youngest was two years and a half; of the oldest, forty; seventeen
were twelve years or under; nine from thirteen to twenty years; and
seven, twenty-one or upwards. The seat of the wound giving rise to the
disease, occupied, in fourteen cases, some part of the frontal region;
in seventeen the parietal; and in two the occipital. In fourteen cases
the brain was lacerated, and a portion of its substance discharged;
in five it was wounded without loss; in one its surface was simply
denuded; in ten there was no exposure; and in three its condition
is not noticed. The dura mater was torn in twenty-one cases, and in
another perforated; the cranium in all, except one, was broken into
several fragments; and in twenty-four the scalp was more or less
lacerated; in another it was pierced; in three there was no solution of
continuity; and in five no mention is made of its condition.
The period of the appearance of the morbid growth from the occurrence
of the injury varied in different individuals. In eleven cases it
manifested itself prior to the sixth day; in fifteen between the
seventh and twelfth; and in five between the twelfth and twenty-fifth.
In one instance it did not begin until the eighth week: in another
the time is not specified. The earliest period of its appearance was
the third day, and that in two cases only; in more than three-fourths
it commenced on or before the twelfth day. The average period was the
ninth day from the accident.
In regard to the volume of the tumour, it varied from half an inch
in diameter to a mass measuring six, by three and a half inches upon
the surface, and two and a half in thickness. In twenty-two cases in
which the dimensions are stated, the tumour in five was of the size
of a hen’s egg; in eight it exceeded that magnitude; and in nine it
fell short of it. The morbid growth was dissected only in eleven of
the cases; in nine of these it consisted of cerebral substance, in
which the cortical and medullary tissues were distinctly recognised,
and in the other two it was composed of coagulated blood of a fibrous
texture. In seven cases the tumour assumed a sloughing character; in
five it yielded a fetid, sanious discharge; in one it bled freely on
the slightest touch; in three it was enveloped by the pia mater; and in
three others the surface was coated with a layer of clotted blood. In
the centre of the largest tumour a cavity existed, filled with an ounce
of limpid serum, and lined by a transparent, glistening membrane.
The general _symptoms_, indicative of disturbance of the vascular
system, and of the cerebral functions, may be next considered. In
twenty-three cases there was more or less excitement of the heart
and arteries; in four none was apparent; and in the other six the
symptoms are not stated. “In fourteen cases some one or more of the
following symptoms of disturbance of the brain and nervous system
were present: coma, delirium, pain in the head, general irritability,
and insensibility. In six paralysis of the side of the body opposite
to the injury was superadded to the preceding symptoms; and in two
convulsions. Three cases were remarkable as presenting some striking
exceptions to the general characteristics, and are, therefore,
deserving of more particular notice; one of them, from the circumstance
that there was no apparent shock to the nervous system, not even as
the immediate effect of the injury, though its severity was so great
that several fragments of bone and pieces of coal penetrated the brain,
causing a discharge of three or four teaspoonsful of its substance. In
another the patient remained in a state of complete insensibility and
general paralysis for twenty-three days; the hernia appearing on the
seventh day, and no inflammatory symptoms supervening. The third case
exhibited a character of most frightful violence. Besides paralysis of
one side, there were spasmodic actions of the muscles of the face and
of all the limbs; nausea, retching, quivering of the eyelids, fixed
eyeballs, strabismus, grinding of the teeth, alternate contraction and
dilatation of the pupils, intolerance of light and sound, and other
signs of the most alarming nervous commotion, often threatening to
terminate life.”
Of the thirty-three cases in question, seventeen recovered, at a
period varying from three weeks to four months; and sixteen terminated
fatally, on an average, about the twenty-fourth day. More young
persons recovered than old. Of the sixteen fatal cases, eleven were
examined, and exhibited the following lesions: in eight the portion
of _the brain_ subjacent to the hernia was softened, pulpy, more or
less disorganised, and sometimes intermixed with clots, while in
the account of the other three no notice is taken of its condition.
In eight other cases there were signs of acute inflammation of the
_arachnoïd membrane_ as indicated by thickening, opacity, adhesions
to the dura mater, and deposits of lymph or pus. The portion of the
dura mater around the opening through which the fungous mass protruded
was thickened, black, and sloughy, in three of the eleven cases in
question. In four the ventricles were filled with bloody serum; in one
there was a large abscess in the brain full of pus, and lined with a
false membrane. In one case a clot of blood was found between the dura
mater and the cranium; in four the fracture extended through the base
of the skull; and in one of these the edges of the osseous aperture,
through which the hernia protruded, were rounded off by absorption.
In respect to the general _treatment_, it was uniformly antiphlogistic,
consisting of the abstraction of blood by venesection and leeching, and
the use of purgatives, proportioned to the urgency of the inflammatory
symptoms. The local means employed were, excision of the hernial
tumour, the application of the ligature, pressure, and caustics, either
singly or together. In one of the cases that resulted favourably a
spontaneous cure took place after copious hemorrhage from the morbid
mass, excited by an accidental attack of vomiting. In another, after
the ineffectual use of the nitrate of silver and other escharotics,
the ligature was applied and gradually tightened from day to day; in
five pressure alone was sufficient; in two the pressure was conjoined
with lime-water; and in one with the nitrate of silver. In seven other
favourable cases excision was resorted to, either once, or repeatedly,
accompanied with pressure; in some dilute nitric acid—twenty drops to
the ounce of water—lime-water, or nitrate of silver, were employed
in addition. In the sixteen cases that terminated fatally the local
treatment was, pressure alone in two; in five excision with pressure;
in two the ligature; in one both ligature and excision; and in another
escharotics. In five no mention was made of the local means.—ED.]
[27] [Dr. Maunoir, of Geneva,[28] relates a curious instance, strongly
corroborative of the occasional hereditary tendency of this affection.
While investigating this subject, he became acquainted with the history
of a woman whose grandfather, uncle, two aunts, and two cousins, all
on the paternal side, had had cataract, and who had all been operated
upon. She herself, at the age of twenty, was attacked with it. Finally,
out of four children which she had, one was born with cataract; and,
what is remarkable, neither her father, mother, nor sisters, had
ever had any affection of the kind. The same writer states that Roux
once operated for this disease upon three brothers, whose father and
grandfather had suffered similarly. A brother, much younger than
themselves, had the affection in its incipient stage. Instances more
frequently occur in which several members of a family are affected with
cataract, without any traceable hereditary predisposition on the part
of either parent. Professor Drake met with a case not long ago, where
five out of nine children were blind from this cause; and last autumn
I operated on two boys and a girl from Mississippi, who had lost their
sight in a similar manner.—ED.]
[28] Essay on Cataract, translated by Dr. Bowditch, of Boston.
[29] [The two subjoined tables, the one constructed by Mons. Maunoir,
and the other by Professor Fabini, demonstrate the immense influence
which age exerts upon the production of cataract:—
TABLE I.
From 20 to 29 years 5 patients
30 39 3
40 49 11
50 59 25
60 69 41
70 82 27
———
112
TABLE II.
From 1 to 10 years 14 patients.
11 20 16
21 30 18
31 40 18
41 50 51
51 60 102
61 70 172
Above 70 109
———
500
It has been said that men are more liable to cataract than women; the
difference, however, if any, is probably very slight. Thus, in the
first table, 61 were males and 60 females; in the second, 268 were
males and 232 females.—ED.]
[30] [This expression admits of some modification. In young persons
with good constitutions, whose previous health has been good, and who
have not been subject to ophthalmia, I should not hesitate to operate
on both eyes at the same time. In six or eight cases, in which I have
lately followed this practice, no unpleasant effects whatever occurred:
in all the inflammation was exceedingly moderate.—ED.]
[31] [In congenital cataract there can be no valid reason for
postponing the removal of the opaque lens even to as late a period
as that mentioned in the text. The operation is perfectly simple,
unattended with risk, and may be performed within six or eight weeks
after birth.—ED.]
[32] [This must, I suppose, be a typographical error. The author can
certainly not mean that the instrument should be introduced at the
centre of the cornea, as would inevitably happen if we were to carry
out his directions. The proper point is the lower and outer part of
the cornea, about a line anterior to its junction with the sclerotic
coat.—ED.]
[33] See Elements of Pathological Anatomy, vol. i., p. 489, for
description of this fascia.
[34] Boston Medical and Surgical Journal, Dec. 29th, 1841.
[35] [This opinion is certainly erroneous. That the obstruction
occasionally exists in the situation adverted to, cannot be doubted,
but that it does so constantly, or even generally, is not true. When
the lining membrane of the antrum is inflamed, it does not follow that
it must be so throughout its entire extent; most commonly, indeed,
there is reason to believe that the morbid action is circumscribed,
and hence when matter forms it may readily, in many cases, find its
way into the nose. It is only where the whole of the mucous lining is
involved, or that portion of it which covers the inner wall of the
antrum, that the edges of the communicating aperture will be likely
to be so much thickened as to produce complete obstruction. It is
difficult to conceive how Mr. Liston could have committed such an
error.—ED.]
[36] [These abscesses are sometimes acute, the suppuration occurring as
a consequence of active inflammation. They are seated in the submucous
cellular substance, and often acquire a large size; at first there is
merely soreness in the throat and pain in swallowing, but when matter
begins to be poured out difficulty of breathing is superadded, from
the pressure which it exerts upon the epiglottis and mouth of the
larynx, and if it be not speedily evacuated the patient may die from
suffocation. As soon as fluctuation is recognised, or even before, if
there be much swelling and difficulty of respiration, relief should
be afforded by a free incision, made with a sharp-pointed bistoury
with the back towards the tongue, which is to be depressed with the
forefinger of the left hand.—ED.]
[37] [There is no subject of greater importance to the country
practitioner than the extraction of the teeth; an operation which, from
his insulated situation, he is constantly obliged to perform. Like the
operation of venesection, it may be executed well or indifferently, and
precisely as he does the one or the other will be the measure of his
standing with his patients. The following observations in relation to
this subject are condensed mainly from the excellent work of Mr. Bell,
“The Anatomy, Physiology, and Diseases of the Teeth,” which should be
in the hands of every physician in the country.
Mr. Bell thinks that the separation of the gum from the teeth, as a
preliminary measure, is unnecessary; a view in which I must entirely
disagree with him. That it materially facilitates the removal of the
organ from its socket, ample experience has long since convinced me.
The operation may be performed with a gum-lancet, or, what I have
always preferred, a sharp penknife, which should be passed completely
round the neck of the tooth, down to the alveolar margin of the
jawbone. In the removal of the first teeth in children the previous
separation of the gum is unnecessary.
The incisors of the upper jaw will require the use only of a small pair
of straight forceps, the application of which is extremely simple. As
the roots of these teeth are conical, and generally perfectly round,
they will require merely a slight rotation, when they may be drawn
downwards in the direction of the socket. The forceps should be placed
as high on the root as the alveolar process will admit, and pressed so
firmly as to prevent the blades from slipping, while at the same time
care is taken not to crush the tooth.
The extraction of the lower incisors is effected in a very different
manner. The roots of these teeth being very much flattened laterally,
it is obvious that they cannot be dislodged upon the principle of
simple rotation in the socket. When the tooth is even, or nearly so,
with the others on each side of it, the best instrument will be the
hawk’s-bill forceps, of very small size, and with narrow blades. The
instrument being fixed as low on the neck of the tooth as possible,
a gentle but firm movement is to be made forwards, so as just to
separate the organ from the back part of the alveolar cavity, and then,
continuously with this motion, the tooth is at once to be raised out of
the socket.
The superior cuspid and bicuspid teeth may generally be removed by
means of the same straight forceps as the incisors. The extraction
of the former will be considerably facilitated, by giving a slight
degree of rotation previous to its actual dislodgement from the socket.
The bicuspids, on the contrary, having flatter sides, and less solid
roots, will not allow of any degree of rotation; and must therefore be
dislodged by first of all moving them a little outwards towards the
cheek, so as to destroy the attachment to the inner alveolar plate, and
then, by a perpendicular pull, they may be lifted directly from the
socket.
The cuspids of the lower jaw are to be removed by the same means as
the incisors. For the extraction of the bicuspids the key is the best
instrument. The claw, placed in the usual position, should be rather
small, and the fulcrum well covered with lint.
The removal of the first and second molars of the upper jaw will
generally be best effected with a pair of large forceps, slightly
bent at the blades. In applying this instrument to the teeth in
question, the edges must be thrust as far under the border of the gum
as possible, and a firm, steady hold taken of the tooth. It is then
to be dislodged by first a steady, gradual bearing outwards until
it is slightly moved, when, with a contrary motion into its former
position, followed by a firm pull downwards, the tooth is removed with
considerable facility. The corresponding teeth of the lower jaw may be
extracted by the same means, or with a pair of hawk’s-bill forceps, the
longer blade of which is to be placed on the inner gum. The operator
standing on that side of the patient from which the organ is to be
removed, and having taken a firm hold, first moves the tooth a little
outwards towards himself, and then, with a steady and continuous
movement, draws it almost straight from the socket; a motion which the
inclination of the handle will greatly facilitate. The wisdom-teeth are
best extracted with the forceps; their roots are small, and but little
force is required for their removal.
When the crowns of any of the teeth are so entirely destroyed that the
forceps and the key are alike insufficient to remove the roots which
remain, the elevator, as it is called, will be found a very simple
and efficient means to effect it. The edge of the instrument is to be
inserted between the root and the alveolus, so far as to secure a sure
hold, and the root is then to be lifted, as it were, from the socket,
by resting the instrument upon the alveolar process, or even upon the
side of a neighbouring tooth. There is not the least danger of injuring
the latter if care be taken not to depend too exclusively, nor to bear
with too much force upon it.—ED.]
[38] [I have been in the habit, for many years, of keeping the edges of
incised wounds of the face, forehead, and eyelids, in contact with gold
pins finer than the most delicate sewing-needle. They should be from
an inch to an inch and a half in length, and be provided with heads of
sealing-wax, by which they can be more easily carried across the skin
than in any other way. From the materials of which they are composed
they are entirely exempt from oxidation, which is not the case with the
common needle; and I am convinced, from ample experience, that wounds
thus healed are seldom attended with permanent deformity, from the
formation of unsightly scars.—ED.]
[39] [In this country goitre is most common in the mountainous
districts of Pennsylvania, Virginia, New-York, Connecticut,
New-Hampshire, and Vermont. It is very rare in the natives of the
western and southern states.—ED.]
[40] [I have in two instances succeeded completely, and in another
partially, in curing goitre of long standing, by the internal and
external use of iodine; and am disposed to place more reliance upon
this remedy in the treatment of this affection than upon any other with
which I am acquainted. To be beneficial, it should be administered
in large doses, and be continued for at least three or four months.
The local remedy which has best succeeded in my hands consists of
equal parts of iodine and of camphorated mercurial ointment, rubbed
thoroughly upon the surface of the tumour twice a day.—ED.]
[41] [To obtain a full stream of blood, the lancet should be carried
_obliquely_ upwards and outwards, by which means the fibres of the
platysma-myoid will be cut across, instead of being divided vertically,
and the edges of the incision will retract so as to form a much larger
orifice. The pressure below the opening should not be removed until the
wound has been closed, to avoid the introduction of air into the vein,
an accident which may occur when this precaution is neglected.—ED.]
[42] [I am induced to subjoin the following example of axillary
aneurism for which the subclavian artery was tied, in the belief that,
from the unique manner of its termination, it will be interesting and
instructive to the reader. The particulars of it, together with an
analysis of twenty-six other cases reported by different surgeons, will
be found in the _Western Journal of Medicine and Surgery_ for June,
1841.
Daniel Monday, a married negro, thirty-six years of age, of a stout
muscular frame, and a brickmaker by occupation, consulted me, in
February, 1841, for a circumscribed, pulsating tumour, produced by
the recoil of the butt-end of a yager, and situated beneath the right
pectoral muscle, extending from the clavicle down towards the cartilage
of the fourth rib. It was of an irregular, conical shape, and about the
volume of a large fist, measuring fully four inches at its base in one
direction, by three and a half in the other. In its feel it was tense,
as well as inelastic; the blood rushed into it with a whizzing noise,
and the pulsation was so distinct that it could be seen at the distance
of some feet from the patient. The clavicle was thrown above its
natural level; the whole limb, from the top of the shoulder to the ends
of the fingers, was benumbed, painful, and almost deprived of power;
the pectoral muscle was much stretched; and the patient constantly
inclined his head towards the affected side, keeping the elbow nearly
at a right angle, and supporting it carefully with the opposite hand,
to prevent tension of the tumour. The swelling of the limb, however,
was slight; the temperature was also good, and the pulse at the wrist
was nearly as distinct as in the natural state. For the last four weeks
the pain was almost incessant; it was particularly severe at the chest
and shoulder, and had become so agonizing of late as to deprive him of
sleep, and even prevent him from lying down. The appetite was also much
impaired, and the countenance expressive of the deepest distress. The
tumour had grown with great rapidity during the last two months; and,
as there was danger of its bursting, an operation was at once decided
upon.
The patient was placed upon a narrow table of moderate height, the head
and chest being elevated with pillows, and the face turned slightly
towards the opposite side, while an assistant pulled at the wrist,
to depress the affected shoulder. The integuments over the clavicle
being stretched upon the chest, I made my first incision along the
centre of that bone, beginning near the sternal origin of the mastoid
muscle, and passing out towards the acromion process of the scapula for
about three inches and a half; thus dividing at one stroke the skin,
cellular substance, and fibres of the platysma-hyoid. The parts being
allowed to retract, left the lower margin of the cut parallel, and on
a level with the superior border of the clavicle. A second incision,
about two inches in length, was carried along the posterior edge of
the sterno-mastoid muscle, at a right angle with the preceding. The
triangular flap thus formed was then dissected up and held away, care
being taken not to interfere with the external jugular vein, or any
of the smaller arteries of the neck. Having advanced thus far, the
cervical aponeurosis was detached from the clavicle by cautious strokes
of the handle of the scalpel, which laid bare the brachial plexus of
nerves and the omo-hyoid muscle. At this stage of the operation a small
vein, a branch of the subclavian, was divided, and, although it bled
very little, it was immediately secured by a temporary ligature. Taking
the omo-hyoid for my guide, I divided the loose cellular substance in
the triangular space bounded above by the muscle just mentioned, by
the clavicle below, and by the anterior scaleni muscle internally, and
thus approached the artery as it passed over the first rib. The vessel
here lay at some distance from the inferior branch of the brachial
plexus of nerves, rather deeply behind the collar-bone; and with a
common aneurism needle, armed with a double ligature of saddler’s silk,
no difficulty was experienced in securing it, the instrument being
carried from before backwards and from below upwards. The ligature was
then drawn very firmly with the fingers, and tied with a double knot
within a few lines of the anterior scaleni muscle: as soon as this
was accomplished, all pulsation in the sac, as well as at the wrist,
ceased. One end of the ligature being cut off, the other was left
protruding at the inner angle of the wound, the edges of which were
closed by three sutures and adhesive strips. Not half an ounce of blood
was lost during the operation, which lasted twenty minutes.