using the bistoury without having first dipped it in oil, seem to me entirely without foundation. By attaching itself to the pores of the bleeding surface, the oil would even have the ill effect of impeding the circu- lation of the fluids, the exudation of the plastic lymph, and the cohesion of the sides of the wound, if it is intended to eftect this by primary inosculation; a cerate which could be removed by washing would be more suitable if any fatty substance whatever could be of use. It cannot be denied, that after being held for a moment in warm water, as is advised by M. Richerand, or in any other way kept at the temperature of the body, according to the opinions of M. J. Guyot, the operation of the instrument can be supported with less pain to the patient, but upon a close examination the difference is not very strongly marked ; the precaution would cause too much embarrassment for it to be adopted in practice, or to be accorded any great degree of importance. It is first to the hand of the operator, and next to the qualities of the bistoury, and not to such accessory circumstances, that we are to look for the remedy desired.

Have a light and sure hand, a bistoury with a fine and keen edge, give your incision at the first stroke all the length and depth which it ought to have, if you can do so without danger ; act promptly and without hesitation ; give to the wound an extent rather too great than too small, yet without unnecessarily prolonging it, and you will have to regret or to apprehend no other pain than that which is inherent in the operation, and which no human contrivance can detach from it. Any further details on this subject would be entirely superfluous.

SECTION III.

Punctures.

Whenever the surgeon thrusts the point of the instrument through any of the tissues, he makes a puncture. Those from within outwards are almost always made with the bistoury, the suture needle, or with spring instruments. Those which pass inwards from without are made sometimes with the straight bistoury or the lancet, as we have seen above, sometimes with the needle or other particular instrument, a trocar, &c.: with a round straight needle, in certain sutures, provided with an eye at the blunt end similar to ordinary sewing needles: with a needle longer than the other, and provided with a head, a handle, or a ring, such as that used for acupuncture: with a needle cutting at the point on one or both sides, straight or curved, for the purpose of exploring certain tumors, or collections of a doubtful character, as has been recommended by many practitioners after Dr. Hey : with a needle curved

OPERATIVE SURGERY. 17

in the arc of a circle, edged, andprovided with an eye to carry the thread used in most kinds of suture : with the different kinds of trocar, when a canul^ is to be introduced into tlie bosom of some reservoir or cyst, in order to extract the fluid, without leaving any considerable wound to cicatrize.

1. By acupuncture is understood a puncture which traverses the tissues without breaking the continuity of their fibres. The needle which is used for this operation should be a regular cone. The surgeon pushes it in, rolling it at the same time between the fingers of one hand, which hold it like a pen and press it gently upon the skin, which is stretched by the other hand : thus conducted, its point removes from its track, but does not divide the organic fibres ; can traverse the arteries, the heart itself, the most essential organs, without occasioning the effusion of any liquid, and without leaving the least trace of its passage. In China and in Egypt where acupuncturation has been known and practised from time immemorial, and with great success, thej frequently strike with a little mallet on the extremity of the needle as it is held in the left hand, to cause it to enter, instead of rolling it between the fingers of the right hand. Entering it more rapidly by a simple effort of pressure, as is practised by some persons amongst us, generally causes some- what more pain than is necessary, and prudence will not allow us, on the principles here laid down, to pass it through any great vascular canal.

2. The needle assigned to ordinary punctures is more easy to conduct, and should not be so slender. Although the round needle has been recommended for opening a gaseous collection in a strangulated portion of intestine, the needle, shaped like the head of a lance, with the point straight or curved, is almost always used for the purpose of exploring. A tumor presents itself in a complex region of the body 5 you are not certain that it contains a liquid, or if it does, whether this liquid is of blood, pus, or serum ; whether it is an abscess, a cyst or aneurism. The puncture with an appropriate needle at once dissipates these doubts. If there is any fluid at the bottom of the mass, it allows some drops to ooze out and affords an opportunity to determine its nature. The small wound which is produced is immediately closed, even in the case of arterial cyst. The surgeon then takes his course with a full- knowledge of the case.

3. The use of the trocar is distinguished principally from that of the needle, by the canula which the instrument carries with it, and which becomes the conducting tube for the fluids which are intended to escape. Its point should be flattened like that of a lancet, or pyramidal with three cutting edges, and as it is generally blunt it requires some force to make it penetrate; hence the necessity of grasping the trocar with the whole hand. The handle is placed between the thenar and hypothenar eminences, or between the hollow of the palm and the last two fingers flexed. The thumb and the middle finger a little farther advanced, hold it near the root, whilst the fore- finger extended sustains the body of the instrument near the point, in order to limit the depth to which it should penetrate. In case of necessity, we might for greater safety detach the middle finger from the instrument, and rest it on the side of the point to be pierced. When it is entered, the fore- finger and thumb of the left hand hold the canula with the point of the cup downwards, whilst the right hand pulls by the handle and raises the perfo- rating shaft. The sac is emptied, and the liquid contents received in a vessel. In order to withdraw the tube it is only necessary to draw it quickly by the head, whilst the fingers which, until then had sustained it, are applied to the sides of the puncture, so as to retain in its position the skin or the outer wall of the cavity.

3

18 NEW ELEMENTS OF

CHAPTER IL

REUNION.

The reunion of the divided parts is effected by the position of the patient or of the wound, and by means of bandages, of plasters, and particularly of suture.

Art. 1. — Suture.

The bringing together the lips of a wound with the assistance of threads or of metallic wires, is the only one amongst the various means used in eflfectin^ reunion which deserves the title of a bloody operation, and the only one which it is necessary at present to examine.- The suture, which is evidently borrowed from the art of the tailor, formerly enjoyed more favor than can be easily conceived at the present day, from an examination of the practice of the greater number of operators. Since the time of Pibrac^ who 80 heartily condemned the practice, and who, in a memoir, at best by no means conclusive, endeavored almost entirely to banish it from the domain of surgery, the suture has continually lost ground in the estimation of prac- titioners; so that now it is no longer actually recommended in classical works, except in a very limited number of cases. On both sides, as usual, the bounds of truth have been transgressed. If the suture does not merit the praises formerly lavished upon it, as little does it deserve the neglect into which it ,has lately fallen. The only well-founded reproaches which can be advanced against it, are, that it prevents the due escape of fluids, increases the pain and the inflammation, and prolongs the operation. But the first of these objections lies against the immediate reunion, rather than against the suture; and it needs only to have witnessed what occurs in cases of hare-lip, staphyloraphy, rhynoplasm, genoplasm, cheiloplasm, and enter or aphy, to be convinced that tlie second and third objections have been at least much exaggerated. In these kinds of reunion, it is not the pain nor the inflammation which occasion failure ; and the operator would be fortunate indeed, if, in a like case, he had to contend with no other difllculties than these. As to the greater duration of the operation, who will venture to lay great stress upon tliis, if the suture really possess the advantages accorded to it before the time of Pibrac and Louis ? In justice it must be said, that it is not actually dangerous, as has been contended by the old academy of surgery, but yet that it is most frequently useless, and at most but seldom indispen- sable. It can only be indicated in wounds where the immediate reunion of the parts is desired ; and even in this kind of lesion there are many cases in which it might be omitted without injury. While we count it better than any kind of bandage or plaster that can be contrived, where it is necessary to bring into apposition the edges of large flaps of integuments, movable or ill- supported, or of membranous or very thin organs, it would be but a feeble resource in wounds of which the lips are firm and loaded with cellular tissue, which penetrate to the great muscles of the limbs, or of the trunk, and of vhich the sides are perpetually swayed by the movements of the parts beneath.

OPERATIVE SURGERY. 19

When the suture is used, no pressure is required ; the wound can be gently dressed without any dragging of the surrounding skin ; and the apposition, which incurs no risk of beinff deranged, extends through the whole thickness of the bleeding edges. In the use of strips or bandages, the skin is more or less irritated ; the contact is rarely perfect, and if the skin be in the least degree soft or loose, the lips of the wound continually tend to roll inwards, and only touch by the part of their thickness next the epidermis. The least effort, the least imprudence, causes a separation. Besides, this mode of effecting a reunion is not applicable to every region of the body; we do not gee that it is much more difficult to relax or to cut a stitch than an emplastic strap or a piece of linen, if strangulation should occur.

Without reposing in this method as much confidence as is conceded to it by Delpech, Gensoul, and most of the surgeons of Marseilles, Brest, and Toulon, and the principal cities of the south, an abstract of whose views has been given by M. Serre, of Montpeliers, in his treatise on '* immediate union," I am inclined to coincide with him, as also with MM. Dupuytren, Roux, and Lisfranc, in the opinion that it is worthy of resuming a more prominent place in the practice of surgery.

Of all the kinds of suture which have been devised, the science has only preserved, and in fact, only should preserve the interrupted suture (by separate stitches), the "seamed," or that of the glover, the *' zig-zag suture," the suture of Le Dran, the " twisted," and the "quilled" suture.

§ 1. Interrupted Suture.

To eff*ect a suture by separate stitches, it is necessary to provide as many pieces of thread, single, double, triple, or quadruple, as you may intend to make stitches ; taking care that they are well waxed ; next, a sufficient number of needles. The needles which were used in the last century, curved and flattened only in the anterior half of their length, straight, round, or slightly depressed laterally, and pierced in the same direction, with an extended eye, are now entirely abandoned. The needles universally preferred, are regularly curved in the arc of a circle 5 of equal width and thickness from one end to the other, except within a few lines of the point; provided with a square opening in the posterior extremity made in the direction of the thickness.

It is only necessary to place a needle at each extremity of the thread, when the stitch is to be made by piercing first one and then the other of the lips of the wound from its internal or cellular side towards the surface, other- wise one needle suffices for each ligature. All other things being equal, it is best to pierce one of the edges of the wound from without inwards, and the other from within outwards ; the operation is more prompt and less painful, draws skin less from the exterior to the interior than in the other direction, and does not involve the embarrassment of changing the needle nor the hand, in passing from one edge of the wound to the other. The right or upper lip of the wound is that with which it is most convenient to begin. The surgeon pinches it with the thumb of the left hand on the internal face, and the fore -finger prone upon the external face, raising it and turning it a little outwards, he seizes the needle already threaded with the right hand, holding it like a pen, the thumb in the concavity, the fore and middle finger, sometimes, if the needle be large, even the ring finger, upon its convex part, so as to turn it into a, lever of the third class, applies the point to the skin at three or four lines distance from the edge, pushes it by a circular movement so as to make it come out by the wound where the thumb indicates its direction and passage, leaves the heel as soon as it is sufficiently advanced, seizes the point with the

£0 NEW ELEMENTS OF

thumb on its convexity, continues itsprogress, and brings it out by turning the hand towards a supine posture. Taking it then, as at first, he proceeds immediately to the second step of the operation, which is the same with the first, except that the needle ought to pierce the second lip of the wound by commencing on its inner surface, and that the thumb should be used instead of the fore-finger to support the skin. The remaining stitches are only repe- titions of the first ; and, when several are to be made, the operation is usually begun at the right or inferior extremity.

If any reason exist for following the old method of placing a needle at each end of the ligature, the right or upper border of the wound, bold as above directed, should be first pierced from its adherent surface outwards, the hand being at first supine with the thumb on the concave side of the needle, which is pushed in with a movement towards pronation. The perforation of the other edge is made with the second needle just as in the former method.

To close the operation then, the surgeon dries the part or causes it to be dried, seizes successively each ligature by its two extremities, adjusts the co-aptation of the parts, and ties the threads one after the other at the lower side of the wound. The practice of laying lint between the knot and the wound so that the ligature shall not lie immediately upon the skin, although it has been recommended by many persons, can only be justified in cases where it is necessary to relax the suture within one or two days after its application. In every other case the ligature should rest upon the skin, without any thing to intervene. A pledget of lint, or charpie, spread with simple cerate, then some dry lint, and one or two turns of a roller applied over all, will serve to support them, where it is not thought sufficient to cover the parts with simple compresses saturated with cold water, or even to leave them exposed to the open air.

If nothing particular occurs, the thread is not to be withdrawn until about the third, fourth, or perhaps the fifth day, in order to which the lower extre- mity of the exposed part of the ligature is cut with the scissors. The surgeon then takes hold of the knot or superior extremity with the right hand, and removes the ligatures gently one after the other, whilst with the fingers of the left liand he keeps in place the skin and the corresponding lip of the wound.

§ 2. Suture of Le Dran.

Le Dran conceived the idea that, especially in enteroraphy, after having passed the threads with a straight needle, as in the interrupted suture, it would be advantageous to unite the extremities of all the ligatures in a single cord, and to retain them, thus collected, upon the exterior without a knot. His object was, to be enabled to leave them in longer, and to withdraw them separately witliout the necessity of cutting any thing. The fault of the process of Le Dran is, that a wrinkling or plaiting of the membranes is produced by 4U*awing tlie ligatures together on each side into a single cord. The suggestion, tlfccrefore, is not available, except in cases where a single ligature will suffice, or when, if several have been passed, the extremities can be retained on the a;^terior separately, as is now done in some intestinal sutures.

* Continuous Suture (seamed).

The suture, properly called the furrier's, not Pelletier's,* as it has been

• The mistake has arisen from the correspondence of the above eminent name with the French word for glover, or furrier.

OPERATIVE SURGERY. 21

written in several modern books, in which the authors have taken, not the name of a port, like the ape in tlie fable, but that of a trade for the name of a man, is that which is usually employed after the opening of dead bodies, and in veterinary surgery. Although formerly as often used in the practice of human surgery, it is now almost entirely excluded, but, I think, very impro- perly. Wounds that are somewhat long, or such as involve hollow organs, are as advantageously treated with this suture in the living body as in the dead ; and the strangulation, which it is charged with causing so easily, is • with so little propriety urged as a motive for rejecting it, that this is, in fact, less frequently followed by that accident than the other kinds of suture.

The seamed suture is so well known in the furrier's and tailor's arts, that its very name is equivalent to a description. It is commenced like the interrupted suture, except that a straight needle is more convenient than one which is curved, and that instead of piercing the lips of the wound, one after the other, you endeavor to bring them together, and take them up in the same fold, so as to penetrate them both at the same stroke. An assistant then draws and stretches out the two extremities of this fold ; the operator pinches it from above with the thumb and fore-finger of the left hand in a prone posi- tion, brings the needle to the right or superior lip at a convenient distance from the fissure, transpierces the fold, withdraws the thread, the extremity of which is held by the assistant, or which he stays with a knot, brings back tlie needle obliquely across the wound to the same side of the skin, three, four, or five lines from the first puncture, and continues in this way until the last stitch passes a little beyond the other extremity of the fold, so that the entire suture shall present a certain number of spiral turns. If it does not appear to be sufficiently closed, the two ends are drawn before being fiistened ; in the contrary case, the lips of the wound are somewhat separated. If it is well done, the lips of the wound, without being tiglit, should touch along their whole extent, and the fold should be wholly eftaced. The suture is then definitively finished, by passing each of the extremities of the ligature, like a slip-knot, around the adjacent spiral. Wiien you wish to remove it, each oblique loop is to be cut with the scissors, and then withdrawn singly ; or you may merely unfasten the upper end, and then disengage successively the different spiral turns, and draw it out entire by its lower extremity.

When both lips of the opening cannot be included in the same stroke of the needle, each turn of the seamed suture is practised exactly as in the case of suture with separate stitches, from which, in fact, as we have seen, it very slightly differs.

§ 4. Zig-zag Suture.

This suture, the idea of which is attributed to Bertrand, is made with a continued thread, the same as the one just described, and is begun and finished in the same way ; but instead of crossing spirally in front of the wound, the thread passes through the fold alternately from right to left and from left to right, forming a complete zig-zag, which leaves the anterior aspect of the bleeding surface entirely free and uncovered. In performing this suture the needle traverses the tissue, beginning with the right border; being drawn out by the left border, it again passes through, but in an opposite direction, a little above, coming out by the right border; it is then returned on this side some lines higher, and being again drawn out on the other, it is carried, as in the first case, somewhat further, so that it proceeds in a serpentine, and not in a spiral course, as in the case of the furrier's suture. Some surgeons

22 NEW ELEMENTS OF

ascribe to it the advantage of not tearing, or cutting the tissue so easily, in consequence of the lateral loops which it forms between every two punctures, and that it does not strangulate the parts like the other, by passing over them. Admitting this to be the case, it must be allowed on the other hand that it has the fault of drawing unequally the two halves of the wound, and of giving no support to the anterior surface. Although slightly improved by Beclardy the zig-zag suture is scarcely ever used, and can always, in fact, without danger or inconvenience, give place to the interrupted, or to the seamed suture.

§ 5. The Twisted Suture.

One of the sutures most in vogue, is that which is practised by means of threads passed in different ways around metallic pins, which are allowed to remain in the thickness of the flesh. Needles of iron, steel, gold, silver, lead, copper, brass, &c., straight, curved, thick, thin, long, short, round, and flat, have been employed in this operation; but at last this great variety has given wav to the almost universal employment of ordinary pins, which are every where at hand, and which are found in actual practice to answer every purpose as well as needles of the most precious metals and most ingeniously contrived. They are prepared by sliarpening and flattening the point upon a stone, and covering them with cerate. If the wound is seated in a movable part, such as the lips, or the eye-lids, the pin nearest to the free border of the organ is the first applied, the others are afterwards successively inserted. As this species of suture is to be minutely described in treating of hare-lip^ it would occasion useless repetition to detail here the particulars of the operation. When the two extremities of the woUnd are closed, or it is required to connect cutaneous flaps, the placing of the needles is not subject to the same rules. The operator then commences at the centre, the extremities, the point, the sides, or the base of the parts which he wishes to bring in apposition, according to the difliculties which he thinks he has to surmount. In this respect he must rely upon his own particular intelligence. The right lip of the wound being seized with the fingers of the left hand, as in the case of the interrupted suture, or with the forceps, the hook, or any other operative means, according to the case, he plunges tlie prepared pin from without inwards, and causes it to appear in the interior of the wound, continuinjj to push against the other lip, which he seizes in turn and pierces from withm outwards, so that the needle will come out at the same distance up)n the skin. He embraces the needle immediately with a turn of thread which he passes under the head and point, at the same time that it crosses the front of the wound, and tends to press the two sides against each other. An assistant takes the ends of this looped thread and holds them a little extended, while the surgeon proceeds to the application of the other pins.

As soon as they are all placed, the surgeon proceeds to secure them by casting the thread around them. The middle of a long ligature put above the last, is passed and crossed many times around its extremities in the form of a figure 8, then conducted in the form of a X to the next needle, and turned in the same manner around its head and point before it proceeds to the third, from which it is returned to the second and the first by renewed crossings. He then concludes by knotting or twisting the two ends together, and turning them under the body of the needle. To prevent these needles from wounding the integuments, a small strip of plaster or roll of charpie is placed under each of their extremities. Notiiing further is required, than some suitable covering if such a thing is deemed requisite.

OPERATIVE SURGERY. 23

These are to be removed at the same time as all other sutures. We com- mence bj the needle which supports the parts the least, so as to leave the removal of the others until the next day, if we do not find a reunion suffi- ciently solid. If there be any fear on this head it is proper only to remove the needles and leave the thread a day or two longer, which, being attached to the parts, and having become more or less consolidated, perform the office of adhesive strips. This fear further requires that the surgeon should care- fully support the right lip of the wound with the fingers of the left hand, while with the other he draws out the needle by the head in a straight line, or by giving it small rotatory motions.

The punctures which the needles leave suppurate a day or two, and cicatrize like all other wounds of the same class.

§ 6. Quilled Suture,

The practice of infibulation, which is still in use among some of the oriental nations, but which has for many years ceased to be used in Europe, except to prevent the approaches of the male of certain animals to the female at improper times, is a sort of quilled suture ; but instead of the metallic rods used in operating upon the mare, this suture is effected upon a human subject with threads and two small rolls of something more solid. The quilled suture is performed in the same manner as the interrupted suture, but with double threads, preserving a loop at one extremity. When they are all placed, a slip of wood, the barrel of a quill, a bougie of elastic gum, or even a rouleau of waxed cloth, or a small metallic rod, in short, any cylindrical body of a con- venient length and thickness, is slipped along parallel with the wound into each of the loops. The other extremity is then also undoubled for the purpose of receiving a similar slip of wood or other body, upon which the threads are successively tied, having previously secured an accurate apposition of the edges. Care must be taken not to exercise too forcible a constriction, nor yet to allow any gaping of the sides of the wound.

Altliough rarely indispensable, the quilled suture has always the advantage of exercising a pressure perfectly equable upon all the points which the thread is intended to bring together, of being more firm than any of the others, of being less apt to lacerate the parts, and of being particularly adapted to straight, long, and deep wounds of the walls of the abdomen and of the limbs. The only objection to this suture is, that it requires a little more time and care than the continued suture.

In using any species of suture, we must avoid needlessly multiplying the stitches or leaving them too far apart. The intervals must vary according as the strain to be opposed is more or less considerable — the incision more or less extended — the parietes to be repaired more or less flaccid — more or less difficult to be kept in apposition. A stitch for every half inch is generally sufficient; while there are cases which require one in every three lines, and others in which the stitches may be an inch apart. What has been here said however, cannot be fully understood without the aid of particular examples, which would here be out of place.

d4 ^. NEW ELEMENTS OF

COMPLEX OPERATIONS.

OPERATIONS UPON THE BLOOD-VESSELS.

CHAPTER I.

OPERATION FOR ANEURISM.

The true aneurism or a dilatation of all the arterial coats (•* the circum- scribed arteriectasis"), so lonff admitted as the most common, but the existence of which has been contested by Scarpa and Delpech, although really very rare, has yet been sometimes obseiTed. Hodgson cites several examples : M. Floret declares that he has seen a number situated at intervals on the first four intercostal arteries, and M. Berard, sen., has deposited in the museum of the faculty a preparation, which leaves no doubt upon the subject. It will be perceived in the preparation, that on its passage between the pillars of the diaphragm the aorta presents a fusiform swelling as large as the fist, in which three arterial coats are still distinguishable ; the root of the cceliac trunk, which corresponds with the middle of the tumor, is itself much dilated and spread out like a funnel, and the same appearance is presented by the superior mesenteric.

Another species of true aneurism can now be established, which also some- times claims the assistance of Operative Surgery. It is the diffused Arteri- ectasis, which only affects the arteries of the fourth or fifth order, which are then thickened, dilated, and contorted, as if aff'ected with hypertrophy, and somewhat similar to varicose veins. It, however, occupied the femoral as well as all the other arteries of the leg, in a case which was treated last year by M. Dupuytren, at the Hotel Dieu. Park has seen the posterior tibial artery in tnis state, and Pelletan the occipital, temporal, and frontal, in the same subject. All the arteries of the hand and of the fore-arm are some- times thus aflfected, as I once had an opportunity of observing at the lectures of Beclard.

Perhaps it would be well to give the name of true aneurism of the capillary system to those erectile tumors which have already received so many appella- tions, and which appear to have been encountered even in the thickness of the bones.

False Aneurism, which is characterized by a rupture of some of the coats, or of the whole tliickness of the arteries, ought, in theory at least, to bear another denomination, but practical utility rules, and this custom, though by all acknowledged to be vicious, is yet by all observed.

OPERATIVE SURGERY. 25

Tlie primitive or diffused false Aneurism arises from the opening of an artery, and consists of an effusion of blood, more or less considerable, in the neighborhood of the lesion, and in that particular diflfers essentially from all other kinds of aneurism.

In the circumscribed false Aneurism some foreign body has perforated the artery, but the blood, escaping by degrees through this opening, forms for itself a sac at the expense of the surrounding cellular substance, and of the external coat of the wounded vessel.

If the blood pass directly from an artery into a vein, by an opening in the adjacent coats of these two vessels, an aneurismal varix is the result.

If a sac is formed in which blood may accumulate between the opening in the artery and that in the vein, there is a false circumscribed aneurism complicated with an aneurismal varix^ or as some would style it a varicose aneurism.

Mixed Aneurism, or that which is formed by the spontaneous solution of the continuity of a part of the coats of an artery, and by the mechanical dilatation of those which are sound, presents itself, according to authors, under two forms. Sometimes the internal coat distends itself and bulges out so as to form a cyst through an opening in the other two, and which constitutes internal mixed aneurism, or aneurismal hernia; at other times, on the contrary, it is the external or cellular coat alone which dilates and receives the blood through a perforation of the internal and middle coats : this is an external mixed aneurism, or mixed aneurism, properly so called.

But there is no proof that the first of these two varieties is really possible, or that it has ever been positively observed : tlie fact which is attributed in all the books to Messrs. Dubois and Dupuytren, and which is brought fonvard in demonstration of its existence, is not conclusive. The experiments of M. Casamayor on dogs, and the new observation which M. Dupuytren has just communicated, do not appear to be mu«h more so. Those of Haller, who has seen, in operating upon frogs, the internal coat of the mesenteric artery form a hernia through the lesser and external coats, can have no weight here, as it will be more easy to explain, together with all that relates to aneurism, after having briefly sketched the surgical anatomy of the arterial system.

SECTION I.

Anatomical Remarks,

Every artery of any considerable size is composed of three coats, three concentric cylinders, very distinct in the great trunks, but which mix insen- sibly with each other as the vessel diminishes and can no longer be separated when it approaches its capillary extremity.

1st. The Middle Coat, also designated as the muscular coat, the yellow coat, the tunica albuginea,is composed of incomplete fibrous circles, and not of longitudinal fibres, united to one another by lamellas and filaments of the same nature ; no vessels, either lymphatic or carrying red blood, are to be traced in it, although certain observers have pretended the contrary ; it is almost inert, and breaks like glass ; if it is tightly encircled with a thread it tears, instead of being distended when it is subjected to a pressure superior to its natural power of resistance. Although it is elastic like the yellow tissue of tlie trachea and the ligaments of the vertebrae, which it to a certain 4

Xb NEW ELEMENTS OF

point resembles, it is almost impossible to draw this coat in a direction •parallel to its axis without breaking it. By its outer surface it is united to the external coat, through the intervention of an irregular layer of laminar tissue, imperfectly organized ; on the inside, the internal membrane is connected -with it by a simdar medium. As this tunic is devoid of sensibility, and of almost all the properties of animated matter, it is not astonishing that the diseases of which it is the subject should be in great measure independent of the vital phenomena, and should seem to develop themselves under the influence of the laws which govern inanimate matter. It is this coat which distinguishes the arteries from the veins, keeps them patulous after they have been cut across, determines their form and color, renders inflammation of these vessels so difficult and rare, prevents wounds or incomplete divisions of them from cicatrizing by aggktination, and enables them better to resist the lateral pressure of the blood. As the arterial trunk approaches the heart and is enlarged, or when it is destined to sustain a greater pressure, the middle coat is increased in thickness, and that rather more on the convex side of the curve than on the other. When it has reached the branches of the fourth or fifth order, and is approaching the final ramifications of the arterial system, it is observed gradually to become thinner and less distinct, until, at last, it is confounded in a common tissue with the other coats of the vessel. From this it follows that, all other things equal, the arteries are more flexible, more extensible, and less easy to rupture, in proportion as they are smaller and farther removed from the centre of the vascular system.

2d. The Internal Tunic, which has been compared by some to a mucous, and by others to a serous membrane, is smooth and generally unctuous on its free surface : on the other it adheres to the preceding coat only by a thin layer of laminar tissue, in which there exist no vessels, nor indeed any other eleuientary organ. This coat contains no fibres or vascular canals of any description, and is in fact nothing more than a lamella of a homogenous sub- stance something like the cornea, the substance of the nails and tlie corneous tissue in general, facilitating the passage of the blood through all the ramifi- cations of the arterial tree. In the small and capillary branches, this layer is no longer separated from the cellular tunic by the middle membrane, but approaches more nearly the character of a really organized substance, admitting the fluids on its external surface by direct circulation ; besides, it is thicker and more distinct, but extremely fragile. It is separated from all the