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SCIENTIA
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The
George E. Wantz
(UM Medicine 1946)
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To Burrett Sherwood M.
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respects of the
Author

20.3 C

SURGICAL ESSAYS
AND
CASES IN SURGERY.
BY
DAVID L. ROGERS, M. D., &c.
NEW YORK:
JOHN WESTALL, PRINTER, 11 SPRUCE STREET,
1850.
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PREFACE,
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I & III
CONTENTS.
OBSERVATIONS ON ANEURISM,
COITARESO WE A
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REMARKS UPON THE APPLICATION OF A LIGATURE TO THE
ARTERIA INNOMINATA,
A CASE OF FRACTURED SPINE, WITH DEPRESSION OF THE
SPINOUS PROCESS, AND THE OPERATION FOR ITS REMOVAL,
@
A CASE OF EPILEPSY, FROM DEPRESSION OF BONE, CURED
BY TREPHINING. WITH OBSERVATIONS,
ON THE UTILITY OF TYING LARGE ARTERIES, IN
PREVENTING INFLAMMATION IN WOUNDS OF THE PRINCIPAL
JOINTS, AND IMPORTANT SURGICAL OPERATIONS. ILLUSTRATED
BY CASES,
CASE OF OSTEO-SARCOMA OF THE SUPERIOR MAX-
ILLARY BONE, WITH THE OPERATION FOR ITS REMOVAL,
CASE OF OVARIAN TUMOR, SUCCESSFULLY EXTIRPATED.
(WITH A PLATE,)
CASE OF INGUINAL ANEURISM, IN WHICH THE OPERATION
OF SECURING THE EXTERNAL ILIAC ARTERY BY LIGATURE,
WAS PERFORMED WITH SUCCESS,
A CASE OF ANASTOMOSING ANEURISM OF THE EX-
TERNAL MAXILLARY ARTERY, TREATED SUCCESSFULLY
BY TYING THE COMMON CAROTID ARTERY,
PAGE
5
249
45
54
60
72
90
94
102
108

iv
CASES IN SURGERY, I. & II. ABDOMINAL ABSCESS,
III. & IV. IMPERFORATE ANUS,
V. HYDROCEPHALUS,
VI. HERNIA OF THE LIVER,
VII. GANGRENE OF THE APPENDI-
CULA CECI-VERMIFORMIS
•
A NEW OPERATION FOR THE RE-ESTABLISHMENT OF THE
URETHRA,
•
62299
DESCRIPTION OF A NEW INSTRUMENT FOR EXCISING
ENLARGED TONSILS. (WITH A PLATE,)
CONTRIBUTIONS TO PATHOLOGICAL ANATOMY, .
110, 113
118, 122
124
126
CASE OF TUMOR SUCCESSFULLY EXTIRPATED. (WITH A
PLATE,)
CASE OF OSSIFICATION OF THE MUSCULAR TISSUE,
A NEW INSTRUMENT FOR THE OPERATION OF FISTULA IN
ANO. (WITH A PLATE,)
Exa
127
131
138
143
152
155
159

99
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bomsab
PREFACE.
bedail
villha ban
ALLIED by family traditions and connections
with the Medical Profession, I early in life be-
came devoted to its pursuits. Surgery had for me
peculiar interest, and for many years I was labo-
riously engaged in its practice. While thus
engaged, the advancement of Surgery was my
highest object, and the consideration of its difficult
problems the subject of my most earnest attention.
But the unremitting exactions of professional life
left me little time to contribute to its records or
literature. A few Essays and Cases, published at
long intervals, and for the most part hastily written
at the request of editorial friends, form the sum
of such contributions. These, with a few extracts
from the notes used by me in instructing my office
students, and, afterwards, in lecturing from the
Surgical chair of Geneva College, constitute the
materials of this volume, Stu
Jegor

vi
I have not deemed these papers sufficiently im-
portant to be offered to the profession at large.
When such of them as have already been pub-
lished first appeared, I deemed them of some in-
terest to my brethren, and I hope they tended, in
some small degree, to advance professional know-
ledge and usefulness; but whatever of freshness
and utility they possessed, may have passed away
with the lapse of time-more recent and thorough
observations may have rendered them uninterest-
ing, if not antiquated. Such is the rapid stride of
modern progress, that the novelty of to-day be-
comes the antiquity of to-morrow.
Yet some
things may be, and I trust are, herein contained,
which are not without interest at the present time.
The controlling motive for printing this book is,
that it may serve as a memento of me to my
friends, especially to that large number of them
among the Medical Profession of New York,
who, for many years, honored me with their con-
fidence. It is for them that this volume is espe-
cially intended, and to them it cannot fail to be
interesting. It will awaken in them old associa-
tions. They will recognize in it cases in which
they once felt deep interest, and which we have
together watched with mutual hope and fear. In

vii
forwarding it to them, I beg them to accept my
sincere gratitude for their generous confidence
and support during my professional career, and
my sincere and hearty well wishes for their future
welfare, whether they have retired from the
arduous labors of the profession, or still discharge
its humane and honorable duties. There were
some who, in my early struggles, supported me by
their strength and guided me by their wisdom,
whose eyes have been closed for ever. They,
alas! cannot see this expression of my gratitude;-
I think of them and become silent.
CLINTON PLACE, May, 1849.

Corohituos
bas 190759
600
STOSE
bes
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70
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20912 edi
$10
ests
Joids

OBSERVATIONS ON ANEURISM.
INAUGURAL THESIS, PRESENTFD TO THE COLLEGE OF PHYSICIANS
AND SURGEONS OF THE UNIVERSITY OF THE STATE OF NEW
YORK, FOR THE DEGREE OF M.D.
[PUBLISHED IN THE MEDICAL REPOSITORY, VOL. VII., 1822.]
UNTIL of late, an aneurism of the carotid artery
has been looked upon with dismay, and considered
as inevitably fatal. It was formerly considered
as utterly impossible to secure this artery by liga-
ture. This supposed impossibility originated
from the idea, that, should so large a current of
blood as that proceeding from the heart to the head,
be intercepted by ligature, it would prove imme-
diately fatal-but owing to the rapid improvements
in anatomical knowledge since the close of the
last century, these doubts have been dissipated,
and it has been clearly proved that one artery is
sufficient to answer all the demands of nature.
The innovation of Mr. Hunter, in passing a liga-
ture upon the cardiac side of an aneurismal sac,
proving effectual in the obliteration of the artery,
2

10
has led to new and important discoveries in this
branch of surgical science.
In the year 1805, Mr. A. Cooper made the first
attempt to cure an aneurism of this artery, by
securing it in a ligature; and although it proved
fatal, yet from the length of time which the
patient lived, the practicability of the operation
was sufficiently established to warrant his second
attempt, in 1808; which last operation equalled
his most sanguine expectation, and fully proved
its utility. This operation has since been per-
formed so often, and with such unvaried success,
that its possibility and usefulness are now fully
demonstrated, and surgeons no longer hesitate to
make the attempt, nor are they doubtful as to the
result.
The connection of the carotid artery with the
veins and nerves of the neck-its direction and
relative connections with the muscles-its being a
single and undivided trunk from its origin to its
bifurcation at the angle of the lower jaw-the
facility with which it is secured at some parts,
owing to its being superficial; and the difficulty
and danger that must ever follow an attempt to
secure it at other parts, will render an investiga-
tion of its pathology, at all times, interesting to
surgeons. But to give a detail of the surgical
anatomy of this artery, would be foreign from my
design; I shall therefore select such parts as tend

11
more particularly to elucidate the subject, referring,
as occasion may require, to such authors as have
written expressly upon it.
For surgical purposes, the carotid artery may
be divided into three parts. First, that part which
extends from its origin to the intersection of the
Omohyoideus muscle. Second, that which extends
from the Omohyoideus muscle to the angle of the
lower jaw-and thirdly, that part superior to the
angle, and where the branches are given off.
These divisions should be well understood, as
each part differs in its connections with the veins,
nerves, and muscles. The surgeon should also be
intimately acquainted with the peculiarities of
each of these divisions, for upon this knowledge
will in a great measure depend his success as an
operator, and the life of his patient.
Notwithstanding many valuable works have
been written upon the anatomy of this artery, by
men of the first standing in their profession; yet
I humbly conceive that something more may be
done. I would therefore suggest the propriety
of an additional operation to the present mode of
securing this artery by ligature. I mean in those
cases in which the present mode of securing it
would be deemed impracticable.
Brasdor's proposition of passing a ligature upon
the distal side of an aneurismal sac is known to
every person conversant with disease. Its origin,

12
success, and rejection, is likewise familiar to every
practitioner; it might, therefore, appear somewhat
presumptuous to revive a doctrine which has been
so unsuccessful, and so severely reprobated by
some modern authors of distinction, who contend,
that "It is absurd in theory, and experience
proves that it is ruinous in practice."-(A. Burns
on the Head and Neck.) Admit, if you please, that
I may fail in establishing the theory, still we believe
the opinion of the learned gentleman premature,
inasmuch as his conclusions were drawn from the
only two cases on record, (see Descamp's and A.
Cooper's cases,) in which this operation has been
performed. Yet even in those cases, every sur-
geon must admit that the principles upon which
aneurisms are obliterated were totally lost sight of
-that the performances were at variance with
every idea of obliteration, and a cure could not
hence be anticipated, even by those who performed
the operation; for the blood having a free passage
through the tumor, it could never be at rest-coag-
ulation could not take place, hence an obliteration
could not have been expected. That this plan of
curing aneurism is equally applicable to any part
of the arterial system, I will not assert; yet I am
of opinion that under certain circumstances it
should be resorted to. By thus advancing an
opinion as to the practicability of the operation, I
would not wish to be understood as saying that
•

13
the chance of success is equal to the present mode
of curing aneurisms; but that in cases where the
present mode is insufficient to effect a cure, this
should be resorted to. The general principle upon
which arteries are obliterated will be adduced in
support of this practice. It would appear that
the means used in curing aneurisms, is to inter-
cept the direct current of blood to the sac, or to
diminish its quantity and velocity; and not that
the flow of blood into the sac should be totally
obstructed; for a pulsation is perceptible in
the tumor for several days after the principal
trunk is destroyed. The collateral branches
being enlarged, convey a sufficient quantity
of blood into the sac to continue the pulsation.
The blood being removed from its course of
circulation, there immediately succeeds an accu-
mulation of coagulum, until the mouth of the
artery and sac are completely filled and obliterated.
Generally speaking it is impossible to pass a liga-
ture around any artery for the cure of an aneurism,
without leaving some branches between the liga-
ture and sac. This accounts for the continual
pulsation.
"It is essential to the success of this operation
that no large vessels arise from the sac, or from
that portion of the artery situated between the
sac and ligature; for the stream of blood passing
through the tumor may, under such circumstances,

14
prevent the coagulation of its contents, and continue
the disease."-(Hodgson on the Veins, p. 292.)
It is evident from the case related by Descamp,
that this fact entirely escaped his notice, or the
circumstances of the case were of too desperate a
nature to allow its admission.
The tumor was situated in the upper part of
the thigh near Poupart's ligament. From its situa-
tion, it was thought impossible to pass the ligature
above the sac. The tumor increasing rapidly in
size, and the danger of its bursting, urged him to
adopt this practice. Although from the derange-
ment of the parts, he was not able to select the
most proper situation for passing a ligature, in-
asmuch as the artery was not seen during the
operation, but he had to secure it by a plunge of
the needle; yet it evidently appears from his own
statement, that the profunda passing off between
the ligature and the sac would not prevent the
obliteration of the cyst; and that it would have
been cured with at least as much facility as by
the usual practice. This patient, however, died
four days after the operation, owing to the quantity
of blood lost in opening the sac and securing the
ends of the artery. Upon examining the limb, it
was found that the profunda remained between
the sac and ligature; and that its trunk was
nearly as large as that of the femoral artery.
Mr. A. Cooper witnessed a case in which the

15
same error was committed. The aneurism was
situated in the external iliac, in which there
was not a possible chance of securing it above
the sac.
The case had been of so long standing
that every moment's delay seemed to endanger
the patient's life. The artery was secured be-
tween the epigastric and profunda; the epigastric
and circumflex iliac remaining between the sac
and ligature. Could it have been anticipated that
an obliteration would have taken place beyond
the first collateral branch in the two cases above
cited? Is it not evident, from the arteries being
between the sac and ligature, that the blood con-
tinued to circulate through the cyst with the
same facility as it did previous to the operation;
and if not at rest could coagulum take place?
And, may
I not add, in thus performing the opera-
tion, the very object intended to be accomplished
was defeated. They appear to have lost sight
of the very principle upon which aneurisms are
cured; for should a current of blood continue to
flow through the sac, it is of no consequence
whether it be carried off by anastomosing branches,
or directly through the principal trunk; so long as
the blood continues to flow freely through the artery,
it would react upon its stimulus with its usual
energy, and the blood would be propelled with
sufficient force into the aneurismal sac to prevent
coaptation, and consequent obliteration. Thus it

16
happens when a ligature is applied near a large
branch, that a secondary hemorrhage frequently
occurs, and the obliteration of the principal trunk
is prevented, because there is not sufficient space be-
tween the ligature and branch, for coagulum to form.
Mr. Hodgson's case, (p. 198,) is an exception to
this general rule, there being sufficient space
between the ligature and nearest branch, and yet
no coagulum formed, although the patient lived
three weeks after the operation. It is, however,
a general rule that when a ligature is applied to
an artery for its obliteration, its calibre is destroyed
to the next important collateral branch, in both
directions. For should a ligature be applied to
any part of the carotid artery, previous to its
bifurcation, it would be obliterated from its origin
to its division at the angle of the lower jaw.
Dr. Mott secured the carotid artery at the lower
part of the middle third, for the extirpation of a
tumor situated at the upper part of the neck, and
involving all the other vessels arising from this
artery. The ligatures came away on the twenty-
first day after the operation, and the wound closed
as well as the nature of the case would admit;
but the disease returning, the patient gradually
sunk under the discharge, accompanied with an
affection of the lungs, and died three months after
the operation.-(Med. and Surg. Register, part 2,
vol. I, p. 397.)

17
66
Upon dissection, the carotid was found com-
pletely obliterated from its origin to its bifurcation,
leaving a fine ligamentous cord which was divided
into two parts, showing the place where the liga-
ture was applied." I have lately had an opportu-
nity of examining the external iliac artery which
had been secured at the point where the epigas-
tric is given off; it was completely filled with
coagulum to its origin.
dom
Mr. Hodgson (p. 197) thus expresses himself:
"I have invariably found the canal of the vessel
obliterated, and its coats converted into a solid
ligamentous cord, in which no vestige of the origi-
nal structure could be traced. In most instances
the obliteration extended on both sides, from the
part at which the ligature had been applied, to
the origin of some considerable ramification; but
this does not always occur."
Although the formation of a coagulum, and the
obliteration of the artery do not always follow
the application of the ligature, yet the exceptions
are so rare that it cannot form a serious objection
to the usual mode of operating; for it more gene-
rally depends upon its location. It may originate
entirely from the ligature, being located near the
origin of some larger branch.
A. Cooper's case of the femoral artery on which
the ligature was applied close to the origin of the
epigastric, terminated fatally, by secondary hem-
3

18
orrhage, on the fourteenth day after the operation.
In this case there was not sufficient space for a
coagulum to form between the ligature and the
artery; nor were the adhesions of the artery equal
to resisting the force of the circulating blood,
which acted immediately upon the mouth of the
artery, the difference between the ligature and the
branch not being perceptible. The acute angle
which the blood must of necessity make, caused
the whole force of the circulation to spend itself
upon the newly cicatrized wound. It sometimes
happens that there will be a considerable length
of artery between the ligature and the branch, and
yet no coagulum will be formed.-(A. Burns on
the Heart, p. 230.) The artery remains pervious
and of its usual dimension for the space of two or
three inches, during the lapse of twenty years
after the performance of the operation. These
cases, however, are very rare, and may originate
from the fact, that the ligature does not produce
an irritation sufficient to cause a deposition of
lymph, or that the inflammation does not extend
beyond the ligature. It cannot be said that the
circulation is carried on in this insulated portion of
the artery; because it is in the same situation as
the hypogastric artery, which is frequently per-
vious even to the umbilicus at the adult state.
Its coats are collapsed and of their usual size, and
therefore its sides would not unite, unless there

19
should be some exciting cause sufficient to produce
an inflammation in its mucous coats. Upon the
same principle there would be no more probability
of a union between the coats of an artery without
previous inflammation, than there would be in the
folds of the mesentery whilst lying in contact with-
out any exciting cause. Surely, no one will say
that blood is propelled into the useless hypogastric
artery, since, as a thing of course, it must return
by the same passage through which it entered.
Several cases of unobliterated arteries, notwith-
standing the application of a ligature, are related
by Mr. Hodgson, (p. 201,) in the greater number
of which secondary hemorrhage was the conse-
quence. However, the above cases cannot be
adduced in argument against the general rule, viz.:
that coagula take place in insulated portions of
arteries; since the failure originated from an im-
proper application of the ligature, or from the age
and vitiated habits of the patients.
If the obliteration of the arteries is governed by
these general principles, and it be a fact that by
intercepting the current of blood they lose their
action and are rendered incapable of carrying on
the circulation, is it reasonable to suppose that a
fact so important can be of no use in the cure of
aneurisms; or shall we be deprived of its efficacy
because it has failed when improperly performed?
Yet, notwithstanding the violent opposition that

20
is offered to this manner of securing arteries for
the cure of aneurisms, its most rigid opponents
acknowledge the theory correct, though they dis-
card the practice.
We are told by one theorist, that the adhesion
of the sides of a vessel may be procured, provided
the flow of blood be intercepted along its canal.
If the obliteration of an artery depends upon the
flow of blood being intercepted, it is then evident
that, if a ligature be passed upon the distal side of
an aneurismal sac, no branches being given off
between the ligature and tumor, the blood thus
removed from its course of circulation will become
coagulated; "For the artery thus abandoned di-
minishes gradually in its size, until it is obliterated.
In this case compression is recommended to faci-
litate a coagulation in the sac, thus depriving the
aneurismal cyst of any share in the circulation.
If it be thus done, the absorbents will soon perform
their part of the process."-(Scarpa; Wishart's
Translation, p. 213.)
If it be admitted that the obliteration of an
aneurismal cyst can be accomplished by intercept-
ing the flow of blood through the sac, and that
too by its subsequent coagulation, I have then
only to prove, that passing a ligature upon the
distal side of the sac will answer the end I have
in view, viz.: If a current of blood be prevented
from passing through an artery, that a coagulum

21
will form and its actions and functions be de-
stroyed.
It is generally admitted that the heart and
arteries carry on the circulation; that their actions
are mutual, and that either will cease to perform
its office when the corresponding action of the
other ceases. This fact is illustrated by the
ossification of arteries in the extremities; the
member becomes cold, insensible, and finally
mortifies. "If an extent of vessel be converted
into a calcareous cylinder, it loses its elasticity
and organic power, insomuch that it is unable to
afford any assistance to the propulsion of blood."
(Hodgson, p. 42.) It is therefore strong pre-
sumptive evidence in favor of their action, that
should the arteries undergo the same change, the
parts to which they are distributed would not be
capable of supporting their vitality-that blood
is not entirely dependent upon the action of the
heart for its propulsion through the arteries-and
that they are not inelastic tubes dependent upon
the laws of hydraulics.
That the arteries do possess active power and
materially assist in the circulation of the blood,
there can be but little doubt; since in the restora-
tion of a limb after the principal trunk has been
secured by ligature, the collateral branches in-
crease their size in proportion to the demand of
blood to supply the part, and the action of the

22
vessel increases in equal ratio with its increase
in size, thereby carrying on the circulation as effec-
tually as if the principal trunk remained perfect.
It would certainly seem erroneous to suppose that
the heart determined this increased quantity of
blood to the collateral branches, or that it pos-
sessed the power of determining what particular
parts required more than what would pass through
its branches. "Animals being born without hearts,
is a strong confirmation of the belief that arteries
perform the functions of the heart until they arrive
at a period when a double circulation is required,
when they must of necessity perish. Insects that
require but one circulation are without hearts, and
the blood is of course propelled by the action of
the arteries."-(J. Hunter, p. 91.) "The contrac-
tile state of an artery arises from the action of its
muscular power, and is restored again by its elas-
ticity."-(J. Hunter, p. 117.) If by any means
the elastic coat is prevented from acting, the blood
ceases to flow through that artery and seeks new
channels to supply the part. We thus destroy the
elasticity of the coats by securing the artery in a
ligature, hence also destroying the action of the
artery, inasmuch as the antagonist muscle is pre-
vented from acting. If there were no other power
except the force of the blood to overcome the
action of the muscles, the artery would be kept
in a constant state of contraction, for the mere

23
force of the heart would not be sufficient to over-
come the combined strength of the muscular coats
of all the arteries in the system. The facts, which
we think are admitted by all who are acquainted
with the circulating system, viz.: the action of the
arteries, and the circulation of the blood being as
rapid at the extremities of the arteries as at its
origin from the heart, are abundantly sufficient to
satisfy the most sceptical.
The danger of bursting the sac by the force of
the circulation has been considered as an insur-
mountable obstacle to passing a ligature upon the
distal side of an aneurismal sac. Whether this ob-
jection coincides with reason or experience, I leave
for those to decide who are more experienced than
myself; yet I must say that, in my opinion, it is at
variance with every principle upon which aneu-
risms are cured. It would be a subject worthy
investigation to ascertain at what stage of the
disease laceration is most likely to occur, or
whether it ever occurred except when situated
in the thorax or abdomen, and even in this
situation, I may add, it is not a common occur-
rence. In the only two cases which I have
had an opportunity of examining, it has pro-
ceeded from ulceration.
Mr. Hodgson (p. 13) is positive in the opinion
that aneurisms never burst from laceration, (with
the exception of those cases in which the aneurism

24
is situated in the thorax or abdomen,) but by the
gradual process of ulceration; and by attending to
the different stages of an aneurism, the absurdity
of such an objection will plainly appear. In fact,
the cyst is capable of making greater resistance to
the force of the blood than an artery possessed of
all its natural power.
Aneurisms are properly divided into three stages,
1st. That in which by the rupture or destruc-
tion of the internal coat, the blood escapes and
forms a sac, by dilating the cellular tissue.
2d. That in which (what John Hunter terms)
the thickening of necessity, takes place in the
aneurismal sac, and in which the surrounding
cellular substance is thickened, condensed, and
forms a strong wall to the cyst.
3d. The last or ulcerated stage, when the
tumor looks black, sphacelates, and pours out
blood through many small openings. It doubt-
less must be this last stage that excites so many
apprehensions in the minds of the timid. For in
the first stage it possesses a power equal to re-
pelling the force of the circulation, as in the natu-
ral state; but with this difference, that it must
gradually yield to a force upon which it cannot
react.
Thus we account for the gradual enlargement
of the sac.
In the second we have not only the increased

25
thickness of the parietes of the sac, but also the
accumulation of the coagulum, as an additional se-
curity against a rupture by force of the circulation.
In the third stage, I am willing to admit that
such an effect as is often anticipated, might pos-
sibly follow; yet by applying the proper bandages
or plasters to the tumor, the practice, even in this
extreme case, would still be correct; for it would
be the dernier resort of nature and art to support
life. But I contend that such an occurrence is
highly improbable even in this last stage, since
the action of the artery being interrupted, the
current of blood to that artery must necessarily
cease. Mr. J. Bell, in his usual style, ably con-
futes every supposition of this kind; he says,--
"When you tie an artery, the blood returns in it
backwards, forsakes the obstructed artery, and
passes along the other arteries in a backward
course. Under such circumstances, the blood is
not driven in this retrograde course by any power
vested in the heart; but by the action of those
arteries which are deprived of their usual supply of
blood.
99
As a still further proof of the above position,
I shall add the opinion of Scarpa, viz.: "That
whenever the blood meets with a powerful ob-
struction to its passage through an artery, it
leaves that artery and enters another."-(Wish-
art's Translation, p. 213.)
brid
4

26
It is therefore evident, from the above facts,
that the circulation of the blood must depend, in a
great measure, upon the action of the arteries, as it
can exert no force upon vessels after their calibre
is destroyed, or when the arteries by their action
unite to invite the flow of blood; this admits of
demonstration, for when the part ceases to require
its usual quantity of blood, the vessel diminishes in
size.
The impregnated uterus is supplied with blood
in proportion to the growth of the foetus-its
quantity is increased in ratio with the demand;
for at the birth of the child when so large a
quantity is not needed, it ceases to flow-the
arteries lose their increased action, and return to
their usual size. It is upon the same principle
that nature has provided for the preservation of
life after mortification has taken place; for it is the
contraction of the vessels that intercepts the cur-
rent of blood, and forms a coagulum which extends
to the next collateral branch of importance.
If the coagulum which follows mortification is
capable of resisting so effectually the force of the
circulation, then the conclusion relative to a liga-
ture being applied to an artery is correct; Varicose
veins have been secured upon the cardiac side of
the disease, and a rupture was never known to
take place from the pressure of blood from be-
hind.

27
Neither is there a fact in support of the position
that aneurisms will burst from the force of the
circulation. Guattani relates a case in which
there were two aneurisms situated in the femoral
artery. They were both large and distinctly pul-
sated. The inferior bursted and formed the dif-
fused aneurism. The blood was thus diffused
through the cellular substance of the leg, pressing
the superior portion so effectually as to intercept
the circulation, and the obstruction to the free
passage was so powerful that its force was spent
upon the superior sac, and by its increased velo-
city produced a rupture.
A doubt exists as to the cause which led to the
rupture of the sac in the case related by Guattani,
and that doubt is not in the least diminished by
referring to his description of the case. He there
informs us that, at the time of the rupture, the pa-
tient was in a low state of health-so emaciated
and weakened, as to be unable to raise his head
from the pillow; and notwithstanding all this, the
power of the circulation was sufficient to burst
the sac, and diffuse the blood extensively through
the surrounding cellular substance. Is it, then,
probable that the rupture could justly be attributed to
the force of the circulation, since there was scarcely
vitality in the system sufficient to give it motion, or
to ascertain to a certainty that there was a circu-
lation? Is it not more reasonable to suppose that

28
the antecedent debility was too great for a healthy
inflammation, that the powers of the system were
so much diminished as to produce an ulcerative
instead of adhesive inflammation? For we know
that by a too rapid depletion in phlegmon the
power of renovation is destroyed, and thereby the
patient is placed in danger of ulceration, and some-
times of sphacelation.
Had Guattani informed us of the actual state of
the sac after death, or examined it critically him-
self, he would unquestionably have given us a dif-
ferent opinion. In all probability he would have
found the sac, which had given way, thin, ragged,
and wholly incapable of supporting its own weight.
By referring to my note-book, I find a case
similar to the one related by Guattani:-
I. Jackson, a sailor, was admitted into the New
York Hospital, September 19, 1821, aged thirty-
two years.
He was received for two aneurisms
situated in the course of the femoral artery. The
inferior was of six weeks' standing, the sac having
given way one week previous to his arrival in the
city. The blood having extensively diffused itself
through the cellular substance, from the ancle to
some distance above the knee, there was no pul-
sation perceptible; and the surrounding parts
were so perfectly filled with blood that, without
doubt, the circulation for some distance below the
disease was destroyed. The superior tumor had

29
a pulsation, and from the constant sufferings of the
patient, and the length of time the disease had ex-
isted, the system had become very irritable. The
patient appeared very much exhausted both in
mind and body. These circumstances prevented
the possibility of gaining a correct history of the
disease.
From the occupation of the patient, and the
circumstances of the case, it was thought advisable
to preserve the leg if possible, by securing the
femoral artery above the sac.
He remained very
comfortable for two days after the operation, and
strong hopes were entertained of his speedy re-
covery; but on the third day a vesication appeared
on the foot, with a cadaverous coldness extending
to the knee. The symptoms increasing, on the
fourth day it was found necessary to amputate the
thigh in order to preserve life. There was but a
small quantity of blood lost while performing the
operation, yet, from the great irritability of the
system, he survived four hours only after the ope-
ration. Upon examination, the inferior cyst was
found about two inches above the tendonous arcade
of the triceps, and the parts which had given way
were found very thin and ragged. The rupture
evidently proceeded from ulceration.
Aoittee
The superior cyst was situated one inch below
the profunda. It had a dark and lobulated appear-
ance, and was evidently on the point of bursting.

30
There are some very important facts connected
with this case which I must beg the privilege of
citing.
1st. The aneurisms appearing without any sen-
sible cause, and the rapidity with which they ter-
minated, both of which appear to be at variance
with the general rule, viz., that aneurisms are
always slow in their formation; and even those
that originate from punctures are formed gradually.
2d. This man stated that some time previous
to the tumors appearing, he had been under a
severe ptyalism for the venereal disease.
A similar circumstance is related by Guattani,
in his case of spontaneous aneurism. And al-
though he has not suggested it as predisposing
the system to this disease, I can see no reason
why it should not, by enfeebling the system, pro-
duce a state of irritability, and predispose the
arteries to disease. That mercury has any specific
effect upon the arterial system, independent of
other parts, I will not say; but I do consider it a
subject worthy of consideration by those who
investigate the pathology of the human system.
There is some analogy between the case last
mentioned and an aneurism of the carotid, in
which the ligature is passed upon the distal side
of the sac; for between the two cysts there were
but two small arteries, and those not of sufficient
size to destroy the force or velocity of the blood;

31
therefore if it be true that the heart possesses
power sufficient to lacerate the sac, it would un-
doubtedly have occurred in this case.
This appears evident from the facts, that there
was an obstruction to the current of the blood,
and that the superior sac had not formed an adhe-
sion with the surrounding parts. This non-adhe-
sion may have been one principal cause of its rapid
growth and rapid termination. There was a con-
siderable quantity of coagulum formed in the upper
part of the sac; from a small quantity of blood
continuing to circulate through the cyst, the pul-
sation continued, and the process of coagulation
was in a certain degree destroyed. Mr. A. Cooper
saw a case of aneurism situated in the external
iliac, and from its size, situation, and advanced
state, it was impossible to pass a ligature superior
to the sac. The artery was, therefore, secured
below the cyst, between the profunda and epigas-
tric arteries. The pulsation continued till the
death of the patient. The ligature came away in
due time, the wound healed, and the tumor dimi-
nished in size; and it was generally believed that
a cure would be effected. But the patient impru-
dently went into the country for the restoration of
his health; the tumor progressed gradually, till it
arrived at a state of ulceration; and in six weeks
after the operation, the eschar separated, and the
tumor discharged its blood into the cavity of the

32.
peritoneum, and occasioned the death of the
patient. (Hodgson on the Veins, p. 251.) Quere
-Were the gentleman's fears realized as to the
bursting of the sac, and thus consigning the victim
to immediate death! On the contrary, under
circumstances peculiarly opposed to every pros-
pect of affording relief, there was a diminution in
the size of the sac. In this case, the blood had a
free passage through the sac, and was carried off
by the collateral branches between the ligature
and the tumor, and these branches gave almost
as free a passage to the blood as the original trunk
had formerly done. Descamp's case was, in this
respect, equally conclusive, and evidently goes to
prove the fact that aneurisms never burst by the
force of the circulating blood. For it would be
absurd to suppose that the blood makes such a
powerful exertion to force its passage when its
principal trunk is obstructed. This would force
us to the supposition that there was a redundancy
of blood, and no other channel through which it
might pass off; or rather that it acted like a
rapid current obstructed in its course, where the
the greater the obstruction the greater would be
its force, arising from an accumulation behind. I
trust, however, the number of those who, at the
present day, adhere to such palpable absurdity is
small.
If the doctrine of obliteration, as received in the
-

33
schools of this day, be correct, and founded upon
facts, is it not surprising that the same objection
has not been offered to passing a ligature around
an artery in other cases! if by passing a ligature
around an artery we intend to obliterate it, by
separating its two internal coats; and we are
informed by Mr. Jones, (p. 161,) that this must
necessarily take place, in order to produce a com-
plete adhesion. The object of tying an artery, is,
"to cut through the internal and middle coats,
and bring the wounded surfaces into perfect con-
tact." The ligature has this effect upon the artery,
and we therefore place it in the same situation as
would exist in the first stage of an aneurism; for
an aneurism consists in the rupture of the proper
coats of the artery, and consequent effusion of ar-
terial blood under the cellular sheath.
The inference is therefore a correct one, viz.:
that if the blood continues to exert its force upon
an artery, after its action has ceased, we should,
in every effort to produce obliteration by ligature,
cause an aneurism. But we consider an artery,
after an impediment is offered to a free passage of
blood, similar to the ductus arteriosus and hypo-
gastric; for the arteries never would become ob-
literated if the circulation depended entirely upon
the momentum given to the blood by the action of
the heart. The blood is invited to flow by the
66
1
5

34
action of the arteries, and stops when the action
of the arteries ceases.'
To suppose that the arterial system is not
governed by the same laws, and that it is not
acted upon by the same living principle as other
parts of the organic system, betrays an ignorance
unpardonable in this enlightened age. It was an
unfortunate circumstance that a surgeon of the
standing of Descamp should fail in his first at-
tempt to introduce this practice, inasmuch as the
opinions of such men as himself and Cooper are
too apt to persuade others from making an attempt
in which they have failed, resting fully satisfied
that if they have condemned the system, it must
therefore be impracticable. By thus implicitly
adhering to the opinion of those who stand
high in their profession, we forget that they are
only men, and therefore subject to error. We
neglect to investigate, because they condemn :
we dare not recommend to others what these
great men have denounced. But in the present
case, that system which art and influence have
rejected as erroneous, nature has demonstrated to
be true, and thus exposed the fallacy of all reason-
ing, and the liability of men to err in judgment,
whilst their intentions are perfectly pure. The
opinion that aneurisms might be obliterated by
pressure anterior to the sac, and that they did
occasionally undergo a spontaneous cure, was

35
an idea entertained by Scarpa, E. Home, and
others; however, they never carried their system
into operation. By referring to the records of
surgery, a sufficient number of cases may be found
to confirm the belief in the correctness of the
practice.
Mr. Hodgson's dissection of patients who died
with this disease, throws much additional light
upon the subject; I shall therefore take the liberty
of making free extracts from his treatise: Case
xix. (p. 11) was that of a robust soldier, who had
for three years been afflicted with a very large
aneurism of the aorta, which had caused the ab-
sorption of the whole of the upper bone of the
sternum, and appeared externally in the form of a
large pulsating tumor, extending nearly as high as
the chin. Some months after he came under his
care, he died, worn out by the extreme impedi-
ments to respiration, and an inability to permit
even fluids to pass his oesophagus. It was after-
wards ascertained that the pressure of the tumor
had produced sloughing and ulceration of a great
portion of that tube. This great aneurism arose
from the anterior part of the arch of the aorta, and
filled the upper part, more especially the left side
of the thorax; the left subclavian artery resem-
bling in its size and shape a very large chestnut.
The aneurism of the aorta, by compressing a por-
tion of this artery beyond the little aneurism, had

36
caused its obliteration.
This small aneurism was
nearly filled with layers of coagulum, and the sub-
clavian artery, from the point where it emerged
from this little sac, was completely filled with a
firm ligamentous substance. The vertebral, the
internal mammary, and superior intercostal arte-
ries were much contracted, and filled with a simi-
lar substance. Thus had the cure of this little
aneurism commenced in consequence of the pres-
sure which the greater one had produced upon
the sub-clavian artery. The inferior thyroid arte-
ry was not obliterated, and through it the blood
must have passed in a retrograde direction into
the trunk of the subclavian artery, which, although
much contracted, was pervious to this point. In
consequence of the removal of the parts, "I was
not able to trace the vessels through which the
circulation was carried on, but it is highly probable
that the circulation was through the inferior
branches of the thyroid, the cervical, and the
supra-scapulary arteries, all of which anastomosed
very freely with corresponding arteries of the
opposite side, and with the branches of the supe-
rior thyroid, the occipital, and the vertebral arte-
ries. Nothing indicated the obstruction during
life, but it was remarked that for many months
previous to the death of the patient the pulse
could not be felt in the wrist."
The second case, which is in most respects

37
similar to the first, is given by Mr. Hodgson, (p.
113.) This case is related by M. Beauchine in
Corvisart, Roux, et Boyer's Journal de Médi-
cine: "The Princess of G-, about sixty years
of age, died of dropsy in the chest and inflamma-
tion of the intestines; the calibre of the aorta was
dilated to at least three times its natural extent."
The subclavian artery was slightly dilated, and
contained, from its origin to the part which
passes behind the scalenus, a dark-colored clot
of the consistence of jelly. That portion of the
vessel which passes behind the scalenus, for the
extent of an inch and a half, was filled by a very
fine gray plug, which was impermeable to the
blood, and adhered so intimately to the coats of
the artery, that it could not be separated without
laceration. This portion of the vessel was inti-
mately connected to the surrounding parts by
dense cellular membrane. Its calibre appeared
contracted; but from its inferior side a small sac
originated, which rested upon the upper rib, and
was filled with a friable clot of a dark gray color."
Besides the above cases, many are recorded by
Desault, Petit, Baillie, Ford, Guattani, and Corvi-
sart, in which the spontaneous cure of aneurisms
was effected without the interference of art.
I am not conscious that this operation has been
exclusively applied to the carotid, or is applicable
only to the aneurisms of that artery. If it is so,

38
I have not been able to acquire the information.
The idea of tying the artery upon the distal side
of the aneurismal sac, suggested itself to me almost
at the commencement of my studies, on examining
a tumor situated immediately above the clavicle ;
from the pulsation communicated to it by the
artery, I mistook it for aneurism, and suggested to
my preceptor, Dr. V. Mott, the practicability of
securing the artery above the tumor, who honored
me by presenting the subject to his class in the
winter of 1820-21.
I have considered this mode of curing aneurisms
as applicable only to the carotid. I am, however,
of the opinion that it may, with equal propriety,
be applied to the common iliac; for the same
facts which support one case are equally applica-
ble to the other. But as the carotid first attracted
my attention, I shall confine my remarks particu-
larly to that artery, and to substantiate the position
which I have advanced on this point, I need only
urge the argument already advanced.
1st. That this artery never gives off branches
from its origin to the angle of the jaw, except
when it bifurcates low in the neck; which is a
very uncommon circumstance, and Occurs not
oftener than once in a thousand cases. I know
of but one case on record, mentioned by Mr. A.
Burns; besides, there is never any danger of

39
branches remaining between the ligature and the
sac.
2d. That by stopping the current of blood
through an artery by ligature, the artery is always
obliterated to the next collateral branch in both
directions. Hence the artery is obliterated from
its origin to its bifurcation.
3d. That the action of the heart and arteries is
mutual; the heart can exert no influence upon
the arteries after their action ceases; the blood
then coagulates, and obliteration must necessarily
follow. It is upon these grounds that I conceive
this operation applicable only to the carotid, it
being the only artery in the human body upon
which the operation would be performed with the
certainty of not meeting with collateral branches.
It is the longest artery in the system that does
not give off branches, and those at irregular
intervals; in this respect there is a regularity truly
admirable.
The difficulty of distinguishing an aneurism,
which originates from the arch of the aorta, in-
nominata, or subclavian, from one that originates
from the carotid, may present itself, as an insuper-
able objection, particularly to the young practi-
tioner, and cause him to doubt the propriety of
performing this operation; and his doubt may still
be increased by the fact that he is to be guided

40
by no one symptom, but by a combination of
symptoms.
With a history of the case, an experienced
surgeon may, with some considerable degree of
certainty, determine the seat of the disease. Mr.
A. Burns was consulted in a case of an aortic
aneurism, which he mistook for one of the carotid.
It was situated behind the clavicle on the acromial
edge of the sterno mastoid muscle; there was no
pressure made upon the "aspera arteria" yet the
numbness and oedema of the arms, together with
irregularity of the pulse, would have been suffi-
cient, in my humble opinion, to have distinguished
it from an aneurism of the carotid; for I know of
no case in which an aneurism of the carotid
would have produced a like effect upon the arms.
At least I can find none by examining the his-
tory of carotid aneurisms. The situation of the
tumor in the neck might sometimes lead to mis-
take, because the clavicle and sternum do not give
free passage to the tumor. "From this circum-
stance, the disease has the appearance of origina-
ting above the chest, aad in many instances, the
stricture formed by the resistance of the clavicle
and sternum is so considerable, that it appears to
tie the artery between the sac and the chest."
Mr. Hodgson has seen one case of this kind,
which appeared so distinctly above the clavicle,
that it was proposed to pass a ligature around the

41
0
artery below the sac. But, upon dissection after
death, it was found to arise from the arch of the
aorta and innominata. Being perfectly ignorant
of this subject from practice, I know of no better
way of communicating a correct idea than by ex-
tracting the two following cases from Mr. Hodg-
son, (Case xiv.) "A robust man, between thirty
and forty years of age, had been for several
months afflicted with an extreme difficulty of
breathing, great pain, and a sense of suffocation
at the upper part of the thorax, a constant irri-
tating cough, and a copious expectoration of thin
frothy mucus. These symptoms resembled those
of incipient phthisis pulmonalis, except the thin
and frothy state of the expectoration, and the ab-
sence of fever."
"A robust man, of about forty-seven years of
age, died on the 16th of January, 1812. For
some months before his decease, he had been
afflicted with a great difficulty of breathing, and
wheezing cough; a quick, strong, and irregular
pulse; difficulty in swallowing; and a severe
pain in the region of the collar-bone, extending
over the dorsum of the scapula to its inferior
angle; and a sensation of numbness, and a want
of natural feeling in the right arm and fingers.
Soon after the commencement of these symp-
toms, a pulsating tumor was observed a little
above the sternal extremity of the right clavicle
5

42
He had a constant hacking cough, which was
frequently accompanied with a croup-like noise,
and an expectoration of thin mucus, which was
effected with extreme difficulty of breathing.
Upon dissection, an aneurism was found to have
existed at the anterior part of the arch of the aorta,
near to the origin of the innominata."
The important rules laid down by Mr. A.
Cooper for distinguishing aneurisms of the carotid
from those situated in the chest, are very con-
clusive, viz.: The difficult respiration and deglu-
tition which are produced by the pressure of the
sac upon the trachea and oesophagus. The fascia
of the neck would never confine an aneurism of
the carotid sufficiently to produce this symptom
to any great degree. The numbness, pain, and
oedema of the superior extremities, could never
be produced by the pressure of a tumor of the
carotid, on the axillary nerves and absorbents.
These symptoms may, however, be produced by a
disease of any other artery which is situated near
the neck.
Many exertions have of late been made, to dis-
tinguish the different aneurisms originating above
the upper part of the chest. Although it may
please the inquirer to discover something new,
and though in these excursions of the imagination
the object may be to exercise the mind and im-
prove the practice, yet the nice and particular dis-

43
tinctions thence arising can be of no possible use
to the operating surgeon. Agreeably to the pre-
sent recorded opinion, it would be of no conse-
quence to the patient, whether the disease existed
in the lower part of the carotid, innominata or
aorta, in those situations they would be equally
fatal. If an aneurism was situated in the lower
part of the carotid, lying upon, and passing over
the clavicle, it would be as impossible to pass a
ligature below the sac, as it would be to secure
the aorta. Hence, a patient under these circum-
stances must inevitably die, and with the poor
consolation of having had every possible assistance
that art could afford.
Should this mode of practice be considered
worthy of adoption, those nice distinctions would
then be of great importance, and its further in-
vestigation would be a subject of interest to the
profession.*
Should a case occur in which this practice
should be deemed advisable, it might be thought
proper to pass the ligature at the middle, or at the
superior part of the middle third.
This I would recommend for two reasons:-
* For further particulars respecting the distinctions between
aneurisms of the upper part of the chest, I would refer to Mr.
Hodgson on the Veins, and to Mr. Burns on the Surgical Anatomy
of the Head and Neck.
1

44
1st. That the disease of the artery might extend
beyond the mere limits of the sac, and thence
produce an ulcerative rather than an adhesive
inflammation. It would make not the least differ-
ence, as far as the result of the operation is con-
cerned. It would as effectually obliterate the
artery if it were at the superior third. Pedne
2d. By passing the ligature low down, we
might endanger the branches of the re-current
nerves, particularly near the intersection of the
omohyoideus muscle; for, as Mr. Burns observes,
here the branches are large and numerous.*
* To this might be added what surgeons have termed, the medi-
cal treatment, or spontaneous cure of aneurisms, in which the
system of depletion was carried to a great extent. It is of the most
ancient date, and was followed with much success previous to the
introduction of the ligature. It is said that Valsalva, Morgagni.
Alberti, Pellitan, and many others, performed many and great
cures by this practice. Should the efficiency of the former be
doubted, this might likewise be added, and what one failed of doing
the other might accomplish.
bloolle
16
halds
bra
gong
rey rohoque
T

45
gely!
REMARKS
UPON THE APPLICATION OF A LIGATURE TO THE
ARTERIA INNOMINATA.
The operation of securing the arteria innomi-
nata by ligature has been performed five times;
first by Dr. Mott, in 1818, secondly by Professor
Graffe, in 1822, thirdly by Mr. Normon, in 1824,
fourthly by Mr. Lizars, in 1837, and fifthly by Mr.
Huton, in 1842. It appears from the published
reports of those cases, that the operation has thus
far been unsuccessful, and in each case the proxi-
mate cause of failure has been secondary hemorr-
hage. As the possibility of securing the arteria
innominata by ligature can be no longer doubted,
as the fear of affecting the head or heart by inter-
cepting so large a current of blood is not at present
entertained, and as it is admitted that the right
arm has a sufficient supply of blood; it has be-
come a matter of importance to ascertain from
what cause such secondary hemorrhage has
arisen.
We are struck, at the commencement of the
investigation, with the remarkable fact that the

46
secondary hemorrhage, after applying a ligature
to the arteria innominata, does not occur until
long after the time when, in other cases, we con-
sider the patient free from danger; and in pursu-
ing the investigation by the light of the cases
above referred to, we further notice the rapid
return of the circulation to the arm, indicated by
its warmth, and the pulsation of the arteries. In
order to investigate this subject properly, it will
be necessary to review the facts in the cases
already presented, and to offer a supposition, the
truth of which can be established only by future
experiments.
yiby 1981
The operation for tying the arteria innominata
was performed, for the first time, by Professor
Mott, on the 11th day of May, 1818, for an
aneurism of the right subclavian artery. The
ligature was applied "half an inch below the
bifurcation." The report goes on to state, that on
tying the ligature, pulsation ceased in the right
radial and temporal arteries. The head and
lungs were not in the least affected. Two hours
after the operation-" The temperature of both
arms is very nearly the same "-at three hours
"there is still a trifling difference in the tempera-
ture of the two arms." At five o'clock on the
second day the temperature of both arms is re-
ported as the same. At ten o'clock it is stated
that "The veins of the fore-arm and hand (since

47
the operation) have been as much distended as
previous to it; and upon compressing them so as
to stop the circulation, and allow the veins to
become empty for some distance above, the col-
umn of blood is seen to distend the vein immedi-
ately upon the removal of the pressure, plainly
showing that the circulation is going on with con-
siderable rapidity, although no pulsation has been
felt in the brachial, or radial artery. The radial
artery can be easily distinguished by the finger,
and seems to be filled with blood." The above
quotations extending to ten o'clock on the se-
cond day after the operation, shows a peculiarity
in the circulation that is not usually observed after
the main current of blood leading to a part is cut
off. So little was the temperature diminished
that it was not at first necessary to use any artifi-
cial means to retain it, and secondly, that the
circulation should be so far restored, within
twenty-four hours, that the blood was distinctly
felt in the radial artery. If we add to this, that a
pulsation or undulation was, at intervals, felt in
the radial artery, on the fourth day,* we must
come to the conclusion that the ordinary collateral
circulation was inadequate to give this supply of
blood in so short a time. We could hardly sup-
* Professor Lizars reports the pulsation to have returned in the
radial artery on the third day.-Lancet for 1842, page 446.

48
pose that the communication existing between
the epigastric and internal mammary, or between
the intercostal and thoracic arteries, would have
been sufficiently established, at this early period,
to have given so large a quantity of blood to the
arm. If then it be admitted, that the arteries
above mentioned could not furnish the quantity
of blood circulating through the arm, the question
arises, how are we to account for this rapid return
of the circulation? My supposition is, that the
arm was supplied by a retrograde current of
blood through the carotid artery of the right side.
Many facts connected with the case of Dr. Mott
go to confirm this supposition. The hemorrhage
which occurred on the ninth day could not be
accounted for upon any other supposition. "It
came on when preparing to renew the dressing-
the stream was large, and fears were entertained
for the man's life." This hemorrhage, doubtless,
proceeded from a partial division of the arteria
innominata by the ligature. That the blood
flowed from that portion of the artery anterior to
the ligature must be evident from the fact, that
it was arrested by slight pressure, and did not re-
turn. It must likewise be admitted that if the
blood had flowed from that portion of the artery
internal to the ligature, slight pressure would not
have arrested it, as it would have been under the
59510

49
force of the heart's action, and beneath the stern-
um, so that no pressure would have been sufficient,
for a moment, to save the patient. The ordinary
dressing, for a time, prevented a return of the
hemorrhage, owing to the pressure, the circulation
through the right carotid was interrupted, but
when the circulation with the left carotid became
more freely established, and the right more distend-
ed with blood, it acted with greater vigor, and
the adhesions formed at the divided end of the
innominata were insufficient to resist the pressure
of the blood. A rule has long existed in the
application of ligatures to the arteries, that a suffi-
cient space must exist between the ligature and
the next collateral branch, and in both directions
for a coagulum to form. I am under the impression
that the violation of this rule has been the cause
of failure in all the operations for tying the arteria
innominata. In the report of Professor Mott's
case we are informed, that the ligature was applied
to the innominata half an inch below the bifurca-
tion, a distance equal to the diameter of the carotid
artery. If then the supposion is admitted, that the
arm was supplied with blood by a retrograde
current through the right carotid, which passed off
to the subclavian at an acute angle through the
upper part of the innominata, we must allow that
there was neither space nor time for a coagulum
to form at the angle. In the early stage of these
7

50
cases the carotid artery was partially filled with
blood, and no impetus being given to it by the
action of the heart and arteries, the slight adhesions
formed by the action of the ligature were sufficient
to prevent its breaking out, but as soon as the
artery became distended with blood, and its coats
began to offer resistance, a very little increased
action was sufficient to destroy the recently formed
adhesions. This may be illustrated in the case of
Professor Mott's patient. On the twenty-third day,
"something arrested his attention, which caused
him to turn his head to the opposite side suddenly
and he felt the gush of blood from the wound."—
(Cooper's Surg. Dict.) The hemorrhage was
arrested by lint pressed into the wound. In proof
of the proposition I have offered, it may be re-
marked here, that the pressure applied on the
twenty-third day was sufficient to arrest, in part,
the circulation through the carotid artery, for at
9 o'clock, P. M. the temperature of the right arm
was a little less than in the left, and for the first
time since the first day, warm bricks were ordered
to the arm. From this time to the twenty-sixth,
the hemorrhage was observed to return after the
removal of the dressing, but to decrease in quantity
as the patient grew weaker; showing that although
the adhesions had been destroyed by the first
hemorrhage, the dressings were sufficient to com-
mand the languid circulation through the carotid.

51
The post mortem examination in the several cases
in which a ligature has been applied to the arteria
innominata establish two important facts,
Scarv
1st. That the carotid artery of the right side
remained pervious, although in Professor Mott's
case, it was much obstructed by a coagulum adhe-
ring to its inner surface "more than twice the
thickness of its coats," showing that it had been
gradually deposited by the blood in passing through
the artery. This deposition of lymph may have
taken place within the last three days by the
interruption offered to the circulation through the
artery, by the pressure applied to its lower ex-
tremity.
2d. In the case reported by Professor Graffe, it
appears that the wound had nearly healed, when
a slight hemorrhage came on, which was easily
suppressed, but which was repeated, at intervals,
to the sixty-seventh day, when his patient expired.
The examination, after death, proved that the
hemorrhage did not proceed from that portion of
the innominata internal to the ligature, as this
portion of the vessel was found closed with lymph.
(Cooper's Surgical Dictionary.) A coagulum was
likewise found in the arteria innominata below
the ligature, in the cases reported by Professor
Mott and Mr. Lizars. (London Lancet, 1832.)
Having for several years entertained the opinion,
that the secondary hemorrhage which has so

52
uniformly followed the tying of the arteria innomi-
nata, proceeded from a retrograde current of blood
through the right carotid artery; I have, annually,
for many years, when lecturing upon this subject,
advised my class, in case they should venture upon
the operation of tying the innominata, to secure at
the same time the right carotid artery in a ligature,
as the ligature to the carotid could be applied by
the same operation, and with a trifling additional
dissection; this would give a longer space for a
coagulum to form anterior to the ligature, and if it
should happen, as has been supposed by some,
that the hemorrhage was caused by a retrograde
current from the subclavian artery, that vessel
would be effectually closed up by a coagulum
from its origin to the vertebral and internal mam-
mary arteries.
If future experience should prove the correct-
ness of my views in relation to the arteria innomi-
nata, it would be better in all cases to secure this
artery by ligature in preference to the subclavian
artery upon the sternal side of the scaleni muscles,
as the artery at this place cannot be secured with
any prospect of success. Professor Lizars has
proposed "first to tie the subclavian just at its
origin from the innominata, and then to tie the
carotid about one inch above its origin."-(London
Lancet, 1843, page 605.) It must be admitted
that this proposal gives a much better chance of

53
success, although it may be ojected to, for the
reason that the space existing between the
ligature and the vertebral and internal mammary
arteries, is not sufficient to allow a coagulum to
form.*
* Since writing the above, I find my opinion confirmed by a case
reported by Mr. Liston, who tied the subclavian and carotid arteries,
as proposed by Professor Lizars. The case terminated fatally by
hemorrhage from the distal side of the ligature. Cooper's first lines
by Professor Parker, vol. 2, p. 514.
no
bega
Sa
real
30.
002
ash
201
Shop lenine
galaze
22616 500
hia zid no heasla bas
gairl nedy besabong enav

54
A CASE OF FRACTURED SPINE,
WITH DEPRESSION OF THE SPINOUS PROCESS, AND
THE OPERATION FOR ITS REMOVAL.
[PUBLISHED IN THE AMERICAN JOURNAL OF MEDICAL SCIENCE. VOL. 16, p. 91.]
This case occurred on the 3d of February,
1834, in the person of a Mr. Little, aged thirty-
one years, who fell from the roof of a three-story
house, (as is supposed,) upon a coal-box, which
fractured the spinous process of the first lumbar
vertebra, and depressed this process upon the
spinal cord; a space was distinctly felt between
the last dorsal and second lumbar vertebra. He
presented those symptoms of paralysis and suffer-
ing, which are familiar to surgeons in such cases.
After reaction was fully established, the paralysis
of the lower extremities continuing, with other
distressing symtoms, it was determined to remove
the depressed process.
Operation. The patient was laid upon a cot,
and placed on his side, as symptoms of suffocation
were produced when lying on his face. The

55
shoulders and hips were carried forward, which
caused a projection of the spine; an incision of
about five inches in length was made, in the
direction of the spine; several fragments of bone,
broken from the spinal process of the last dorsal
vertebra presented; these were removed. From
the comminuted state of the depressed process, it
was thought it could be removed without the saw,
and in elevating it, every part was detached except
at the oblique processes. An attempt was made
to separate these with the knife alone, but without
success; Hay's saw, of a small size, was now em-
ployed, but the mobility of the part rendered this a
tedious and difficult part of the operation, the irreg-
ular edges of the bone occasionally coming in con-
tact with the spinal cord, caused excruciating pain,
accompanied with convulsive contraction of the
muscles of the back; with the aid of the double
hook and elevator it was fixed, and by gently
sawing it was separated on one side, but could
not, by this mode, be detached from the other side.
Again the knife was used, and the capsular liga-
ment was divided from the outside; the process
was then drawn upwards and outwards, so that
the probe pointed bistoury might pass between the
articulating surfaces, which completely separated
its attachments. About two inches of the spinal
cord was now exposed, covered with coagulated
blood, quite firm; this was removed with the

56
forceps. The spinal cord did not seem to be
injured. The wound was drawn together by a
suture and adhesive strips, with a bandage. The
patient was laid upon a firm mattress, on his back.
In about fifteen minutes after the operation, he
said he was much relieved; sensibility returned
to the lower extremities, respiration became easy,
and with the assistance of an anodyne, he slept
for several hours.
The above operation was performed on the
morning of the 5th. At 8, P. M., of the same
day, he complained for the first time of pain in
his feet, and of difficulty in passing his urine.
A catheter was introduced, and about a quart of
urine discharged. Gave him lemonade and gum-
arabic water for the night.
6th morning. Has rested well during the night;
complains much of pain in his feet, they are highly
inflamed and visicated-twelve leeches applied
to them; skin dry. Pulse 106. Ordered spirit
mindereri. Seven o'clock, P. M.-Pulse much
excited; skin dry; complains of pain in the
wound; turned him on his side, which gave much
relief; was directed to take at bed time, proto-
chloride hydrarg. grs vi; Pulv. ipecac. compos.
grs. x. M. The lemonade omitted for the night.
Warm fomentations to the feet.
7th morning. Rested well a part of the night;
complains of pressure about the wound. Pulse

57
100, and tense. Bladder much distended with
urine. Bled him ten ounces, when he became
faint. 7, P. M.-Was much relieved by the
bleeding; slept several hours during the day;
urine drawn off twice to-day. Ordered pulv.
ipecac. comp. grs. x, at bed time.
8th morning.-Vomited during the night, which
caused much distress in the wound; no discharge
having taken place from the bowels since the
operation, notwithstanding several injections had
been given, he was directed to take Ol. racini 3j,
tinct. opii gtt. xx, and effervescent draught. 7,
P. M..-Cathartic has not operated.
9th morning. The cathartic has operated sev-
eral times during the night; says he is free from
pain; pulse 91, and soft; the wound in the
back dressed, has in part closed; granulations
seem healthy.
10th morning. By the aid of anodynes he
rested well for the night; skin moist; pulse 98;
the right foot has lost its sensation, much tume-
fied; crepitation was felt on the ankle, resembling
emphysema. Being satisfied that gangrene had
commenced in the foot, I immediately made an
incision in the part from below the inner ankle to
the great toe, down through the distended cellular
tissue. The whole of the foot was gangrenous,
extending above the ankle. The nitric acid
lotion was applied with lint, and the part covered
8

58
with a poultice. He was directed to take gum
opii, gr. ss. and carb. ammonia, grs. ij. every two
hours.
11th morning.-Delirium; refused his medicine;
gangrene extended; made deep scarifications into
the sound parts; continued the same dressings as
yesterday. Directed arrow-root, with wine and
porter.
12th morning.—Is more composed this morn-
ing; slept several hours during the night; took his
medicine regularly. The soft parts about the foot
have separated from the bones, most of which are
in a state of comminuted fracture.
13th morning.-Delirium returned: extremities
cold, pulse hardly perceptible at the wrist. Died
in the afternoon.
Post mortem examination, twelve hours after
death-Viscera of the abdomen healthy; the
membranes surrounding the viscera had a dark
appearance from extravasated blood. The wound
on the back was about half closed by healthy
granulations. The bones of the spine retained
their relative situations. The first lumbar verte-
bra, from which the spinous process had been
removed, was fractured through its body, but no
displacement. The spinal cord seemed in a
healthy condition.
Although all the cases of depression of the
spinous processes in which an operation has been

59
performed have proved fatal, yet I am well satis-
fied that this case presents a strong argument in
favor of repeating the operation under similar
circumstances. The immediate return of sensa-
tion to the inferior extremities after the removal of
the bone, with complete relief from all symptoms
which indicate an injury of the spine, from the
time of the operation to his death, form presump-
tive evidence in favor of his ultimate recovery,
had it not been for the injury and gangrene of the
foot. I think that in a case of simple fracture and
depression of the spinous process, without any
injury of the spinal cord, we have a reasonable
prospect of success in an operation; at all events,
it is the only chance for the patient, and under
such circumstances I recommend it.

60
em
A CASE OF EPILEPSY,
FROM DEPRESSION OF BONE, CURED BY TREPHIN-
ING, WITH OBSERVATIONS.
[PUBLISHED IN THE NEW YORK MEDICAL AND SURGICAL JOURNAL. No. 17.]
Mr. D, æt. 46, the subject of the following
case, has labored under fits of epilepsy for the last
fourteen years.
For the last ten they have oc-
curred so frequently as to disqualify him for labor
of any kind, and they have gradually increased
in frequency and violence. From their long con-
tinuance, his mind is much impaired, and he is
fast approaching to a state of idiocy. By a close
examination I was able to collect from him the
following history of his case :-He stated, that a
short time previous to the first attack of fits, while
working on board a ship, he received a blow from
a bar of iron on the front part of the head, which
fractured a portion of the frontal bone. He was
taken to the hospital; and there not existing any
symptoms of compressed brain, it was not consid-
ered necessary to elevate the depressed portion.
After a few weeks he recovered from the immedi-

61
ate effects of the injury, and left the hospital in
good health. Shortly after this he had an epilep-
tic fit, which returned once a month for three or
four years. In the intervals, between the fits, he
enjoyed good health. For the last ten years the
fits have increased in frequency, and, at this time,
he has two or three a day. His appetite is
voracious; he is indifferent as to the kind of food
which he eats, and seeks only for a sufficient
quantity to satisfy his hunger. He complains of
pain on the injured side, which extends down the
neck and left arm; the eye of the same side is
diminished in size; the sight much impaired, and
his memory almost entirly destroyed.
The wound was easily found by the large
cicatrix which remained. It was situated im-
mediately above the left superciliary ridge of the
frontal bone, and over the superior orbital hole.
From the situation of the fracture, I was led to
suppose, that the external plate of the frontal
sinus alone was involved in the injury, but upon
a close examination of the bone above the sinus,
I discovered a depression sufficiently large to
admit the extreme point of my finger. This
depression was so small that it might readily have
been mistaken for an irregularity of bone, or the
mere depression of the external plate, had not
the history and circumstances of the case called
my attention to it.
дак

62
Although the appearances, on examination,
would not alone justify an operation, yet, from
the regular progress of the disease, I felt assured
that the irritation, producing these fits, originated
from this injury of the head; and concluded that
either a portion of the frontal bone was depressed
--giving rise to the irritation, or that a spicula of
bone projected from the fracture into the substance
of the brain, and from the constant pain felt in
the part, which was increased on the approach of
the fits, I was led to recommend the removal of
the injured portion. The friends readily con-
sented to the operation, the man being incapable
of judging for himself.
On the 7th of July, 1825, assisted by Professor
Mott and Dr. F. G. King, I proceeded to remove
the depressed portion of the bone by the application
of the trephine. Much difficulty occurred in
elevating the bone, in consequence of the inequality
in its thickness; this proceeded from the saw
having to pass through the upper part of the fron-
tal sinus. The bone, after considerable difficulty,
was elevated; but unfortunately, the dura mater
was cut through for one half of the circumference
of the circle. The membranes and the parts
around the wound were, by far, more vascular
than I have been in the habit of seeing them in
operations of this kind. The removed portion of
bone, upon examination, was found to have a

63
corresponding ridge upon its internal surface, not
sufficient, however, to produce any compression
of the brain.
Having made a section of the frontal sinus, a
part of the posterior table was removed with the
circular piece. This portion of the internal table
had been fractured, and separated for some dis-
tance from its inferior attachments to the frontal
plate, and driven back into the substance of the
brain, to the extent of half an inch. Its sharp
edge was worn round and smooth, resembling the
natural termination of bone.
Those present were satisfied that this portion
of the frontal sinus, was fractured and separated
by the blow on the head, and was the cause of
the subsequent mischief. The parts were drawn
together and dressed in the usual form.
2d day. He has been very restless through
the night; he complains of considerable pain in
the head, and is in great dread of the return of
the fits; the excitement is less than was expected.
He was ordered a strict antiphlogistic diet, with
a drachm of the sulph. magnesia every two hours.
3d day.--He has no return of the fits, and
has rested much better through the night; his
medicine has operated freely; the pain continued
in the head and arm; the same treatment pur-
sued. He continued from this time gradually to
improve, without any return of the fits, until the

64
twenty-fifth day after the operation. The wound,
at this time was entirely healed, and he was
permitted to sit up for a short time; when he
imprudently overloaded his stomach with food,
in the absence of the nurse. I was called in
haste to witness a return of the fits. I found him
stupified and almost insensible, much resembling
apoplexy. This was followed by high arterial
excitement and inflammation of the brain. By
active depletion he was, in a few days, relieved.
The pain in the head and numbness in the
left arm gradually subsided. He was discharged,
as cured, on the 20th of August.
Nine months after the operation, I saw this
man in the street. He stated, that his memory
had nearly recovered its usual strength. He has
had no return of the fits, and is so far restored to
health as to attend to his business without any
inconvenience.
A few general remarks, in relation to fractures
of the skull, may not be considered improper in
connection with the present case, as it may possibly
be referred to in favor of the indiscriminate use of
trephine in fractures of the skull.
The division of fractures into simple and com-
pound, has led surgeons to make a difference in
the treatment of these accidents. In the first, it is
advised not to operate without symptoms of com-
pressed brain; and in the second, to elevate the

65
bone without any reference to its immediate
effects upon the brain.
Although the distinction between compound
and simple fracture is proper in the extremities,
inasmuch as the treatment of the two accidents
materially differ, yet when applied to the head, I
am not satisfied of its practical utility. It is apt
to lead those astray who believe that a difference
in name must necessarily require a difference in
This not being the fact in the present
case, and these two varieties of fracture requiring
the same general treatment, the distinction of
simple and compound, for practical purposes, should
be avoided.
treatment.
It is now generally admitted, that the operation
of trephining is unnecessary in simple fractures of
the skull, unattended with compressed brain. Mr.
Abernethy has done much to establish this propo-
sition, and the result, thus far, has been in its
favor. Cases are daily occurring of depression of
bone much below its natural surface, which
recover without being elevated, and, as a general
rule, no inconvenience is experienced from the
injury; and as far as my observation extends, I am
well satisfied that the simple depression of bone
seldom or never produces compression of the brain
without an extravasation of blood, which I believe,
in most cases, is the cause of compression.
A course of bold depletion is necessary to prevent
9

66
arterial excitement, which is the only circumstance
that is to be dreaded in the treatment of these
cases. If a considerable portion of bone is de-
pressed, and inflammation is permitted to progress,
it frequently happens that the expansion of the
brain causes symptoms of compression, and we are
obliged to resort to the saw for the removal of the
bone. This may, however, be prevented by proper
depletion and care on the part of the surgeon.
I am well aware that it is the practice of some
surgeons to trephine for simple fractures. An
operation has lately been performed in the neigh-
borhood of this city, when the patient had, at least,
sufficient sense to walk about the room, and dis-
cuss with the surgeon the merits of the operation.
Such a practice should be severely reprobated; it
unnecessarily places the life of the patient in great
hazard. I shall here offer two cases of simple
fracture, with depression, which recovered under
the depleting plan.
Case I. J. R., aged 12 years, fell from a hay-
loft upon a stone, the 16th of April, 1823.
He was brought to the house insensible. I saw
him two hours after the accident; he had recov-
ered his senses perfectly, but complained from the
contusion of the scalp. The blow was received
on the right parietal bone, a portion of which was
depressed, of about three inches in circumference,
and at least two lines below the surface. As no

67
symptoms of compression were present, I did not
consider it proper to elevate the bone; and accord-
ingly bled him freely from the arm-ordered a
mild cathartic, with bread and water for his diet.
On visiting him the next day, he complained of
considerable pain in the head, with intolerance of
light, and an inflamed state of the eye. I bled him
largely from the arm, and ordered six leeches to
the temple. This practice was continued for
twelve days, and he was bled at least once a day,
with other means of depletion. The symptoms
gradually subsided, and at this time he enjoys good
health, without experiencing any inconvenience
from the injury.
Case II. I was requested by Dr. C. to visit a
poor child, which had fallen upon the corner of a
chair and fractured its skull. The doctor had left
it insensible, and laboring under symptoms of com-
pressed brain. I saw it three hours after the
injury; it was then insensible; I found a consid-
erable portion of the frontal bone driven in. The
depleting plan was advised. I have learned from
Dr. C. that this child completely recovered.
Many surgeons adhere to the old practice of
elevating depressed portions of bone, from a belief
that its unnatural situation would be a source of
irritation to the brain, and, at some future time,
epileptic fits would be the consequence.
This
opinion is supported by Sir A. Cooper, in relation

68
to compound fractures; and he recommends the
removal of bone. We are not satisfied as to the
correctness of this distinction; or from what cir-
cumstances, connected with these injuries, we
should dread epilepsy in one case more than in
another. The only difference, in the two cases,
proceeds from the bone-in the one case, being
exposed to the air, while in the other it is covered
by the integuments. In relation to the bones,
they are in the same situation, and in either case,
our fears are founded upon the belief, that newly
formed bones occasionally proceed from the inter-
nal surface of the depressed portion; and from
their irritation on the brain, produce epilepsy.
This distinction, we are well convinced, cannot
be supported by practice. The question would
naturally arise, why is depressed bone exposed to
the air more likely to have preternatural growth,
or protuberances projecting from it, than those
covered by the common integuments?
Unless this question can be satisfactorily an-
swered, I should be inclined to regret this dis-
tinction in fractures of the skull, and to pursue the
same plan of treatment in all cases.
I shall submit two cases of compound fracture
of the skull, which came under my care while
Resident Surgeon to the New York Hospital.
One I have transcribed in detail, to show the ex-

69
tent to which depletion may be carried in these
cases with safety and advantage to the patient.
*Case III. O. Platt, a robust man, aged 21
years, was admitted into the New York Hospital,
Jnly 6th, 1822, with a compound fracture of the
skull, produced by a fall from a scaffold about ten
feet high. The frontal bone was fractured on the
right side, with a depressed portion of four inches
in circumference. At the time of his admission,
the wounded temporal artery was bleeding freely;
his senses were perfect, and without any symptoms
of compressed brain. He complained of slight pain
in the head. He was placed in a dark room, and
ordered bread and water for his diet, with simple
dressings applied to the wound. Two hours after
his admission considerable reaction came on. He
was bled 3xvj from the arm.
7th.-Passed a sleepless night; complained of
pain in the bowels, with great irritability of the
stomach; pulse quick and hard; bled 3xx; gave
him the aqua ammoniæ acetat. 3ss every hour,
and applied warm fomentations to the abdomen.
7 P. M., pain returned in the head; bled 3xvj,
which gave him much relief.
8th. Rested well the first part of the night;
* I unintentionally omitted in the first publication of Case III. to
state that Dr. J. K. Rodgers was the attending surgeon, who direct-
ed the whole treatment; and to his energetic skill the patient was
indebted for his recovery.

70
the pain in the head has returned, with slight
symptoms of compression; bled 3xxv; he has not
had a passage from his bowels in two days; let
him have the infus. sennæ cum sulph. magnesiæ,
to be followed by an enemata. 7 P. M., the me-
dicine has not operated; he was ordered ol. ricini
zij, and bled 3xvj.
9th. The constipation continues: cathartics
continued; pulse much excited; bled 3xx. 7 P.
M., the cathartics have not operated; bled 3xvj.
10th-Passed a very restless night; complains
much of his head; pulse hard and quick; has had
no passage from his bowels; let him have calomel
grs. x. every six hours; bled 3xvj. 7 P. M. much
relieved by the operation of the calomel.
11th-Rested better than usual; slight pain in
the head; bled zxvj.
12th.-Rested well, and feels but little pain in
the head; dressings removed from the wound-it
looks healthy, with a free suppuration; an abscess
has formed under the occipito frontalis muscle, ex-
tending to the right side; an opening was made
for its discharge, and the wound dressed as before.
The suppuration, under the scalp, gradually les-
sened by the use of compresses and bandages.
Granulations, from the edge of the wound, in a
short time covered the bone; and at the time of
his discharge from the house, his health was com-
pletely restored and the wound nearly healed.

71
This man I occasionally see, (1826), and he
has felt no inconvenience from the injury.
Case IV. J T., admitted Nov. 12th, 1822.
This poor man received a blow from a brick
thrown at him with great violence. The integu-
ments were extensively lacerated, and a portion
of the frontal bone driven in; the pulsation of the
brain could be distinctly seen; his senses were
perfect. The depleting plan of treatment was
pursued, but not to the extent of case third. The
mild symptoms of inflammation which came on
subsided in a few days, and in three weeks he
left the hospital in good health.
Not having seen this man after he left the
house, the result of the case is uncertain. The
dressings to the wound in this, as well as the last
case, were not removed until all symptoms of in-
flammation had subsided. This we consider as
an important improvement in the treatment of
wounds and operations about the head.

72
ON THE UTILITY OF TYING LARGE ARTERIES,
IN PREVENTING INFLAMMATION IN WOUNDS OF THE
PRINCIPAL JOINTS, AND IMPORTANT SURGICAL
OPERATIONS, ILLUSTRATED BY CASES.
[PUBLISHED IN THE NEW YORK MEDICAL JOURNAL, Vol. III. p. 453]
The unfavorable termination of wounds in the
large joints, and the little success attending the or-
dinary mode of treatment, have led surgeons, in
many cases, to doubt the propriety of attempting
to save the extremity: and in the majority of cases,
amputation is subsequently resorted to, in order to
save the patient's life. A surgeon (Sir A. Coo-
per's Lectures, p. 108) of great eminence, whose
opportunities have been sufficiently ample to lead
to a correct conclusion upon this subject, enter-
tains but slight hopes of preserving the limb, if
we fail in uniting the wound by the first intention.
The synovia is allowed to escape, and inflam-
mation ensues upon the internal surface of the
joint. "If the patient be not very strong, it will
be necessary to amputate the limb; but if his sta-
mina be good, the patient may probably escape
with anchylosis."

73
In offering these remarks, it is my intention to
show, first, the inefficacy of the ordinary mode of
treatment in wounds of the large joints; and, se-
condly, to invite attention to the propriety of cut-
ting off the supply of blood to the large joints and
other parts endangered by inflammation. This
practice, so far as related to important surgical
operations, has been frequently urged by Professor
Mott from the surgical chair, and well illustrated
by his recent operations on the lower jaw.*
An ordinary case of simple incised joint attracts
but little attention from persons unacquainted with
the serious nature of the accident. A cloth is
bound about the part, and they attend to their
usual occupation, unconscious of the terrible result.
Many hours will frequently elapse before surgical
advice is obtained. Inflammation commences in
the joint, and the constant discharge of synovia,
by lubricating the parts, renders union by the first
intention very doubtful. A surgeon acquainted
with the nature of the accident would resort to
the most active depletion, both local and general.
The disease gradually progresses, and after many
months of confinement and pain, amputation is at
last resorted to. This is the most frequent ter-
* The principle of cutting off the supply of blood to parts endan-
gered by inflammation I was the first to recommend and practice
in wounds and injuries of large joints.
10

74
mination of wounds of the large joints; but they
sometimes terminate differently. The ends of the
bones are denuded of their cartilages, a gelatinous
substance is thrown out, which is gradually ossi-
fied, and firmly unites them, as in case of simple
fracture. In confirmation of the above, I shall
here add a few cases out of many that have come
under my observation :
CASE I.-A. Hannah, aged twenty-four years,
of steady habits and a good constitution, was re-
ceived into the New York Hospital, November 12,
1822, for a wound of the knee joint from a small
penknife. The incision was about two lines in
length; simple dressings were applied to the
wound, and he walked to the hospital twenty-
four hours after the accident. The knee was
much inflamed and painful; the dressings soaked
with synovia, which continued to discharge in
great quantities. His habit being full, he was
bled largely from the arm, and ordered a brisk
cathartic. The wound was carefully brought
together by adhesive straps; leeches and cooling
washes applied to the knee; and every exertion
made to arrest the inflammation.
Notwithstanding the active measures that were
adopted, and continued from time to time as cir-
cumstances required, the disease continued to
progress. The wound remained open. The ter-
mination of the disease in anchylosis failed; mat-

75
ter in large quantities was formed in the joint,
burrowing itself both above and below the knee,
from the spinous process of the ilium to the ankle
joint; and after five months of great suffering, it
was found necessary to amputate the limb.
CASE II.-Master C., aged twelve years, was
thrown from a horse, and fell upon a pavement:
the left arm was extended to break the fall, which
brought the weight of the body entirely upon the
elbow joint, which gave way; the condyles of the
os humeri were driven forward through the integu-
ments, and lay perfectly naked on the fore-arm.
He was immediately brought to my office for ad-
vice. The soft parts were badly lacerated, the
bone, denuded of its covering, lay four inches from
its natural situation. The tendon of the biceps
and the brachial artery were pushed to one side,
and lay posterior to the bone. After considerable
difficulty, the bone was replaced in its proper situa-
tion, and the wound brought together by adhesive
straps. From the great extent and dangerous na-
ture of the wound, I was anxious that something
more should be done, in order, if possible, to pre-
serve the limb; and I accordingly recommended
to his friends that the brachial artery should be se-
cured by ligature. The necessary preparations
were immediately made for performing the opera-
tion; but the anxiety of his friends had induced
them in the meantime to request the attendance

76
of their family physician, who unfortunately differed
with me as to the necessity of the operation. The
arm was accordingly dressed and the boy sent
home. Further advice was requested, and twen-
ty-four hours after the accident two eminent sur-
geons were called in, who proposed immediate
amputation; but the supervention of tetanic symp-
toms rendered the operation inadmissible. He
was ordered large quantities of opium to lessen
irritation, and emollient applications to the arm.
These symptoms were relieved in a few days by
a profuse suppuration from the wound, and after
many weeks' confinement he recovered with an
anchylosed joint.
I would remark upon this case, that as the fa-
vorable termination of this wound could not have
been anticipated, it would have been consonant
with the best rules of surgery to have amputated
the arm, (vide Hennen's Observations, pp. 159 and
274,) and no surgeon would have been censured
for so doing; and in the second place, the pro-
posed operation of securing the brachial artery
was offered as the only chance of saving the arm.
By cutting off the current of blood leading to the
wound, it would have prevented a high degree of
inflammation, and consequently lessened the sub-
sequent irritation, at the same time allowing the
soft parts an opportunity of uniting by adhesive
inflammation. I am well persuaded, from subse-

77
quent experience, that it would in all probability
have preserved the use of the joint. The cartil-
ages and ligaments in their healthy state, are said
to be insensible, or at least their complaints are
not conveyed to the sensorium; and consequently
we are not aware of the contusions which they
must daily receive in our ordinary occupations of
life. But when diseased, or excited into action
by local causes, they become exquisitely sensible.
Possessing but slight powers of life, they resist dis-
ease badly, and are easily destroyed by inflamma-
tion, thus laying the foundation for the most ob-
stinate and fatal maladies. In disease, as in health,
they appear to be placed beyond the control of the
system; and surgeons,* from the earliest days, have
been conscious of the difficulty of controlling inflam-
mation in the large joints by the usual treatment, and
they generally resorted to immediate amputation.
A surgeon,† a few years since, in a case of a
wounded knee joint, to arrest hemorrhage, secured
* Wiseman, in his Chirurgical Treatise on Wounds of the Joints,
Book VI., page 87, observes, "The greater wounds are attended
with much more vehement pain, inflammation, delirium, convul-
sions, gangrene, and are commonly deadly." The Art of Surgery,
by Daniel Turner, M.D., Sec. V., page 500, in treating of wounds
of the joints, says, "Passing by the stiff and useless limbs, loss of
the same sometimes occurs, and frequently of life also." See John
Bell's Surgery, Part III.
† American Medical and Philosophical Register, Vol. IV., page.
176.

78
the femoral artery in a ligature. The successful
termination of this case established the principle,
as far as one operation can go to establish an im-
portant rule of practice.
I shall here cite a case of a similar nature, which
came under my care, and which, to me, has been
truly interesting in its nature and termination.
Case III.-I was requested on the 14th of Au-
gust, 1824, to visit Mr. M'Cay, aged 30 years, a
wheelwright, who had the day previous wounded
his knee with a gouge. I found him lying on a
mattrass, drinking spirits and enjoying the company
of his friends. He was a man of full habit, with
a constitution much injured by high living, and
consequently a bad subject for a serious injury. So
slight did he consider the wound, that he neglect-
ed to ask advice, and had drawn it together by
three sutures. The wound was situated on the
side of the joint, about one inch in length, and
was allowing a free discharge of synovial fluid.
The knee was much swelled and painful, the in-
flammation extending above and below the joint
to a considerable distance. He had a furred
tongue, a full and hard pulse, and loss of appetite,
with great thirst. The stitches, which included
the divided portions of the capsular ligament on
each side, and added greatly to the original cause
of irritation were immediately removed. I apprised
him of his dangerous situation, and solicited fur-

79
ther advice. Dr. Mott was accordingly requested
to visit him, and after maturely considering the cir-
cumstances of the case, and the slight chance that
could be offered him of saving the leg by the usual
mode of depletion, I proposed to cut off the supply
of blood to the joint by securing the femoral artery
in a ligature. To this proposition Dr. M. readily
consented, at the same time expressing a doubt as
to the result. The man was accordingly laid upon
a table, I passed two ligatures around the artery at
the upper part of the middle third of the thigh, and
the wound was dressed in the usual way. The
edges of the wound on the knee were brought to-
gether and retained by adhesive straps.
The pa-
tient ordered to bed with a strict iujunction not to
move the leg.
2d day. On visiting him this morning, I found
all the dressings removed; he had passed a very
restless night. His countenance flushed, and the
pulse full and hard. The swelling of the knee
has much subsided, and the pain by far less than
it was prior to the operation. The wound was
again dressed, a saline cathartic was ordered, and
the strictest abstinence enjoined.
3d day. The cathartic had operated well, he
rested much better during the night, and had no
pain since the preceding day. From this time no
symptoms of importance occurred during his re-
covery.

80
In a few days the pain and tumefaction entirely
subsided, without any further discharge of synovia.
On the tenth day after the operation, the dressings
were removed from the knee. The wound had
nearly closed, and granulations had sprung up
from the bottom; the edges were again brought in
cantact by plasters, and left until the fifteenth day,
when upon removing them, I was much gratified
at finding the wound completely closed. On this
day the ligatures came from the femoral artery, and
the wound was nearly healed. On the twenty-
fifth day he walked out without experiencing any
inconvenience from the injury, except a weakness
of the limb.*
How far the practice of tying the femoral artery
in compound fractures and dislocations of the
ankle joint would be advisable in preference to
immediate amputation, I have not had sufficient
opportunity of judging. But as a powerful agent
in lessening inflammation in these cases, I am thus
far well convinced of its utility, and should strong-
ly recommend its adoption in those cases where
an effort should be made to save the limb. From
* Case III. is the strongest proof that I am acquainted with in sup-
port of the utility of cutting off the circulation to large joints when
seriously injured, and the favorable termination of this case may be
attributed entirely to the interruption offered to the current of
blood to the part; as it was unassisted by the Valsalvian depletion
as recommended by Larrey, Guthrie and Hennen.

81
the frequency of tetanic symptoms in these inju-
ries, I am doubtful as to the propriety of hazarding
the patient's life to save the leg. Unless the acci-
dent should occur to a young subject, with an un-
impaired constitution, and enjoying the benefit of
a good country air; the attempt ought, then, as-
suredly to be made. This distinction in the result
of wounds in the country and city ought strictly to
be observed, as it is a well-known fact among sur-
geons of experience, that compound fractures and
dislocations of the ankle joint do well in the coun-
try, whereas in the city, they, as a general rule,
prove fatal.*
Therefore, under other circum-
stances than those alluded to, it would be criminal
to allow our humanity to govern us so far as to
endanger the life of the patient by an unnecessary
delay in amputating the extremity. "However
desirable it may be to save a hand or a foot, yet in
severe laceration the frequency of tetanic affec-
tions should at once lead us to adopt immediate
amputation." (Hennen's Observations, p. 170.)
When an attempt is made to save the limb by
cutting off the circulation, it will lessen inflamma-
*The late Dr. R. Kissam, of this city, who, as a practical surgeon
stood deservedly among the first in his profession, was heard fre-
quently to express his decided disapprobation of any attempt to save
the leg in compound fracture, and dislocation of the ankle joint.
+ Mr. Hennen, in his Observations, states-"I have never been
fortunate enough to cure a case of the acute symptomatic tetanus."
p. 162.
11

82
tion, and aid the healing process. It will, how-
ever, have no influence upon the nervous irrita-
tion, or the accession of tetanic symptoms, which
do not appear to be governed by the increase or
diminution of the arterial excitement. When the
inflammatory action has subsided, and the wound
is kindly healing-in short, when we consider our
patient free from danger, our best hopes are fre-
quently destroyed by the accession of tetanic
symptoms, which in a short time end his existence.
The following case was one of this kind, for the
particulars of which I am indebted to Dr. F. G.
King, house-surgeon of the New York Hospital.
CASE IV. Vosburg, aged thirty-four, laborer,
habit full, free drinker, whilst engaged in removing,
earth from the hills at the Hook, a part of the bank
caved in, and struck him on the left leg just above
the ankle, by which blow the ankle was com-
poundly dislocated upon the inner side, the bone
protruding through the integuments fully half an
inch. This was about 2 P. M. of Friday, Sep-
tember 2d, 1824, and at 3 P. M. he was brought
to the hospital. The wound was there washed,
the sand which had entered the joint cleaned out
as well as possible, the bone reduced, wound dress-
ed, and patient bled. On Saturday afternoon, the
ankle was extremely painful, swelling and inflam-
mation increasing, leeches and cooling lotions not-
withstanding. Dr. Mott resolved to tie the femoral
66

83
artery, for the purpose of lessening the determina-
tion to the part, and reducing inflammation. This
operation was accordingly performed, after which
the wound of the ankle was drawn together by
adhesive straps, and so dressed with lint. On
Sunday, after having passed a quiet night, the
swelling was found not to have increased; limb of
natural temperature, which is less than that of yes-
terday, and pain diminished; wound not examined.
Monday, slept well during the night, swelling dim-
inished, heat natural, wound at the ankle offensive,
and discharging a thin bloody fluid, poultice to
soften dressings and cleanse the part-edges high-
ly inflamed. On Wednesday the wound looked
remarkably well, exhibiting healthy and numerous
granulations, dres: ung: Res: flav. Thursday,
granulations increasing, the wound filling up well,
and presenting a very healthy appearance; no
pain, swelling, or tension in the part; patient ex-
presses himself very comfortable; and thus it was
doing uncommonly well until the seventh day from
the accident, when trismus, &c., set in, and he
died."
Although the above case proved fatal, yet we
may draw some practical conclusions of import-
ance to our present subject. First, it affords a
strong proof in favor of the utility of cutting off
the circulation in extensive injuries, and it must
be considered as a noble effort of surgery to lessen

84
human misery, and to save the unhappy subject
of those accidents from decrepitude. And second-
ly, it gives us a fair specimen of the fatality attend-
ing compound fractures, and dislocations of the
ankle joint. Notwithstanding every effort was
made which science is capable of exerting, and
the plan pursued was justified upon every prin-
ciple of surgery, and the case for a time appeared
to sanction its adoption; yet we are led from the
result of the case to admit that immediate amputa-
tion would have been preferable, inasmuch as it
would in all probability have preserved life.
In the treatment of wounds and surgical opera-
tions, inflammation in its progress is a subject of
serious consideration to the practical surgeon, as it
frequently baffles his best directed efforts to arrest
its unfavorable terminations; and therefore every
practical fact tending to elucidate its nature or
treatment should be impartially considered. It is
upon these grounds that I solicit attention to the
propriety of cutting off the circulation to parts en-
dangered by inflammation; not only as it is appli-
cable to wounds of joints, but to all serious inju-
ries in other parts of the body, and to operations
of great magnitude, when it is important to pro-
duce an immediate union. I feel the more confi-
dence in urging this practice, as it is firmly be-
lieved that it would in the majority of cases super-

85
sede the necessity of amputation.-(Vide Trow-
bridge's Cases in Surgery.)
To excessive inflammation is attributed all the
mischief that follows extensive injuries, and the
most active means of depletion are carried into
operation to lessen irritation and subdue action.
We therefore resort to local and general blood-
letting, counter-irritants, &c., to take off the de-
termination of blood to a particular part, and to
reduce its volume. If by these means we are suc-
cessful, the part recovers its tone; and is soon re-
stored to healthy action. But in case of failure,
the vessels of the inflamed part enlarge, become
turgid, producing tumefaction and pain; the ves-
sels from the loss of power are unable to discharge
their contents, and the blood collects beyond their
limits of distension. They give way, and the dis-
ease terminates in mortification. It is upon the
same principle of lessening inflammation, which
has hitherto been pursued, that the present opera-
tion is urged, but with this difference: in one case
we take off the current of blood from the diseased
part by reducing the strength of the general sys-
ten, and when suppuration cones on, the consti-
tution is too much enfeebled to support a tedious
discharge, and necessity obliges us to remove the
extremity. But in the proposed plan, the same
indications are answered without seriously affect-
ing the general health. The depletion is entirely

86
local, and confined to the diseased extremity. The
injured part has an opportunity of recovering its
healthy action before the circulation can be suffi-
ciently restored to do any injury, and in case of
failure in uniting the wound by the first intention,
all the strength of the constitution will remain to
support the subsequent suppuration. It might be
objected to by some, lest immediate mortification
should follow the operation. Experience, how-
ever, has taught me to believe that the collateral
circulation will in most cases be sufficient to sup-
port the vitality of the extremity. I shall here
offer two cases from my note-book in support of
this opinion.
beag bigips
CASE V.-A lad, aged sixteen years, was brought
to the hospital, July 4th, 1821, with an extensive
laceration of the arm, which he received from the
discharge of a gun, while imprudently resting his
arm upon the muzzle. The discharge entered
the arm about the elbow joint, tearing off the in-
teguments for six inches in length and three in
breadth. The nerves, veins, and arteries lay like
cords on the surface of the wound. The muscles
lacerated in such a manner as to destroy the ap-
pearance of their original structure. The bone
laid bare, and in some places denuded of its peri-
osteum; he lay for some hours weak and ex-
hausted; his pulse was small and quick. The
extent of the wound led the attending surgeon to

87
believe that the brachial artery, or some of its
large branches, were divided, and hemorrhage
was expected from the wound, as the system re-
covered from the immediate shock of the accident.
To prevent hemorrhage, the brachial artery was
secured by ligature, as it passes out from the
axilla. Little hope was entertained of saving the
arm, but to the astonishment of all who saw the
case, there was merely sufficient inflammation in
the wound to produce healthy suppuration and
granulations. He suffered but little pain during
his recovery; and I may venture to assert that
there was not more inconvenience experienced
from this lacerated wound, than there would have
been from a simple incised wound of the same
extent, where the circulation had not been inter-
rupted. He recovered rapidly, and in the course
of a few weeks left the Hospital in good health.
CASE VI.-John Mylander, aged 30 years, came
into the Hospital Nov. 29, 1823, for an inflamma-
tion in the arm. He stated, that four days previous
he felt a slight indisposition, and applied to a doctor
for advice, who bled him.-That the blood flowed
very fast, and there was considerable difficulty in
stopping it. On his return home, it began to swell,
and was very painful.
the lancet had healed.
such a degree that it
The incision made by
The arm was swelled to
appeared on the point of
bursting; and so very sensible, that he complained

88
bitterly of the pressure from the necessary dressings.
He was bled largely, ordered an anodyne, and
emollient applications to the arm. On visiting him
the next morning, and examining the arm more
particularly, I found a distinct fluctuation of mat-
ter at the upper part, and on the outside of the
tendon of the biceps muscle. I accordingly passed
a lancet into the abscess, and discharged at least
six ounces of matter. A poultice was ordered,
and I left him to visit the other wards. After
having passed two wards, the nurse came after me
in great haste, stating that the man was dying
from the loss of blood. I hastened to the ward,
and found him lying on the floor, faint and covered
with blood, which was flying from the arm half
way across the room. I instantly plunged my
finger into the wound, and after pushing it to its
full length through the sac which had lately con-
tained matter, I was able to find the artery, and,
by pressing with great force, to command the cir-
culation. The attending surgeon immediately saw
him, who made an incision down to the artery,
and found a wound passing completely through it,
about the eighth of an inch in length. After clear-
ing away the clotted blood, which was extensively
diffused through the cellular substance, it was
secured by ligature. The hemorrhage returned
again in two days, when it was found necessary to
secure the artery higher up. After this second

89
operation, which completely cut off the blood from
the arm through the principal trunk, the man ex-
pressed great satisfaction at the almost immediate
relief which it gave him. In this case we might
have expected mortification to have followed the
interruption offered to the circulation through the
principal trunk, as the cellular substance was
crowded with coagulated blood for some distance
above the elbow to the ends of the fingers; and
so great was the tumefaction, that it must have
interrupted, in a great measure, the circulation.
through the collateral branches. But notwith-
standing all the difficulties attending this case, the
tumefaction and pain of the arm rapidly diminish-
ed; the wound healed kindly, and in four weeks
he was discharged, cured. In closing this paper,
I do it, confidently believing that the practice to
which I have essayed to invite professional atten-
tion will, ere long, in abler hands, become an es-
tablished and important rule of surgery in the
treatment of inflammation.
CORD TREE
cabine
no enoitstego abo
bel woo 143-00126 to
berno od algin c
od blano bithom
Bizco 2120 Bidoar edi babivou
medier isso! Serebienoo et il
ed: 10 120m es
Sinest eldstone
not wat towol
Jailed od cr
noitamie vas
boromet visting
Hot
Innohmheroo
good grad doidy pase
12

90
20
dot
252
doldwy
400 do
pu
cile
CASE OF OSTEO-SARCOMA OF THE SUPERIOR
MAXILLARY BONE.
$3900
odt
WITH THE OPERATION FOR ITS REMOVAL.
[NEW YORK MEDICAL AND PHYSICAL JOURNAL VOL. III.]
d
lagu Ist ging
Svods
As the attention of surgeons of late has been
directed to the diseases of the face, and more
particularly to the ossific tumors of this part, it
is important that every fact should be given to the
profession which may have a tendency to elucidate
the character of this disease, or to confirm the
utility of those splendid operations lately performed
in cases of this kind by Professor Mott. For in
the result alone can their importance be estab-
lished; and, like all innovations in practice, they
must, for a time, contend with the prejudices of
professional men, which, however, will gradually
yield, as success becomes more certain. The
favorable result of Dr. Mott's operations on the
lower jaw, for the cure of osteo-sarcoma, led me
to the belief that the disease might be cured in
any situation, provided the morbid parts could be
entirely removed. It is considered a local, rather
than a constitutional affection, as most of the
cases which have been published evidently prove.

91
They were generally submitted to strict medical
treatment, but without receiving the least benefit,
and a resort to the knife rescued them from death.
With the firmest confidence in the utility and suc-
cess of a surgical operation, I was induced to at-
tempt the extirpation of the disease from the up-
per jaw, in the following case:-R. G., born in
Ireland, aged 34 years, came under my care about
the 1st of May, 1824, for an affection of the nose.
His constitution was much injured by previous in-
temperance and hard labor. He stated that the
affection of his nose was of six weeks' standing.
The disease first made its appearance by an en-
largement of the soft parts in the front of the
mouth, and a loss of all the incisores teeth. His
nose soon became obstructed, and a body of a fun-
gus character made its appearance in the right
nostril, pressing upon the septum, and gradually
obstructing the passage of air through the nose.
The disease had progressed thus far, at the time
of my seeing him, without much pain, but with
surprising rapidity, and was then making its way
through the palate. The malignant character of
the disease, and its rapid progress, almost prohibit-
ed any attempt, with the least prospect of giving
the patient relief. It being evident that unless
some energetic measures were adopted to arrest
its progress, it must soon terminate his existence,
I therefore determined to attempt its extirpation.

92
The operation was accordingly performed on the
tenth, in the following manner :-An incision was
made first through the filtrum of the upper lip,
which was dissected from the tumor and alæ of
the nose, so as to turn both portions of the lip
over upon the cheek. The second incision was
to detach the cartilaginous portion of the septum
narium from the top of the tumor. After extract-
ing the two first molar teeth on each side, a fine
saw was used, which readily divided the superior
maxillary bone, including the palatine process,
the two incisions meeting at the palatine suture ;
after sawing through the principal bones, the tu-
mor was easily removed, akhough it extended
much farther back than was at first anticipated.
It was found necessary, during the operation, to
remove the two inferior turbinated bones, a part
of the septum narium, the vomer, and a part of
the right antrum. Only a small quantity of blood
was lost during the operation, considering the ex-
tent of the disease, and the vascularity of the part;
this may be attributed to the frequent use of the
saw. After the operation, the soft parts were
brought together and secured by three sutures
and adhesive straps. No unpleasant symptoms
occurred during his recovery. The parts adhered
by the first intention. There was considerable
falling in of the upper lip, in consequence of the sup-
port which it gave to the nose. In two weeks

93
4
from the time of the operation, the patient was
able to walk out, and on the fourth, to return to
his daily labor. The situation of this man will
be rendered comparatively comfortable with the
assistance of a cork palate.*
*So far as I have been able to discover from the records of sur-
gery, this is the first case in which the superior maxillary bone
has been removed by a surgical operation.
A notice of a previous operation having been performed has ap-
peared in several publications. The case has not to my know-
ledge ever been published, and was not known until the above case
appeared in print. From the authority of those who were present,
and witnessed the operation, it appears that it extended to the
removal of a small portion of the alveolar process of the superior
maxillary bone only, for the removal of a tumor from the antrum.
guibag
984
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beasoro
vad geble agized of gainatze mad has fiel ada
bainamo godile bus bet
sed fosmose
cabrent ved
amsogony guiod
nise gansplant grade and
Ayat 2567
20
461
sasasib adiazanqui aids Saff
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diw bossong of ho
bowol
bottense bad om
ad of
03
eply

94
moil
[COOPER'S SURGICAL DICTIONARY ]
CASE OF OVARIAN TUMOR,
.050
SUCCESSFULLY EXTIRPATED, [WITH A PLATE.]
aid
seed
IN July, 1829, I was requested by Dr. McCaffry
to operate on Mary Gurly, for peritoneal dropsy;
after drawing off the water, I observed that the
abdomen remained unusually large; upon exami-
nation I discovered a large tumor occupying the
left iliac region, and extending to the right side.
She gave the following history of its original
growth:-Two years before, in her passage from
Ireland to this country, after being two weeks at
sea, she had a suppression of the catamenia, which
was soon followed by a sharp lancinating pain in
the left iliac region; previous to which her health
had always been good. On landing, the pain in-
creased, and the abdomen began to swell; first, on
the left, and then extending to the right side; her
stomach became affected, and although unmarried,
her friends accused her of being pregnant.
In consequence of this impression, the disease
was allowed to proceed without any medical ad-
vice, until time had satisfied the friends to the

1.
Leach del.
Case of Ovarian Tumar.
W. Main Sc.
2


95
contrary, when a physician was called, who pro-
nounced the disease dropsy, and recommended
her to be tapped. A large quantity of water was
drawn off, but in two months it had re-accumulat-
ed, and the operation was repeated five times pre-
viously to my seeing her. It is computed that
within the two years, eighteen gallons of fluid were
drawn off.
00 ods
I observed in this case what I have remarked
in several others--that the fluid discharged differ-
ed from the water in common ascites. It is much
more mucilaginous; of the consistence of honey;
of a milky color, and differs from any other secre-
tion that I am acquainted with. After deliberately
examining the tumor, and as far as possible ascer-
taining its character and connections, I suggested
to her the possibility of its being cured by an ope-
ration, at the same time stating the great risk of
life attending the performance, and the slight
chance of her recovery. I likewise requested
Professor Mott, who was consulted in this case, to
make a similar statement. Her good constitution
and general health all urged the obligation of mak-
ing an attempt to save her. After the first sugges-
tion, nothing could alter her determination to avail
herself of the chance of relief which even so des-
perate an operation might afford, and, as she ex-
pressed it, "I would rather die than live in my
present situation." It was accordingly determined

96
to perform the operation as soon as the weather
would permit. In the meantime she was placed
upon a vegetable diet. One week previous to the
operation I again drew the water, and directed her
to live upon bread and water, to take a saline ca-
thartic every morning, and to lose blood to the
amount of twenty ounces on the day previous to
the operation. This preparatory treatment was
rigidly carried into effect by Dr. McCaffry, and
to his care I feel much indebted for the success of
the case.
On the 14th of September I proceeded
to the operation, assisted by Professor Mott, Dr.
Vache, and my brother, Dr. J. H. Rogers, in the
presence of my pupils. She was laid on a table
of convenient height, and with a large scalpel I
commenced an incision a little below the ensiform
cartilage, carrying it parallel with the linea alba,
and terminating at the symphisis pubis.* The
integuments being divided, the dissection was con-
tinued through the tendon of the linea alba to the
peritoneum. This was at first supposed to be
much thickened, but by a cautious dissection
through a membranous texture to the depth of a
quarter of an inch, the water gushed out with
considerable force. With a probe pointed bis-
toury the opening was enlarged to the full extent
of the external incision, and to our surprise we
* From the enlarged state of the abdomen, the incision was at
least twenty-four inches in length.

97
found that a sac was opened which appeared to
fill the whole circumference of the abdomen, and
at first its attachment appeared commensurate
with its size. It lay in connection with the liver,
stomach, spleen, and bladder. By pulling up the
sac, it was found that the adhesions were much
less than at first expected. It was determined,
therefore, to dissect them from the peritoneum and
omentum. Some of the adhesions were so slight
as to be separated by the finger, others by the
handle of the scalpel, but the greater part required
to be separated by a tedious dissection, and in
some parts the adhesions were so close that por-
tions of the peritoneal membrane were removed.
These adhesions extended for three or four inches
around the umbilicus.-[See fig. 1.] After com-
pleting this part of the dissection, the tumor was
drawn out and supported by an assistant, and the
dissection continued; separating it from the ovari-
an ligament, [see fig. 2,] which required much
care, from the large and numerous vessels going to
it from this source; the largest was at least the
size of a goose quill. After occupying two hours
in the operation, this large mass of disease was
safely removed, and laid on the table.
The liga-
tures were all cut close to the knot, and left to
absorption. The wound was closed by sutures,
dressed with adhesive straps, lint, a compress and
a bandage applied firmly to the abdomen. I place
13

98
some confidence in the close application of a band-
age, as it brings the divided surfaces in contact for
the purpose of adhesion, and likewise as an im-
portant auxiliary in preventing inflammation. She
was then removed to bed; her pulse at this time
was feeble, but regular. In the course of the even-
ing, considerable reaction came on, with some heat
of skin. The following minutes of the case were
kept by my pupil, Mr. Leach:
mo
Sept. 15.-Slept but little during the night; at 8
A.M. pulse 120 and quite thirsty; considerable pain
on coughing, quite easy otherwise; at 7 P. M.,
slept for two hours during the day; skin dry and
hot; restless and in some pain-bled 3xvj
16th. She slept better last night; complains of
being chilly-applied bottles filled with hot water
to her feet; cough troublesome, occasioning some
pain; pulse 112-venesect. 3xvj.
17th. At 8 A. M., pulse 116, and some pain;
at 8 P. M., quite comfortable.
18th.-Slept most of the night; pulse 106, and
regular.
19th.-Pulse 95; very little cough; slept well
through the night-dressed the wound, it had
mostly healed by the first intention; removed the
sutures, and dressed with adhesive straps.
21st.-Slept well all night; no pain on pressure
in any part of the abdomen-dressed the wound,
it had entirely healed; let her have chicken-broth.

99
7010
From this date she continued to improve in health,
without any symptoms requiring notice.
In two
weeks she was permitted to sit up, and to walk
about the room, with directions to return to her
usual diet. In six weeks from the day of the ope-
ration she called at my office to inform me that
her catamenia had returned, and that her health
was perfectly good.
atera
The tumor was composed of a large sac, which
had contained the fluid drawn off in different ope-
rations for tapping. One-third of the tumor was
solid, containing a fibro-cartilaginous substance.
It weighed ten and a half pounds.
0
euro So
In offering this case, it may be proper briefly to
sum up a history of the operations for diseased
ovaria. It may assist others in forming an opinion
of the relative chance of success in future cases.
The removal of these tumors by an operation had
its advocates in the last century; but the authority
of DeHaen and Morgagni was raised against them,
as doubtful in their results, and impossible in their
execution.
efle 20 ziz-yhids
The first attempt to remove them by an opera-
tion was made in 1776, by L'Aumonier, surgeon-
in-chief of the Hospital at Rouen, and is reported
as a successful case.-(Good's Study of Medicine,
p. 423.)
Dr. M'Dowel, of Kentucky, has reported three
sisyo an S1E01 ம்:
201
HOUST
91.00
red

100
eds more!
cases in which he operated successfully for tumors
in the abdomen, ovarian, and hydatid.
UCHIY
27
934
A doubt exists in relation to these cases; and
certainly the mode of describing them is calculated
to confirm that doubt. We are bound, however,
upon the authority of others, to believe them, not-
withstanding the improbabilities connected with
their details; and it is much to be regretted that
a more circumstantial account of these cases has
not been given to the profession.-(Medico-Chi-
rurgical Review, Vol. V., p. 216.)
bilez
Professor Smith, of Yale College, has given an
interesting case of the successful removal of an
ovarian tumor by an operation. The tumor was
small, weighing from two to three ounces, and re-
quiring an incision of three inches in length.-
(American Medical Recorder, 1822.)
De
In the London Medical Gazette for 1829, Dr.
Hopfer, of Biberback, has reported three cases of
extirpation of diseased ovaria, by Carysman.-
The first was performed in 1819, and proved fatal
in thirty-six hours after the operation. The se-
cond in 1820. This case was successful, and the
woman has since borne children. The third case
terio-
occurred in the same year, and never recovered
from the shock of the operation. Thus, of the
three cases,
but one recovered.
S
wor
Mr. Lizars, in the Edinburgh Journal for Octo-
ber, 1820, relates an attempt to extirpate an ovarian

101
tumor, but unfortunately on cutting into the abdo-
men, he found no tumor to remove.
This case
certainly
ly should not be included in the unsuccess-
ful operations for this disease. The same distin-
guished surgeon has since reported two cases of
the operation, but their results have not been made
known.
Thus we find in the twelve operations that have
been performed for the removal of this disease,
seven have been successful, and two remain
doubtful.
He all beligge
botas
bro lo 220m
itasle
Isinged off sala
bat
idwo cons
grisd
Jaiclomeo
Modw
tio
obds
bda od midhiw 3000
Comp uprio aid T
1036919 room to nedtons etusi
aid borewens Jasminte
Jon kew ti and onto ods
zehisomib div
seitsemib div hobratanu govewod
bersexe si doid w sam
mid booubet
eidi rezonani
Boltalon, ai anois
sday
edi
al
beerber
done 2014
ylish aid of boons of bonnitago
bennitooed nolibros zi
od enotvang edsow not to coul liten guolisoovs
srb as bemmels carsoed od redw moherego ods
fiel aid al soos gabing llama a lo spus ST09006
grusgil Isauro od woled Jotribemmi
emmi along
botingos bed bus beggelas Hachery com
eid nodwed baillid &
Holayda ald
exia edh

102
shem
omus
burot ad nem
CASE OF INGUINAL ANEURISM,
6
IN WHICH THE OPERATION OF SECURING THE EXTERNAL ILIAC
ARTERY BY LIGATURE WAS PERFORMED WITH SUCCESS.
[MEDICAL RECORDER, VOL. IX., p. 269.]
af
Mr. D., the subject of the following case, for the
period of fourteen years labored under a trouble-
some inguinal hernia; to obviate the inconveni-
ence of which, a truss was applied. His calling
being of an active kind, necessarily aggravated his
complaint, insomuch that a truss of ordinary elasti-
city was wholly insufficient to confine the hernial
contents within the abdomen. This circumstance
induced him to substitute another of much greater
firmness; this instrument answered his expecta-
tions, in relation to the rupture, but it was not,
however, unattended with difficulties. By the
firm and constant pressure which it exerted on the
parts, much pain and irritation were produced. In
this condition he continued to attend to his daily
avocations, until three or four weeks previous to
the operation, when he became alarmed at the
appearance of a small pulsating tumor in his left
groin, immediately below the crural ligament.
The tumor gradually enlarged, and had acquired
the size of a billiard ball, when his physician was

103
28.00
summoned to attend, who made known to him
the nature of his disease, and advised immediate
surgical aid,
botas
90
BIDRI
I was accordingly called in, and on examination
an aneurism of the inguinal artery, of considerable
magnitude presented, one-third of which extended
under Poupart's ligament. An operation was
decided on, and, in the presence of Dr. Mott, and
several other professional gentlemen, I commenced
by making an incision through the integuments,
beginning an inch from the anterior superior spine
of the ilium, and extending it with a slight curve,
obliquely downward and forward to midway be-
tween the internal abdominal ring and the crural
arch; the contiguity of the epigastric artery to
the internal ring, prevented a further extension of
the incision forward. The first incision, (which
was much increased in depth, owing to the thick-
ened state of the skin and cellular membrane,
from the action of the truss and effusion,) exposed
the eponeurotic expansion of the external oblique
muscle; this being divided in the same direction,
and turned up, brought to view the inferior margin
of the internal oblique, which, together with the
transversalis abdominis muscle, being raised, the
internal abdominal ring was laid bare. Here it
may not be amiss to observe, that the hernia, by
its constant protrusion, was no small hindrance to
the easy performance of this operation.
06
OUTSID
3179
**

104
With the finger and the handle of the scalpel,
the ring was sufficiently enlarged to admit the
introduction of the fingers behind the peritoneum,
and brought in contact with the artery; the sheath
of the vessels was now to be opened, but owing
to the extreme inquietude of the patient, and the
unusual depth of the wound, it was deemed un-
advisable to use the knife, the finger-nail was
therefore substituted; a single ligature was passed
round the artery, and tied about half an inch
below the bifurcation of the common iliac. The
wound was brought together and dressed, in the
usual manner with adhesive straps.
bay
OBVE
The patient recovered in six weeks, and con-
tinues to enjoy good health. The hernia has not
re-appeared since the operation; the closure of
the internal ring from inflammation accounts for
this.
31
The history above given, of this case, evidently
shows that the pressure of the truss, was the sole
and only assignable cause of the aneurism. But
to expatiate on the pathology and treatment of
aneurisms is not my present intention.
The prin-
cipal incentive in noticing this case is the favora-
ble opportunity it presents of adverting, though in
a brief manner, to an observation of M. Larrey's,
touching the propriety of tying the external iliac
for the cure of aneurisms. It has been asserted
by that gentleman, "that almott all the subjects
2 200

105
66
who had undergone this operation, showed all the
characteristics of aneurismal diathesis;" and the
assertion wound up with the interrogatory-
What purpose can the operation serve!"*
By this observation an extensive field, for dis-
cussion and comment, is thrown open; but to enter
with free latitude into the argument, would be to
protract this paper beyond its destined limits; all,
therefore, that will be attempted, will be to call to
mind a few well authenticated facts, with the view
of proving the invalidity of the Baron's remarks.
.
66
In the year 1796 Mr. Abernethy first performed
the operation of tying the external iliac for aneu-
rism. Since that period to the present, the result
of similar practice, in numerous instances, has
been most decidedly favorable. A long list of
cases, of this operation, may be seen in a Trea-
tise on the Diseases of Arteries and Veins," by
Dr. Joseph Hodgson. Out of this number,
amounting to twenty-two, fifteen cases of complete
recovery are noticed, and but one case mentioned
as having died of a subsequent aneurism, and
that was beyond the reach of surgical aid, being at
the arch of the aorta. In the Med. Chir. Review
of Sept. 1821, the major part of the above cases
are referred to, with others of successful termina-
tion by British surgeons. Other numbers of the
W
See Review of Baron Larrey's Russian Campaign, in Med.
Chirurg. Rev. September, 1821.
grigh
14
292ro od
ey
do zevidens

106
same journal contain irrefragible proof of the utili-
ty of this operation. In the number of March,
1822, a case of this operation is published by Mr.
Salmon; the aneurism had existed ten months.
At the end of two months after the operation, the
patient was discharged in good health. Thus
much for the success of trans-Atlantic surgery, in
the treatment of inguinal aneurisms. Here, the
evidence in support of the propriety, and, as far as
respects the security of the patient, the imperious
necessity of this operation might cease, as being
fully sufficient to establish it as an axiom of sur-
gery. But it is no more than just to observe, that
cis-Atlantic practice in like cases has not been less
fortunate. The operation of tying the external
iliac has been performed, if I mistake not, six times
in this country; and in no instance has it been
followed by a return of aneurism. In this city
(New York) a case occurred in which the exter-
nal iliac on one side, and the femoral artery on the
other, in the same individual, were successively
tied for the cure of aneurism. In this patient, it
must be admitted there were the most just grounds
for the suspicion that there existed a peculiar con-
stitutional predisposition to aneurism, if, emphatical-
ly speaking, such a state of the arterial system ever
did exist. Notwithstanding this, he perfectly reco-
vered, and still lives in the enjoyment of good health.
In taking a retrospective glance over the
archives of surgery, it appears that the cases

107
above cited are nearly, if not quite, all that can be
collected of this operation; and out of these, very
few deaths are recorded. If this be the fact, it
seems to indicate that M. Larrey had few oppor-
tunities indeed of investigating the truth of his ar-
gument by post-mortem examinations of such sub-
jects. Experience, therefore, shows that what he
advances, in relation to the operation in question,
is untenable.
Could we, for a moment, reconcile such doctrine
to our minds, as valid and satisfactory, might not
the following interrogatories, with propriety, be
put:-What should be our rule of conduct when
called to see a patient laboring under this most
terrific malady? Should we, as conscientious men,
weigh the matter in the balance of sound reason-
ing, and cool, unprejudiced reflection, and, as the
result of these deliberations, decide on an opera-
tion as the only means of security? or are we to
stand by, insensible, as it were, to the hazardous
situation of our patient, and mute observers of his
sufferings, without stretching forth a hand to his
relief, when, by a few skilful strokes of the scalpel,
we might not only give him a chance for his life,
but, if we are allowed to anticipate the result, from
similar precedents, we should be enabled to avert
the fatal event, and subsequently enjoy the pleas-
ing reflection that our duty had been faithfully dis-
charged by a timely and unhesitating adoption of
bold and yet judicious practice.

108
beti ovods
lloo
adines sds
179%
A CASE OF ANASTOMOSING ANEURISM OF THE
100go w EXTERNAL MAXILLARY ARTERY,
dicatedr
TREATED SUCCESSFULLY BY TYING THE COMMON CAROTID ARTERY.
40
[AMERICAN JOURNAL OF MEDICAL SCIENCES, VOL. XIII., P. 271.]
THIS case occurred in a child, aged eight
months, at the time of the operation. At its
birth a small pulsating tumor was observed in the
centre of the right cheek, which continued to en-
large until it embraced nearly the whole of it.
It was bounded above by the prominent part of
the malar bone; below by two-thirds of the infe-
rior maxillary bone; posteriorly by the superior
part of the inner edge of the sterno-cleido mas-
toideus muscle, on a range from above downwards
with the lobe of the ear; anteriorly by a line drawn
from the inferior part of the nostril, and terminat-
ing about one inch from the symphisis of the chin.
The tumor pointed in two places, namely, just
above the ear, and at the angle of the jaw. It was
irregularly convex, having its greater convexity at
its posterior part, and gradually diminishing from
behind forwards; its color purplish, with several
red spots on its surface. The child seemed other-
wise in good health. The operation was perform-
ed on the 12th of December, 1832, assisted by Drs.

109
Mott, Baxter, and Kirby, in the presence of a num-
ber of my pupils. An incision was made through
the skin and the platysma myoides muscle, of about
one and a half inches in length, in the direction of
the inner edge of the sterno-mastoideus muscle, but
nearer to the trachea than to this muscle, which
kept the external jugular vein at a greater dis-
tance. At the first incision, a small artery was
divided, which was secured with a ligature; the
adipose tissue was cleared away, and the sterno-
thyroideus muscle was partially exposed, at the
outer edge of which the sheath of the vessel was
seen; this was punctured, and the artery secured
with one ligature. No other vessels were tied, and
the quantity of blood lost did not exceed a tea-
spoonful. In a short time a diminution of the
tumor was perceptible. The little sufferer was
not much exhausted; it was placed in its mother's
arms, and immediately began to nurse, with occa-
sional restlessness. 20
A gradual diminution of the tumor continued
until it had entirely disappeared, and the child
wholly recovered, and is now in good health.
arch
noed ben
mid gafsee
Se 2617
diw
bas aleriod
afelymes done to le
Boiler
abagg od vd bevoleme
vab at
mid bosiar
01 anotvs
Yator an
olems
of 50
ni nem

110
dguards
ro
ydil has reizs
Lalique vis
mida
M
rod
CASES IN SURGERY.
ausbi
sill to
and
doidw [NEW YORK MEDICAL JOURNAL, Vol. II. p. 292]
aib
1800
qozt
IN offering a detail of cases in surgery, it is not
my intention to observe a systematic arrangement,
but to give them from my note-book indiscrimi-
nately, as they have occurred in practice, or, if
more convenient, to state several cases of a similar
kind, when they shall have a tendency to confirm
a principle, or establish a fact in practice.
boold to val
CASE I.-ABDOMINAL ABSCESS.
no
Toum odr
adsto
100
I was requested in July, 1830, to visit Mr. Jar-
vis, a ship-carpenter, aged about 45 years; I went
in company with Drs. Baldwin and Rockwell.
Mr. Jarvis was a man of temperate habits and
robust constitution. He had for several years
been troubled with a reducible inguinal hernia on
the left side, for which he had worn a truss. He
had been seriously indisposed for several days
previous to my seeing him, with what was suppos-
ed to be constipation of the bowels, and the means
usually employed for the relief of such complaints
had been most actively employed by the gentle-
men in attendance. I visited him on the 1st day

111
of July, when he presented the following symp-
toms; countenance indicative of great irritation-
pulse full and soft-tongue covered with dark
brown sordes,-the skin moist, with a warm
clammy perspiration-the bowels much tumefied,
and painful on the slightest pressure, particularly
in the right inguinal region, which was the origi-
nal seat of pain,-urine highly colored and small
in quantity,--the bowels torpid, and difficult to be
acted upon by the most drastic cathartics, although
he would occasionally have a small discharge, par-
taking of the properties of the medicines. The
stomach was generally retentive, but was some-
times disposed to reject its contents. The hernia
on the left side was soft and natural, and easily
returned, and could not be considered as the cause
of irritation. This case, from its obscure charac-
ter excited much interest: its strong resemblance
to strangulated hernia, connected with the fact of
his being predisposed to that disease, rendered the
diagnosis extremely difficult, as some of the most
prominent symptoms of strangulated hernia were
wanting. The condition of the stomach, the
pulse and fecal discharges, offered strong argu-
ments against this opinion. blogs
On closely examining the right inguinal region,
at the part where he complained of the greatest
pain, a small tumor could be discovered, about the
size of a filbert, in the immediate situation of the

112
internal ring-but on increasing the pressure it im-
mediately disappeared. As no definite idea could
be formed as to the nature of the disease, the
து
symptoms being violent, and threatening to prove
fatal, unless some relief could be afforded; I pro-
posed cutting cautiously down to the internal ring,
to ascertain the character of the tumor, supposing
that it might possibly be a section of intestine
strangulated, and yet the intestine remain suffi-
ciently pervious to give passage to the feces. It
was, however, concluded to postpone the opera-
tion until the next day, and to repeat the treat-
ment pursued by the attending physicians as
bleeding, warm bath, calomel, enemas, and hot
fomentations to the bowels.
bie stol ad no
July 2d. No relief has been obtained by the
treatment adopted yesterday; some of the symp-
toms are much aggravated; he had no sleep, but
much more sickness at stomach; tongue black;
considerable delirium during the night. The
critical situation of the patient admitted of no
delay, although the symptoms of hernia were so
very obscure that it was doubtful if any existed ;
yet, in his situation, almost any practice would be
proper that could offer the most distant prospect
of preserving life. With this understanding, I
commenced the operation, and performed it in the
usual mode of operating for hernia at the internal
ring, in the presence of Dr. Mott, Dr. Baldwin,

113
and Dr. Rockwell; the details of the operation it
is unnecessary to mention. On arriving at the in-
ternal ring, we found a protrusion of peritoneum,
in all respects resembling a hernial sac.
I ac-
cordingly proceeded to open it, with all the
caution observed in such cases, when, to the as-
tonishment of all present, the moment an opening
was made, a volume of most fetid matter rushed
out with a force that projected it two or three
feet; more than a quart was immediately dis-
charged. The mystery of the case was explained;
the tumefaction of the abdomen subsided in a few
days; the tongue cleared off;-the bowels be-
came active and regular, and in a month the
discharge ceased; the wound healed, and he
returned to his usual occupation in good health.
C
CASE II.-ABDOMINAL ABSCESS.
bes
The following claims much interest, as it has
some relation to Case I., although proceeding
from a different cause, and the symptoms being
more determinate of its existence. This case
came under the care of my friend Dr. McCaffry,
who has obligingly furnished me with its history,
which I shall give in his own words,
66
Mrs. S., lately from England, residing at 282
Divison Street, was, after a tedious and difficult
labor, delivered of her eighth child, late in the
month of November, 1830. Her lochial dis-
15

114
charges, which ceased much earlier than formerly,
were succeeded by cough, pain and oppression in
the chest, accompanied with fever, rendering de-
pletion, both local and general, necessary, which
was but in part carried into practice. In the
meantime she was seized with excruciating pain
in the right inguinal region, extending through
the iliac, sacral and lumbar regions, depriving her
of the power of lying on that side, or using the
right leg.
66
Although there was no swelling, or any
symptoms resembling phlegmasia dolens, evening
exacerbations and night sweats succeeded the
foregoing symptoms--no relief could be given to
the sufferer, although attended by two or three
respectable physicians for the space of twelve
weeks. At this time I was requested to visit
her. I found her weak and emaciated, and
suffering from fever and sweats. I paid atten-
tion to her bowels and put her upon the tonic
treatment, but she obtained no relief. Upon ex-
amining the seat of the pain, I discovered a
deep-seated tumor, and something resembling a
fluctuation of matter. Not satisfied with my own
views of the case, I requested further advice."
By the request of Dr. McCaffry, I visited Mrs.
S., and found her situation as he has detailed
it. Upon examining the tumor, I was well satis-
fied that Dr. McCaffry was correct in his opinion

115
that a large abscess existed in the cavity of the
peritoneum. Although the matter was deeply
seated in the cavity of the pelvis, I considered its
evacuation as the only chance that could be offer-
ed of preserving her life, and accordingly proposed
to her that an operation should be performed for
its discharge. To this, she readily acceded. She
was laid on the side of the bed-partly on the
left side. With a common scalpel, I made an in-
cision in the direction of the posterior spine of the
ilium between two and three inches in length, di-
viding the external oblique, internal oblique, and
transversalis muscles. On dividing the last-named
muscle and its fascia, the peritoneum immediately
protruded through the opening. With a pair of
forceps, I cautiously made an opening through it,
when a pint of matter immediately passed out.
Not having visited the patient after the operation,
Dr. McCaffry concludes his report thus :-
"In about five days the discharge entirely
ceased, and the wound closed up; her fever and
sweats disappeared, her appetite returned, and in
two weeks from the discharge of the pus, she was
able to pursue her domestic concerns, although
she had been fifteen weeks confined to bed on the
day the abscess was opened."
10
REMARKS. Having examined several females
after death, who have died of what Dr. M. Hall
would term irritative fever, I have in all such cases,

116
found a large quantity of sero-purulent effusion,
mixed with flakes of coagulable lymph, within the
cavity of the peritoneum. In many cases, by
a close examination, we might detect the exis-
tence of matter in some part of the abdomen,
and by a timely discharge rescue the patient from
danger. Many practitioners hesitate in opening
abscesses within the cavity of the abdomen, pre-
ferring to leave them to be discharged by ulcera-
tion, when, in the majority of cases, the patient
sinks under the irritation before the process is
completed. This delay in opening abdominal ab-
scesses proceeds from two causes, equally un-
founded and absurd. First, it is believed by some,
that wounds of the peritoneum are attended with
peculiar danger; thus they prefer avoiding the re-
sponsibility, and leave it to nature. Every day's
experience teaches a different lesson; large hernial
sacs are opened, and the intestines returned; tu-
mors of large size are removed from its cavity, and
wounds are daily occurring, in which this mem-
brane is even lacerated, and yet these cases recov-
er without being much incommoded by inflamma-
tion. Secondly, it has been the opinion of most
practitioners, that an abscess should have a certain
degree of maturity before it is opened;-others
again, believe that abscesses will do best to be left
to break of themselves, and to this rule they make
but few exceptions. I have been in the habit,

117
for several years, of discharging the matter as
soon as I am satisfied of its presence. I believe
there is no rule more injurious in practice than
the opinion that matter must be left to approach
the surface, and excite a certain degree of inflam-
mation there, before it would be proper to open the
sac. The integuments being inflamed, the punc-
ture must be much more painful than in the natural
state; having become thin by absorption, it is
much more difficult to heal the wound. The in-
teguments having lost their support by the dis-
charge of matter, the edges fall in, a slough follows,
and the result is, you have to heal the wound by
granulations from the bottom. This is observed
in buboes which are allowed to break, and in ab-
scesses about the face and neck, leaving the most
unpleasant scars; whereas, if abscesses are opened
early, previous to the integuments being affected,
the incision may be immediately healed, by bring-
ing the edges in contact, and the abscess cured by
bringing its sides in coaptation, by well-adjusted.
compresses; or, should it be necessary to keep the
wound open for a few days, no injury will happen
to the integuments; the wound will not enlarge, and
when the necessity ceases for keeping the wound
open, it may be closed, and a simple line only will
mark its situation. In some cases, the lives of
persons are hazarded by this delay in opening ab-
scesses, as when matter is situated under the ten-

118
don of the occipito frontalis muscle, the fascia
of the leg, arm, and theca of the fingers. In 1829,
I examined a man who had a severe attack of
erysipelas of the leg; he had recovered from the
inflammation, but died of some irritation which
was not understood. The head, chest and abdo-
men, appeared in a sound state, but a large ab-
scess was found under the fascia of the leg,
which was no doubt the cause of his death. But
notwithstanding the diversity of opinions upon the
subject of abscesses in general, we have but one
rule in relation to those within the cavity of the
peritoneum, which is, in all cases to cut boldly
down and discharge the matter the moment we
are satisfied of its presence.
CASE III.-IMPERFORATE ANUS.
In 1825, I was requested to visit a female child,
four days old. The nurse informed me that the
child was of the usual size, and perfectly healthy
when born. It nursed well shortly after birth, but
vomited in a few moments. Not having passed any-
thing per anum, the nurse was led to examine it
on the third day; an indentation only marked the
situation of the anus. It had several times passed
urine of a deep yellow color. When I saw the
child it was much emaciated, constantly craving
the breast, but never satisfied. The milk would
remain in the stomach ten or fifteen minutes, and

119
was then discharged, combined with a large quan-
tity of bilious matter. In comparing the circum-
stances attending this case, the rejection of its
food so soon after receiving it into the stomach-
its great emaciation and ravenous appetite-with
the negative qualities of flaccid abdomen-its not
having been observed to strain-indicative of its
desire to have a stool-and the absence of convul-
sions, led me to believe that an additional obstruc-
tion existed, near the pyloric orifice of the stomach.
Although firmly impressed with the belief that an
obstruction in the upper part of the alimentary
canal existed, yet it was deemed proper to give the
only chance which art could afford. I accordingly
performed the operation; and in order to make the
description more clear, I shall extract some re-
marks from a lecture delivered to my private class:
The operation for imperforate anus should be per-
formed by placing the child on a table of sufficient
height, and the position should be much the same
as that adopted for the operation for stone. Ex-
amine first the proper situation for the anus, then
with a scalpel make a crucial incision, so that the
angles shall meet at the proper situation for the
rectum; dissect up the flaps, and lay them over;
this will afford more room for the subsequent part
of the operation. After dissecting up the integu-
ments, you expose the sphincter muscle; this
should be divided from above downwards, or in
66
―

120
the direction of the os coccygis.* By the assist-
ance of a curved pair of spatulas, the parts may
be separated to a sufficient extent to continue the
operation. Taking the sacrum for a guide, we
must cautiously divide the cellular substance, which
fills the pelvis, pursuing its concavity, directed by
the fore-finger of the left hand, until we arrive at
the top of the promontory of the sacrum; beyond
this it would be improper to proceed, in conse-
quence of the large vessels. Caution should be
observed not to wound the middle e sacral artery
below, and the bladder above. If the rectum is
within the pelvis, it may be readily distinguished
by its elastic, doughy feel. After having ascer-
tained its situation, an incision should be cautiously
made through its sides, by a scalpel or bistoury ;
the opening into the intestine should be enlarged
to the greatest extent that its sides will admit of,
as it will necessarily contract considerably during
the process of cicatrization. After the bowels are
well evacuated, a firm tent, composed of linen
* The division of the sphincter muscle has been objected to, from
the time of Albucasis to the present. He directs "to cut cross-
ways at right angles, taking heed not to cut the sphincter muscle."
Mr. Samuel Cooper, in his Surgery, expresses the same fear. He
states, page 289, "The whole of this muscle may be cut, and an in-
ability to retain the feces be the irremediable consequence." I would
merely observe that this fear is ungrounded. If the division of the
sphincter muscle should be attended with a permanent loss of con-
traction of the anus, how terrible would be the operation for fistulo
in ano.
Biroda

121
covered with oil-silk, should be introduced into the
opening; this tent should be removed two or three
times a day, to permit the accumulated feces to
pass out until the wound is cicatrized, and the
opening permanent. The flaps which I mention-
ed in the commencement of the operation, should.
have their angles cut off, so as to fit accurately
around the tent, and he secured by adhesive straps
passing in different directions; by this means a
circular opening is formed, and the integuments
being brought down, adhere to the sphincter ani
muscle; when the tent is removed, the contraction
of the muscle will close the anus in its usual form."
The operation having been performed as described
above, I found a sac occupying the upper part of
the sacrum, which was readily opened with a scal-
pel. The meconium flowed out in considerable
quantity; the wound was dressed, and the child
given to the nurse.
As was expected, the vomiting continued, the
urine flowed in considerable quantity, with a
watery discharge from the rectum; the emaciation
rapidly increased, and the child died twelve days
after birth. It was examined six hours after death.
On making an incision into the cavity of the ab-
domen, the stomach immediately presented, of a
large size, and filled with air; the enlargement
extended to the termination of the duodenum, ex-
hibiting the novel appearance of a double stomach.
16

122
The stomach was well formed, the duodenum ter-
minated in a cul-de-sac, at that part where it
crosses the spine. The small intestines below
this were all pervious, but remarkably small, not
exceeding the dimensions of a goose-quill. The
large intestines were natural to the sigmoid flexure
of the colon; from that to their termination they
were much enlarged. The rectum was found
terminating at the top of the sacrum in a large
sac, occupying all the upper aperture of the pelvis;
from the sac of the rectum proceeded a small
tube, not larger than a goose-quill, which attached
itself to the fundus of the uterus, and passing
down, adhered to the side of the vagina, running
out posterior to its mouth, between the labia;
the bladder was much distended with urine; the
kidneys were united across the spine; forming
an irregular flat body; the right was much the
largest, each having its ureter and proper vessels.*
CASE IV.-IMPERFORATE ANUS.
utor
I shall briefly relate a second case of imperfo-
rate anus, in which the rectum also terminated in
a small tube, by the side of the vagina. This
case was completely within the power of surgery,
and a permanent relief might have been obtained,
but the child was allowed to perish for want
of attention on the part of its parents. This was
* The preparations are now in my collection--Nos. 26 and 27.

123
the child of Mr. R, of Watts-street, aged
two years. Immediately after birth, a dose of
castor oil was administered, and a considerable
discharge was the result; the nurse, on washing
the child found the labia filled with feces, and on
further examination, she found the anus imperfo-
rate. This child had enjoyed good health for two
years, except when the bowels became costive.
From the smallness of the tube, the feces could not
pass out without the aid of castor oil once in two
or three days; if this was neglected, convulsions
would follow. On examining the opening, it was
somewhat larger than a goose-quill; it appeared to
extend upwards, for two inches, and to terminate in
a large sac; a small depression marked the situa-
tion for the anus. I saw the case, with Dr. Brush,
the family physician, and an operation was pro-
posed for its relief. I was informed by Dr. Brush,
that shortly after my visit, the bowels, from the want
of attention, became costive, the opening was ob-
structed, and it died of convulsions.* The symp-
toms attending the imperforation of the intestinal
canal must differ according to the situation of the
obstruction, as the pyloric orifice of the stomach,
lower part of the duodenum, at the upper part of
the colon, or at the anus.
The nature and quan-
* Dr. Read, who wrote a book on Surgery, in 1686, mentions a
case from Fabricius ab Aquapendente, who saw a woman without an
anus, who voided her excrements from the vagina.-Book V. p. 524.

124
tity of the matter ejected by vomiting, would most
readily indicate the seat of obstruction. If the
obstruction is situated at the pyloric orifice of the
stomach, it is known by the immediate rejection
of the food, combined with the gastric liquor. If
at the lower part of the duodenum, it would re-
main longer before being rejected, the process of
digestion be more complete, and it would be com-
bined with bile, which would be thrown off in
great quantities; if at the head of the colon, the
chyle would be discharged perfectly formed; and
again, if the anus is the seat of obstruction, the
situation of the sufferer is truly disgusting, by the
frequent vomiting of feces.*
bastre
92
Aus
CASE V.-HYDROCEPHALUS.
dau&
Mr. B.'s child, aged five months, was born with
a protuberance on the os occipitis, about the size
of a nutmeg. The tumor attracted little attention.
at first, but gradually increasing in size, it attained
at the end of two weeks the diameter of a hen's
egg, when the child evinced marked symptoms of
hydrocephalus, attended with distinct fluctuation
on the top of the tumor. By a gradual and con-
tinued pressure with the hand, the fluid could be
* In the Journal de Médicin (the volume I do not now recollect),
it is related that a child without an anus grew to the age of manhood
without any opening being found for the passage of the feces, which
were constantly ejected from the mouth.

125
completely pressed out, and the tumor diminished
to half its size. The anterior fontanel became
more and more tense, and the child exhibited
symptoms of compressed brain. The symptoms
plainly indicated that there was water in the brain,
which communicated with the tumor; and Dr.
Brush, the attending physician, considered it a
good case for trying the practice of drawing off
the water by puncture, He accordingly made a
small opening into the tumor with a lancet, by
which means the fluid was freely evacuated,
and all the bad symptoms immediately ceased.
The parents informed me that the child did not
suffer any inconvenience, and appeared to be in
good health as long as the opening allowed the
fluid to flow out; but on closing it, even for a
time, the child invariably became affected with
convulsions. The quantity of water discharged
daily was from half a pint to a pint, which gradu-
ally enfeebled the child, and finally destroyed it.
The autopsic examination presented the follow-
ing appearances: The occipital bone wss found
deficient at its superior transverse ridge, immedi-
ately over the usual attachment of the tentorium,
and portions of the cerebrum and cerebellum pro-
truded at this place. On cutting into this part of
the brain, a cavity was laid open which communi-
cated with the two lateral ventricles. We then
followed this communication into the ventricles,

126
which were enormously enlarged, containing at
least twelve ounces of fluid, and occupying the
whole cranium above the tentorium, with the parie-
tes so thin that it appeared to verify the doctrine
of Gall, that the brain is a convolution of mem-
branes.
I consider this case to be an important one, in-
asmuch as it may lead to practical consequences,
and go far to establish the feasibility of puncturing
the brain, as recommended by Sir A. Cooper, in
this disease. The child's general health was, in
the first instance, otherwise good, and its head of
the ordinary size, and continued so during the
whole time; yet notwithstanding all these favor-
able circumstances, the discharge continued uni-
form, as to quantity, to the last. Dr. M--, in the
case of a child, drew off the water from the ven-
tricle, by means of a small trocar, and repeated
the operation several times, without any permanent
relief; for the water invariably re-accumulated, and
the operation was moreover attended with violent
symptoms. The child is still living, and the quan-
tity of water appears to be as great as at the time
of the first operation.
JO159
bus
CASE VI. HERNIA OF THE LIVER. bant
A child of Mr. A, of Greenwich-street,
was born with a tumor situated in the umbilical
Dewo
33

127
region, which was taken for a protrusion of intes-
tine. The child was in other respects healthy.
The tumor, at the time of birth, was about two
inches in diameter, and six in circumference, with
the umbilical cord passing out at its apex. The
covering to the sac soon after birth, became dark,
insensible, and threatened mortification; the ex-
ternal cellular substance was, in part, thrown off,
and the smell from the tumor so great, that it was
extremely disagreeable for any one to approach the
patient. At length, symptoms of obstructed liver
came on, such as bilious vomiting, and yellowness
of the skin, and the child died in convulsions three
weeks after birth.
On examining the tumor after death, it was ob-
served to be covered with a very thin coat of peri-
toneum, the ordinary integuments of the abdomen
being deficient over the tumor. 100 basisme 257
On opening the sac, a considerable quantity of
bilious fluid flowed out, the right lobe of the liver
was seen protruding, making the contents of the
sac, and firmly adhering and strictured at its base.
By pursuing the dissection still farther, we found
the abdominal muscles entirely wanting at this
part. The other viscera of the abdomen were
perfectly healthy. The child evidently died of
strangulated liver.
zidi do tud
OV
94 19
i somitet
ni edi
bde od
had

128
THE
CASE VII. GANGRENE OF HE APPENDICULA
CECI-VERMIFORMIS, FROM A FOREIGN BODY
3000
IN ITS CAVITY.
I was requested to visit Mr. U., a gentleman of
the legal profession, aged 30, in consultation with
my father, Dr. D. Rogers, September, 1837. The
history of the case was very obscure. He com-
plained at first of constipation of the bowels, with
soreness and pain in the right iliac region, follow-
ed by sickness and vomiting. At the time of my
visit, which was on the second day after the at-
tack, he had been actively depleted, by bleeding
and cathartics. The cathartics had purged him
freely without affording any relief. Leeches and
fomentations had likewise been applied to the
bowels, without benefit. His pulse at this time
was small and corded. He was very sensitive to
pressure in the iliac region, and referred all his
pain to that part. All the symptoms in this case
resembled those of a strangulated hernia, with the
exception of a free discharge from the bowels by
the aid of cathartics. I made a close and diligent
search at all the places, usual for hernia to pro-
trude, but could not discover any appearance of
rupture, and came to the conclusion that a section
of the intestine was strangulated in some part of
the abdomen near the iliac region, but of this we
had no distinct indication. We felt much at a

129
loss for a plan of treatment which offered any
prospect of relieving the disease. The symptoms
of irritation increased, attended with hiccup, cold
extremities, and delirium. He died on the fourth
day after the first symptoms of the disease. His
body was examined six hours after death. Upon
making an incision into the cavity of the abdo-
men, we found the peritoneum generally inflamed,
but the inflammation became more intense as we
approached the right iliac region. Around the
caput colli was found a considerable effusion of
lymph, and upon elevating the intestine, the appen-
dicula vermiformis exhibited a dark and sphace-
lated appearance. The lower part of this tube
had sloughed off half an inch. On laying open
the cavity, we found at its lower part some fecu-
lent matter, with the seed of an apple. Not dis-
covering any other, we concluded that the lodge-
ment of the apple-seed in the tube had been the
cause of the irritation. The viscera of the abdo-
men generally were in a healthy state. A few
months after the above case, I was requested by
my friend, Dr. M. Willet, to assist in the post-
mortem examination of a man whose disease had
much embarrassed the attending physicians. The
symptoms were the same as those mentioned in
the above case; and the examination proved the
cause to be the same, with this exception, that the
cause of irritation was the lodgement of a small cal-
17

1.30
culus about the size of a pea in the lower part of
the vermiform appendage. I am not aware that
cases of this kind are reported in works treating
on the subject of hernia. I have, therefore, con-
sidered them worthy of holding a place among the
varieties of this disease, and of calling the attention
of surgeons to the subject. It may not become the
subject of an operation, as the diagnosis is very
difficult in the first stages; but if a surgeon were
satisfied of its existence, I can conceive no objec-
tion to the performance of an operation for its relief.
05
*
othes

131
fors
pinoy
sized bildog odb
izey
A NEW OPERATION FOR THE RE-ESTABLISHMENT
OF THE URETHRA.
Rs. 52000g of
[PHILADELPHIA MEDICAL AND PHYSICAL JOURNAL, VOL. XIX., p. 186.]
A. E. HOSACK, M. D.
DEAR SIR-
It is with pleasure that I comply with your re-
quest, in sending you a brief account of my "Ope-
ration upon the urethra for permanent stricture."
At an early period of my professional life, I be-
came satisfied that the usual practice in the treat-
ment of imperforate urethra from stricture was very
imperfect, for, although in some cases attended with
temporary relief, it was in the majority followed by
evils much greater than the original difficulty.
Without entering into the objections attending
the usual modes of treating strictures of the urethra
when imperforate, I shall briefly state that the in-
sufficiency of caustic applications, as recommended
by Sir E. Home and others, was early impressed
upon my mind, the reasons for which may be found
in every work upon the subject; and the result of
the cases coming under my own inspection has
confirmed that opinion.

132
Finding in the public hospitals a great number
of persons with fistulous openings in the perinæum
from strictures in the urethra, I was led closely to
examine such cases, with a view to ascertain if
any operation could be performed for their relief.
In this investigation I became sensible of a fact,
which led me to propose and execute the opera-
tion I am about to describe. I remarked, in cases
of fistulo in perineo, that after the parts had ulcer-
ated, and the slough cast off, the parts regularly
filled up by granulations, leaving a circular open-
ing of sufficient size to admit of a free discharge
of water from the bladder. This opening was
soon covered with a smooth surface, and insensible
to the action of the urine; in appearance much
resembling a mucus membrane, and possessing all
the properties essential to the functions of a mucus
tissue.be I shall not at this time advance an argu-
ment to prove that these new surfaces are mucus;
or that they are continuations of the lining mem-
brane of the urethra; or are formed independently
in the part from the necessity of the case. It is
sufficient for the purpose to possess a knowledge
of the fact, that nature, in all cases in which an
artificial opening is formed, communicating with
an internal organ whose function is secretory,
superinduces or forms a surface, possessing all the
necessary properties for the duties it is required to
perform. It was with a full knowledge of this

133
fact, that I proposed to form a new portion of
urethra in place of such portions as had been de-
stroyed by disease.
I wish you to bear in mind that the operation
herein proposed is alone applicable to such cases
as cannot be dilated, and in which the stricture is
impervious to the bougie.p
In performing this operation for imperforate
urethra, I proposed, first, to exclude the diseased
portion of the canal,-secondly, to form a new
portion of urethra from the surrounding parts.
To illustrate my method, I shall introduce two
cases from the twelve which I have performed,-
the first and the last.
My first operation was performed in 1823, on a
man by the name of Rolston, aged 41 years. He
had been troubled with a stricture of the urethra
for sixteen years, the effect of gonorrhoea. He
had received every variety of treatment, but lat-
terly by the caustic bougie. The effect of the
caustic had been almost to close the urethra.
Upon examination with the catheter, I found three
strictures. The first was about half an inch from
the mouth of the urethra; the second two inches
and a half above the first, and the third at the bulb
of the urethra. With a small catheter the first two
could be readily passed, the third was permanent,
and impervious to the smallest instrument. The
difficulty of introducing a bougie was much in-
-

134
creased by injury done the urethra by the use of
caustic.
1004
The hopeless condition of this man rendered
him a fair case for my first attempt to form a new
urethra. He was accordingly placed upon a table,
and secured in the position as for the operation
of lithotomy, when I proceeded to operate, as fol-
lows: First, with a straight sound of the largest
size the first and second strictures were forcibly
dilated, which brought the end of the instrument
down to the permanent stricture. Second, an in-
cision was made in the perinæum, as in the lateral
operation for stone; by this incision the bulb of
the urethra was exposed. Third, an opening was
made into the urethra by cutting upon the end of
the sound, through which the instrument was
passed. Fourth, the dissection was then continu-
ed inwards, taking the cord-like urethra for my
guide, for about one inch, which exposed a portion
of urethra, much dilated and filled with urine. An
incision was made into this part with a sharp-point-
ed bistoury. The sound was then removed, and
a catheter of the largest size was introduced into
the bladder. The wound in the perinæum was
brought together by three sutures.
With simple
dressings, no unpleasant symptoms occurred during
his recovery. In two weeks the wound was en-
tirely healed, and the catheter withdrawn for the
first time. At the end of two months the catheter

135
was discontinued, with directions to introduce it
beyond the stricture once or twice a week. At
this time the urine passed in a full stream, and
with little irritation.
I saw this man frequently for several years.
He found it necessary occasionally to introduce
the catheter in consequence of a disposition in the
two anterior strictures to contract.
CASE II. Mr. F., of Jersey City, had for
several years been troubled with a stricture of
the urethra from gonorrhoea. Frequent attempts
had been made to dilate the stricture by bougies,
but latterly he had been treated by caustic with
temporary relief. In the spring of 1836, he had
complete retention of urine; an abscess formed in
the perinæum, which broke, and urine discharged
through the opening. I was requested to visit him
in the following December. From the opening of
the abscess to the time of my seeing him, all his
water had passed through the fistulous opening in
the perinæum. The catheter could be freely pass-
ed down to the bulb of the urethra. All my efforts
failed to penetrate beyond this point. Being satis-
fied that the original passage could not be restored,
I determined to make a new portion of urethra.
He was accordingly placed upon the table, and
secured as in the last case. From the disorgan-
ized state of the parts, I was compelled to change
my usual mode of operating, by making two in-

136
cisions, one on each side of the perinæum, from
above downwards-the two incisions meeting at
the upper part of the fistulous opening. The
triangular flap was then dissected upwards to the
pubis. This gave sufficient room to reach the
urethra at the bulb, so as to lay it
open and
pass
out the catheter. By continuing the dissection
inwards, the opening in the urethra was discover-
ed. In this case, I should judge that more than
an inch of the urethra was obliterated.
hra was
The
catheter was passed on into the bladder and se-
ALES
cured by tapes. The flap was drawn down and
secured by sutures. In two months he had en-
tirely recovered. The urine passed freely through
the urethra with but little irritation. He was di-
rected to use the catheter once or twice a month.
He followed this direction for two or three years,
but gradually neglected the instrument.
On my
return to the City in 1842, Mr. F. called upon
me and stated that he had found the stream of
water gradually to
diminish. Several attempts
had been made to introduce the catheter but
without success, and every attempt had been at-
tended with hemorrhage and great irritation.
The urethra had been so much injured, that I
could not find a passage with the smallest instru-
ment. By his earnest solicitations I proceeded to
cut into his urethra as before; the opening was
more anterior than the previous operation, and the

137
length of the stricture did not exceed a quarter
of an inch. I came to the conclusion that the
part contracted at this time, was the anterior
portion of the old stricture, as the new portion of
urethra formed by the first operation remained
fully dilated. He has entirely recovered from the
last operation, and with care, I am inclined to
believe he will remain in good health. I may
remark, that this is the only case in which a sec-
ond operation has been required.
odi
If you should find the above facts of any im-
portance in your investigations of "Diseases of
the Urethra," you are at liberty to use them as
shall best promote your views.or
esge
alpoffib
I remain, your humble servant,
DAVID L. ROGERS.
NEW YORK, Nov. 10, 1843.
son lowe
zsmit odi mi bom
afood ed sis
ONE
and noto and
T
1 zaibiyib to
ib to stent
odign
080
sw T
ed
ni 915
lu
lood offrab odr
ustry
4000
Sandnes
bas
Insta
margotecn
fons
bestia
of gainet
18

138
DESCRIPTION OF A NEW INSTRUMENT
FOR EXCISING ENLARGED TONSILS.
fignol
[NEW YORK MEDICAL JOURNAL, Vol. II]
1900
PERHAPS there is no operation in surgery, of
the same magnitude, that has been attended with
greater difficulties, than the removal of enlarged
tonsils. The situation of the tonsils, their con-
nection with large vessels of the neck, and the
spasmodic contraction of the surrounding muscles,
have at all times rendered their excision a difficult,
and sometimes a fatal operation. The older sur-
geons resorted to the actual and potential cautery
for their removal. This was not more cruel nor
dangerous than the practice pursued in the times
of Paulus Ægineta, of dividing the mucus mem-
brane, and tearing them from their bed by hooks.
At the present time, the common scalpel, the scis-
sors, and the ligature, are in more common use in
this country and in Europe. I shall offer but a
passing remark upon these different instruments,
which will be confined to stating the inconveni-
encies attending them. The use of the scalpel is
attended with great difficulty, in consequence of
having to employ the double hook in a part so
21

Instrument
for
removing the
Tonsils.
20


139
deeply situated, and is likewise attended with great
danger, from the proximity of the carotid artery
and other vessels of the neck. Of the truth of
this, the records of surgery bear sufficient evi-
dence. (Burns on the Anatomy of the Head and
Neck.)
The objection to scissors must be apparent to
every one. They must of necessity, upon the
principle upon which they cut, make an irregular,
lacerated wound, which is always liable to slough;
and the inconvenience attending ligatures is such,
that no surgeon would willingly employ them, ex-
cept from prudential motives.
Several ingenious instruments have, at different
times, been invented for the purpose of excising the
tonsils, without endangering the neighboring parts.
Among the number, the one proposed by Dr. Phy-
sic, of Philadelphia, is most deserving of notice.
It consisted of two steel rings attached to a handle.
Between the two rings he placed a lancet-shaped
knife, which moved by a spring placed in the
handle. This instrument has undergone several
modifications; one by Dr. Cox, of this city.
There is an objection to this latter instrument,
in consequence of the ring and knife being sepa-
rate, and the knife having to be adjusted after
the ring is placed upon the tumor. The incon-
venience is noticed particularly in children, who
Batwollez

140
will object to a cutting instrument entering their
mouth; and, besides, by their constant move-
ments, the parts within the mouth are in danger
of being wounded.
be The instrument which I now offer to the pro-
fession is so constructed as to avoid the inconveni-
encies and dangers which I have stated as exist-
ing in relation to the others. It possesses the ad-
vantage of a single instrument, and it cannot, by
any possibility, injure any other part than the one
to which it is applied. The great advantage this
instrument possesses over all others, is that it may
be used in children, without producing the least
alarm, as the knife is entirely concealed, and can
be applied without exciting suspicion. A difficulty
often exists in children to keep the mouth open
during the operation. The form of this instru-
ment effectually prevents them from closing it.
One ring will answer for any sized tumor; a
slight movement of the knife fixes the instru-
ment; and lastly, its simplicity and cheapness will
place it within the power of any practitioner to
possess one. Having operated several times on
children and adults, I am not conscious that any
alteration could be made in this instrument for
the better. Having, for the same reasons, request-
ed Professor Mott to use it, and express to me his
opinion of its merits, he has obligingly sent me the
following note:-

141
rod of
DEAR DOCTOR-
25 PARK-PLACE, March 5, 1831.
brote of beha
0110000
2009 01 1
boorteda nego bleif of one
I am delighted with the use of your new instru-
ment for excising the tonsils. The rapidity with
which the operation can be performed, combined
with the safety, gives it, in my opinion, a great
superiority over any other instrument, or method
of removing these parts, of which I have any
knowledge.
9560
Yours sincerely,
Dr. D. L. Rogers, Market-street.
VALENTINE MOTT.
DESCRIPTION OF THE INSTRUMENT.
To a common handle is attached a steel ring,
of sufficient breadth to admit a groove on its inner
surface; deeper at its junction with the handle,
with an opening on its superior surface of half an
inch in length, through which a common probe-
pointed bistoury is introduced, possessing a curva-
ture equal to half the circumference of the ring.
This bistoury is attached to the handle of the in-
strument, fixed to a slide by a rivet, and supported
on its under surface by a small spring, which keeps
the bistoury in its place within the ring. To the
end of the bistoury is attached a handle, of suffi-
cient size to give the operator a complete control
over the bistoury.
In using this instrument, the patient should be
placed in a chair opposite a strong light, and an

142
WOR
mudanos
assistant should stand behind to steady the head,
and one to hold open the mouth on the opposite
side from the one on which you are about to ope-
rate. The bistoury being well pushed forward,
so as to be completely concealed within the ring,
it is then to be placed upon the tonsil. After
being satisfied that it is at the base of the tumor,
a slight movement of the handle of the bistoury
upwards fixes the instrument. When you are
ready to complete the operation, continue to ele-
vate the handle of the bistoury, and at the same
time to pull it forward, when it traverses the
groove of the ring, by dividing everything contain-
ed within its circumference. It is done with such
rapidity that the patient is hardly conscious of its
completion.
200
20
A
Se
202204
w guine
pigil gad
sade
Had
St
Ipupo
bogaid
pega
eggo stado, a ni boosig

143
2001 Das autoune su 10-egbol wond
John 11 hod and
onlooms at poobitong talore ads and bon
CONTRIBUTIONS TO PATHOLOGICAL ANATOMY.
20
[PHILADELPHIA MEDICAL AND PHYSICAL JOURNAL.]
Fate
THE changes which the solids of the body
undergo by the action of disease, must form an
important subject of inquiry to the professors of
the healing art; and as our knowledge of diseased
action increases, will the power exist of control-
ling and curing those diseases. A mere detail of
morbid parts, without the symptoms which charac-
terize these changes, affords but little assistance to
the practitioner of medicine. To render a history
of morbid changes useful, a regular detail of cir-
cumstances should be given, that we may know
the entire chain of symptoms, from the commence-
ment to the termination of the disease. Thus, by
comparing several cases of the same kind, the
different stages would be indicated by positive
symptoms-this renders the investigation of morbid
anatomy valuable, and the record of cases bene-
ficial to the profession. To the investigation of
diseased structure, we are indebted for the most
valuable improvements in medical science. The
history of our profession teaches us that it has im-
proved in proportion to the advancement of our

144
knowledge of the structure and functions of the
human body. It is a fact, which will not be dis-
puted, that the greatest practitioners in medicine
have been remarkable for their correct anatom-
ical knowledge. - The collections of morbid an-
atomy made by Morgagni and Hunter, must ever
stand as monuments of their skill and industry.
It is true, that diseased structure does not, in
all cases, lead to a knowledge of diseased action.
We frequently find appearances after death which
seem irreconcileable with the previous sypmtoms;
but this argues nothing against the utility of ex-
aminations after death. It sometimes happens
that no diseased structure can be discovered after
death, although strong symptoms previously indi-
cated its existence. This may proceed from
transferred sensation, while the disease may exist
in some remote part, as, for instance, in the diges-
tive organs. The irritation is frequently felt in some
distant part, and on examination the seat of the
disease is entirely overlooked; thus the inspection
ends without adverting to the sympathies that
might have led to the previous symptoms. It is
the study of these changes, and the connection
that exists between important organs and remote
parts, that renders the study of morbid anatomy
so essential to the sound pathologist. qui oldular
It is not intended in this article to include a
complete history of the changes to which the

145
different parts are liable from diseased action;
nor is it contemplated to preserve a systematic
order in arrangement.
Hanoi Besoh
The descriptions are drawn up from specimens
in my own cabinet, and the valuable collection of
Professor Mott, to whom I am indebted for the
privilege of thus enriching my observations.
DISEASED STOMACH.
bestigado
Under this head we shall notice five specimens:
1st, a portion of stomach from a man who died
with yellow fever: 2d, a specimen from a case of
typhus fever: 3d, ulceration: 4th, enlargement:
5th, schirrus.
3.
281755
old bhoft thin
Stomach of an adult who died from yellow fever.
-This specimen of inflamed stomach was taken
from the first case of yellow fever which proved
fatal in New York, in 1823. The patient died
with the usual symptoms which characterize the
fatal termination of this disease, such as great dis-
tress in the epigastric region, delirium and black
vomit. The body was examined a few hours
after death with great care. The diseased ap-
pearances were confined entirely to the stomach.
The seat of the disease was confirmed by several
other cases which I examined during that year.
I was well satisfied of the fact, that the disease
was situated principally in the stomach, and the
19

146
derangement of the neighboring viscera was but a
secondary effect, as a consequence of the disor-
dered functions of the stomach. In this case, the
stomach was found much contracted, having exter-
nally a red and vascular appearance; its internal
surface was collected into folds, and to such a
degree as almost to obliterate its cavity. These
folds had a florid appearance much resembling a
fine size injection. Red specks could be observed
resembling small arteries terminating on a recently
divided surface; on different parts of the stomach,
and more particularly at its great extremity, the
villi of the internal coat were destroyed by ulcera-
tion, a small quantity of black matter streaked
with florid blood was found in the cavity; this
blood possessed different shades of color, from the
brightest red, to a dark brown, approaching black.
Stomach from a subject who died of the typhus
fever.--This specimen much resembles that from
the case of yellow fever. Its internal surface is
much less corrugated, but possesses the red florid
appearance with a great congestion of its vessels.
The red specks and ulcers were not observed,
and the only difference that the anatomist could
discover in the two cases from the action of
disease, would be in the degree of inflammation.
The premonitory symptoms being nearly the same,
and the sensibility to pressure in the epigastric
CE

147
region existing alike in the two diseases, would
lead to the belief that inflammation of the stomach,
more or less intense, depending upon peculiar
causes, formed the true nature of these diseases, a
conclusion deduced from the morbid anatomy,
which we consider as the most legitimate source
of pathological knowledge.
The black vomit might be offered as a diag-
nostic symptom, but this may exist at any time,
depending upon a high degree of inflammation.
for its production; we are convinced of this from
the fact of its existing in many cases where the
inflammation of the stomach proceeds from chemi-
cal causes, such as arsenic, nitre, muriate of
mercury, &c.
batasio
Ulcerated Stomach.*-This specimen was taken
from a gentleman, who, for five or six months pre-
vious to his death, was frequently complaining of
a loss of appetite, costiveness, tenderness in the
epigastric region, a heaviness and uneasy sensa-
tion about the stomach. Cathartics and other
medicines were administered without affording
much relief: the symptoms increased in violence,
a burning sensation was felt, when the slightest
nourishment was taken into the stomach, and a
loathing of all kinds of food. For some time
previous to his death, he had incessant vomiting of
* Specimen No. 15, in Dr. Mott's Cabinet.

148
black matter, resembling coffee grounds. He died
very unexpectedly, without any symptoms indi-
cating immediately approaching dissolution. The
examination was made a few hours after death.
On opening the cavity of the abdomen, a large
quantity of black matter was found, such as had
been thrown from the stomach by vomiting. The
stomach was perforated by numerous holes of
different sizes, and was so very tender, as to tear
by its own weight. The edges of these openings
were inverted and had an irregular appearance.
The internal surface was of a dark livid color,
and it was observed, that the internal coat was
much shorter than the external; that is, the peri-
toneal coat had resisted the process of ulceration
much longer than the internal coat, and projected
for some distance into the circle of the ulcer.
This would form a distinction between the des-
truction of the stomach by ulceration, and that by
the action of the gastric juice. A specimen of
the latter, I have before me: its edges are smooth
and regular, as if incised. When the stomach is
destroyed by the gastric juice, as occurs in persons
who die in full health, its situation is generally
at the depending part of the great extremity, and
the stomach usually has a healthy appearance.
Ulceration of the stomach is of rare Occur-
rence, and its destruction by the gastric liquor is
frequently mistaken for it. Anterior to the ex-

149
planation given by J. Hunter, of the destruction
of the stomach after death, by the solvent powers
of its own fluids, it was considered as a frequent
disease. Cases of ulcerated stomach are related
by Morgagni, Baillie and Monro.
migo
beraltron
Enlarged Stomach.-The stomach occasionally
becomes enlarged, without any apparent cause
sufficient to account for it, from a diseased con-
dition of its coats. A specimen before me is
from Dr. Mott's Museum, No. 53. It was taken
from a gentleman aged sixty-five years. The
first symptoms were so slight that they were al-
lowed to advance for some time without notice.
He was naturally a moderate eater, and his food
was prepared in the plainest manner. He at first
complained of a loss of appetite, and a slight
irritation of the stomach after eating. It was
soon found necessary to desist entirely from taking
solid food, and he was confined to broths and the
mildest drinks; but this produced a sense of
weight and uneasiness, until vomiting was excited,
and it was again thrown up. As soon as this oc-
curred he was perfectly easy, and at no time did
he experience any pain. Notwithstanding the
means employed to arrest the disease, the vomiting
increased in violence, and so great was the irrita-
tion that the mildest drinks could not be retained,
and emaciation became extreme before death,

150
He was examined a few hours after death. The
enormous size of the stomach was the first object
that attracted attention on opening the abdomen,
which it appeared entirely to fill. It was removed
from the body, the better to examine its unnatural
size. Its form was unaltered; the enlargement
appeared alike in all directions; externally its
color was natural. It was irregular in its thick-
ness, some parts of it being transparent, and re-
sembling, when touched, a single layer of the pe-
ritoneum. The inner surface of the stomach had
lost its natural appearance. It had a smooth shin-
ing surface, with considerable vascularity. No
traces of a villous coat could be discovered, except
that occasionally a small elevation could be perceiv-
ed which resembled it. The pyloric orifice was
contracted and thickened, but not to such a degree
as to interrupt the passage into the duodenum.
Some idea may be formed of the immense dimen-
sions of this stomach, when it is stated that it con-
tained twelve pints of water, without any force
being applied to distend it.
Schirrus Stomach.*-This specimen is remark-
able, in consequence of its disorganization, as not
a vestige remains of its original structure. The
early history of this case is but little known. In
the latter stages, from its great bulk, it was easily
* Specimen No. 55 in Dr. Mott's Cabinet.

151
felt externally. It was attended with considerable
pain and great irritability, which prevented his
taking a sufficient quantity of food for the support
of life; the lightest food was almost immediately
rejected, attended with a vomiting of black matter
resembling coffee-grounds. The connection of
the stomach with the aorta gave to it a strong pul-
sation. The stomach weighed about four pounds,
after its appendages were removed. Its parietes
measured from an inch to an inch and a half in
thickness, and a section gave the appearance of a
fibrous structure, diverging from the centre to the
circumference, as is observed in schirrus of the
breast and other glandular parts. A great number
of calculus concretions were found interspersed
throughout. The cavity of this stomach was
almost obliterated; it would not contain more
than from one to two ounces of fluid.
It is a question of some doubt, how far the
action of the stomach had any agency in reject-
ing the food from its cavity. The cavity remain-
ing permanently open after death, and the force it
required to bring its parietes in contact, led us to
doubt the possibility of any contraction during
life. We merely state the fact, without attempt-
ing any solution of the question.
One
34
in bus
10 guro edi of 100
Plech

152
oblembie
barns
ochen nis
CASE OF A TUMOR SUCCESSFULLY EXTIRPATED.
(WITH A PLATE.)
Andlingar a
[PHILADELPHIA MEDICAL AND PHYSICAL JOURNAL, VOL. XIII.]
BELIEVING With Mr. Abernethy, that tumors, in
a nosological view, ought to constitute an order
in the class of local diseases, the tumor under pre-
sent consideration, according to his classification,
may be ranked with the sarcomatous genus, and
adipose species, denominated by him, adipose sar-
coma.
Tumors of this species seldom produce any
alarming effects, except from adventitious causes,
being of that inoffensive class, producing but
trifling inconvenience, independently of their bulk
and ponderosity; and their removal is generally
unattended with danger or difficulty, save from
the irritation that not unfrequently arises from ex-
tensive wounds, or, from their locality. The prin-
cipal advantage, then, to be derived from the pub-
lication of such cases is, that they tend, in no in-
different degree, to familiarize the practitioner
with their unseemly appearance, and enable him
more easily to designate to what class, such tu-
mors, when they present, belong; and, at the
same time, to point out to the young surgeon the
f

BNHO
494
344
F. Michelin's Lith 111 Nassau St .N.Y
Adipose Sarcomato's Tumour.


153
most approved and successful methods of relieving
his fellow-beings from such irksome and un-
wieldy burdens. By these means we contri-
bute our mite to the advancement of knowledge,
and afford useful practical information.
Mrs. B. the patient from whom this tumor was
taken, was of the age of fifty, and of a good con-
stitution. From her account, it made its appear-
ance thirty years previous to the operation. It
was situated on the top of the right shoulder,
having a broad base, extending from the mastoid
process to near the acromion, and over the clavicle.
It had now acquired considerable size; and pre-
sented the striking appearance of two heads on
the same individual. She had never experien-
ced any pain in the tumor, but the inconvenience
of its weight and size, induced her, through the
importunity of her friends, to have it removed.
The operation was performed in the presence of
several medical gentlemen. Two incisions were
made round the base of the tumor, commencing at
a point near the mastoid process, and meeting a
little anterior to the acromion scapula, leaving a
sufficiency of integument to close the wound.
By a careful, though expeditious dissection, the
tumor was detached, exposing a large extent of
raw surface, nearly two feet in circumference, com-
pletely denuding the clavicle, and the whole of the
top of the shoulder, including the superior edge of
20

154
the trapezius muscle. The tumor was attached
by pretty firm adhesions to the contiguous parts;
no hemorrhage of consequence followed its re-
moval. Several ligatures were applied to small
bleeding vessels, and the wound dressed with ad-
hesive straps.
The patient perfectly recovered,
and left the city in less than a fortnight. The
weight of the tumor, when separated from the body,
200krong
was eight pounds.
The sketch here given is a true delineation, and
intended to convey a correct idea of the situation
and magnitude of the tumor, and, at the same time,
to point out the course of the incisions; the track
of the superior incision is shown by the dotted
line.*
* In 1839, I removed a much larger tumor of the above descrip-
tion, weighing twenty-eight pounds. The wound healed readily,
and the patient perfectly recovered.
noitusgo
Tusmohues boibam Inte
oth lo esed oil banjor obsta
bloter
nigy #
Th
FOOD 200
bes
dprod
de back astrale ed galben
rebloodz ed
detaly
001

155
ef5bin
A CASE OF OSSIFICATION OF THE MUSCULAR
TISSUE.
[AMERICAN JOURNAL OF MEDICAL SCIENCE, VOL. XIII.]
In June, 1832, I was first consulted in the case
of James Melwill, aged thirteen years.
years. His father
stated that his son, from infancy, had been in good
health, and was remarkable for animation and a
high flow of spirits. About six months ago, it was
perceived that his health began gradually to fail,
and without any perceptible cause. At first, a
loss of motion in the arms was noticed; he was
unable to raise them to his head, or carry the
elbows to any great distance from the body. The
motion of the right arm lessened every day, until
it was permanently fixed to the side of the body.
Shortly after, his head inclined forwards and
downwards on the sternum. At the time I first
saw him, his appetite and digestion did not seem
to be impaired; he slept well at night, and the
bowels were regular. On examination, it was
found that the pectoralis major muscle was ossi-
fied at its superior part, and extended in the
direction of the clavicle to the arm; the bony de-
posits forming high and irregular elevations. The
sterno-cleido mastoideus was ossified from the

156
sternum to its middle portion, with several eleva-
tions. The back exhibited the greatest quantity
of ossific matter, having a tubercular appearance.
The scapula was fixed to the ribs, and studded
with bony excrescences. All the muscles going
to the scapula appeared more or less affected, viz.
-the trapezius, rhomboideus, subscapularis, &c.
The latissimus dorsi formed a large bony plate, from
its origin to the angle of the scapula; at this part
it had united to the ribs, forming a large tubercle.
The longissimus dorsi was in a similar condition,
extending upwards along the spine, resembling a
splint, and to this may be attributed the entire loss
of motion in the lumbar vertebra.
bus
The treatment was various, and may be con-
sidered a series of experiments, to check the
predisposition to the formation of bone.
His general health at this time not being ma-
terially affected, recourse was had to alteratives,
consisting of the different preparations of mercury
with sarsaparilla. Having used these for a length
of time, without benefit, the acids were employed
without effect, viz.-the nitric, muriatic, and the
sulphuric; the carbonate and phosphate of iron
were administered with the same result; the
iodine was also given, but without advantage.
Finding at the expiration of three months that
no change for the better had taken place, and
that the bony depositions had increased, all active

157
treatment was now abandoned, and he was di-
rected to live principally on salted provisions; the
object was to produce a state of his system resem-
bling that in scurvy, as it is known that bony
depositions do not take place in this disease, and
that fractures which have been united for several
years, are sometimes separated in the scorbutic
diathesis.* Until this time he had been an office
patient, but from some cause unknown he omit-
ted to call for several months. In March, 1833,
he was visited at his residence; he was much
changed; his general health had suffered; he had
lost his high spirits, was very irritable, and had a
diarrhoea; was greatly emaciated; the ossific de-
positions had, in some respects, changed their
situations; the sterno-cleido mastoideus muscle
had become free, and the head returned to its
erect position; many of the tubercles of the back
had been absorbed, and others formed in different
places. Bony depositions had taken place also in
the muscles about the trochanter major, particu-
larly on the right side. He was compelled to lie
in bed, for the least movement produced excruci-
ating pain. A large collection of matter formed
in the thigh near the joint, which when discharged
afforded some relief; but the constant pressure on
the bony tubercles on the back, caused extensive
* Lord Anson's Voyage Around the World.

158
sloughing, and after three weeks of great agony he
expired. The body was partially examined twelve
hours after death. The glands of the mesentery
were enlarged; no ossific matter in the vascular
system, but it seemed to be confined entirely to
the muscular tissue. The parts within the abdo-
men and thorax appeared to be healthy. The
pectoralis major and minor muscles were united
into one, and attached to the ribs by solid bone.
During this part of the dissection, a large abscess
was opened in each side, containing about six
ounces of pus; the tendinous parts of the mus-
cles were not affected. The muscles of the back
were all, more or less, in the same condition.
Specimens of the latissimus dorsi, longissimus
dorsi, subscapularis, and pectoralis muscles, are
preserved in my museum.
In several instances,
spicula of bone projected from the muscles one or
two inches; and no doubt, from the irritation they
occasioned, abscesses were formed.
bage
esso for
upds celbenus
grip
1
adr


Instrument for Fistula in Ano
Fig.3.
Fig 2.
Fig. 1.

159
1990
9th
A NEW INSTRUMENT FOR THE OPE-
RATION OF FISTULO IN ANO.
[NEW YORK MEDICAL AND PHYSICAL JOURNAL, VOL. I.]
TO THE EDITOR OF THE NEW YORK MEDICAL AND PHYSICAL JOURNAL.
DEAR SIR-
I send you the plate of an instrument for the
operation of fistulo in ano. While visiting the
great hospital at Milan, I observed a probe-point-
ed histoury, in use for the dilatation of deep and
irregular sinuses; and believing that an instru-
ment of a similar construction might be employed
with advantage in operations for fistulo in ano,
I have modified it so far as to suit it for that ope-
ration. The operation by the common bistoury
is attended with many inconveniences, particular-
ly when the sinus extends to a considerable dis-
tance up the rectum. Although the communica-
tion between the sinus and the gut may readily
be found with a probe, yet every surgeon will ac-
knowledge the difficulty of following the tract of
the sinus with the sharp-pointed bistoury. An-
other difficulty will occur to the surgeon after the
point of the bistoury has entered the intestine, in
being obliged to draw it out under the nail of his
fore-finger, by which the finger is frequently

160
wounded, or it slips from the finger and wounds
the intestine. These accidents have frequently
occurred to me in performing this operation.
The instrument which I offer to the profession,
I believe, will obviate the difficulties which attend
the operation by the common bistoury. This in-
strument consists of a common bistoury, the blade
of which terminates in a small screw, (see fig. 2,)
to which a flexible probe is attached, (see fig. 3,)
of two inches in length. This, when screwed on
the bistoury, completes the instrument, (see fig. 1.)
I have considered the attachment of the probe by
a screw as the best plan, inasmuch as it renders
the instrument more portable, and different sized
probes may be attached, according to circum-
stances.
The advantages of this instrument over the
one in common use are, first, that the probe will
follow the tract of the sinus, and can more readily
be passed through the opening into the rectum;
secondly, it may easily be laid hold of by the fore-
finger, and drawn out at the anus, which its flexi-
bility will admit of; and thirdly, the surgeon may
take firm hold of the instrument, so that by draw-
ing it forward, it will cut its way out.
With much respect,
I am, yours, &c.,
No. 19 MARKET-STREET, June 30th, 1829.
DAVID L. ROGERS.





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