and wrapped in cotton wadding. In less than an hour the temperature,
which had been considerably depressed, was thoroughly restored; the
pain and numbness had greatly abated; and the poor fellow expressed
himself more comfortable than he had been for a month. In less than
twenty hours the tumour was quite solid; the ligature came away on the
morning of the thirteenth day; and the patient was in all respects
convalescent, the swelling having diminished fully one-half in size.
No untoward symptoms of any kind occurred until the morning of the
twenty-seventh day, when the patient was suddenly seized with intense
pain in the right side of the chest, attended with short, hurried,
and laborious respiration, quick and tense pulse, great anxiety of
countenance, prostration of the vital powers, and _entire subsidence of
the aneurismal tumour_. Being absent from town, he was kindly visited
by my friends, Dr. T. L. Caldwell and Dr. S. B. Richardson, until he
expired, early on the thirty-first day after the operation.
The body, carefully examined after death, was somewhat emaciated;
the wound had completely cicatrised, and the pectoral muscles were a
good deal wasted, though in other respects unchanged. The subclavian
artery terminated abruptly at the outer margin of the scaleni muscle,
where the ligature had been applied, its calibre being closed by a
mass of solid fibrin, about one-third of an inch in length, which
adhered firmly to the lining membrane, and thus presented an effectual
barrier to the passage of the blood. Between this and the thyroid axis
the vessel was occupied by a dark coagulum, which, as it was loose,
was probably formed only a short time before death. Beyond the seat
of the ligature the artery had a rough, ragged appearance, and was
sufficiently pervious to admit of the ready passage of a small probe
into the aneurismal sac. Superiorly the tumour was overlapped by the
brachial plexus, while in front, at its lower part, was the subclavian
vein, which, besides being thrown out of its natural course, was
considerably diminished in size. No pus was anywhere perceptible, the
structures involved in the operation being consolidated by plastic
lymph. The aneurismal tumour, placed immediately below the clavicle,
was of a conical form, and about the volume of a moderate-sized
orange, being two inches and a quarter in diameter at its base. Its
walls varied in thickness at different points, from half a line to
the eighth of an inch; and its interior communicated, by means of an
oval aperture, one inch and three-quarters in length by an inch and
a half in width, with the pleuritic cavity: it was situated between
the first and second ribs, nearly equi-distant between the sternum
and the spine, and was the result obviously of ulcerative absorption
induced by the pressure of the tumour. Both ribs were denuded of their
periosteum immediately around the opening, and the serous membrane had
a shreddy, ragged aspect. The aneurismal sac contained a few reddish
clots arranged in a laminated manner, and closely adherent to its inner
surface, especially at the part corresponding with the apex of the
tumour.
The right thoracic cavity contained nearly three quarts of
bloody-looking serum, intermixed with flakes of lymph and laminated
clots; the latter of which were of a reddish-brown colour, and had
evidently escaped from the aneurismal sac. The pleura exhibited signs
of extensive inflammation; and the right lung was greatly reduced in
volume, from the compression of the effused fluid. The left lung was
considerably engorged, and at one or two points almost hepatized. The
heart and pericardium were sound, as were also the abdominal viscera,
and the larger arterial trunks.
From the description of this operation in the text, it will be seen
that Mr. Liston recommends two incisions, as performed in the above
case. Were I to be again called upon to tie the subclavian artery above
the clavicle, I should certainly omit the vertical incision, from a
conviction that it is altogether unnecessary: it does not expedite the
operation, nor does it facilitate the application of the ligature.—ED.]
[43] [I had occasion last winter to tie the humeral artery, for a
wound inflicted upon it in bleeding at the bend of the arm, in a
youth eighteen years of age, from one of the border counties of this
state. The accident had occurred about six weeks previously with a
thumb-lancet. It was soon followed by great swelling and discoloration
of the limb, which gradually extended downwards nearly to the middle of
the forearm and upwards as far as the axilla. The pain was excessive,
the appetite much impaired, the sleep constantly interrupted, and the
countenance blanched and expressive of great suffering. About the
fourth week a large opening formed at the seat of the original orifice,
from which upwards of a quart of thick grumous blood was discharged.
He was brought to town on the 27th of December, and placed under the
care of my friend, Dr. Drane. At this time his health was frightfully
deranged; his strength was much exhausted; he had not slept for
several nights; and the whole limb, benumbed and excessively painful,
was swollen from the wrist to the shoulder. The parts pitted under
pressure, two small foul-looking ulcers existed at the bend of the arm,
the skin was discoloured, and fluctuation could be distinctly felt all
the way up from below the elbow to the insertion of the deltoid muscle.
With the assistance of Dr. Drane, an incision, five inches in length,
was made over the course of the humeral artery; and after much
difficulty, owing to the confused state of the parts, a ligature was
placed above and below the orifice, which was found to be at least
six lines long! All the grumous blood, amounting to nearly a quart,
was squeezed out, when the edges of the wound were brought together
with adhesive strips and a roller extending from the wrist upwards.
Very little sloughing took place; and, notwithstanding the exhausted
condition of the patient at the time of the operation, he made a very
speedy recovery.—ED.]
[44] [_Encysted tumours_ of the breast containing milk are sometimes
met with. They are commonly produced by closure of one or more
_lactiferous ducts_, either from the effusion of lymph, or some other
accidental formation, or from external pressure. The swelling, which
generally arises during the early months of lactation, may be globular,
ovoidal, or pyriform, and rarely exceeds the size of an orange. It
is almost always attended with a peculiar sense of distention, and
distinctly fluctuates under the finger. On cutting into it the contents
are found to be of a whitish colour, and of the consistence of milk,
cream, or whey; the quantity ranging from a few drachms to several
ounces.
A most singular and instructive case of this disease is reported by
my distinguished friend, Professor Parker, in the _New-York Medical
Gazette_, for January, 1842. The woman, who was thirty years of age,
was the mother of five children, the youngest nine months old, and had
always enjoyed good health. The swelling occupied the right breast,
and was first noticed about three months after her confinement: it was
free from pain, and without tenderness on pressure. The skin was a
little more vascular than in the sound state, the veins were enlarged,
and there was evident fluctuation. The child had nursed from both
breasts. With a trocar, not less than three quarts of milk were drawn
off at one operation! Professor Parker requested the woman to wean her
child, and to return to his _clinique_ in a week. At the expiration of
this period the fluid had reaccumulated to the amount of three pints.
In a fortnight thereafter it was evacuated a third time, but in what
quantity is not stated. Since then, as the professor has recently
informed me, he has not heard from his patient; and it is, therefore,
uncertain how much, if any, she has been benefited by the operations in
the way of a permanent cure.
Small swellings of this kind rarely require any treatment beyond the
application of some stimulating embrocation, to promote the absorption
of the effused fluid. When the accumulation, however, is very large, as
in the case above mentioned, it will be necessary not only to evacuate
the milk, but to obliterate, if possible, the sac. This may be done,
I conceive, either by stimulating injections, such, for example, as
are used for the radical cure of hydrocele, by the introduction of
the seton, or by laying open the tumour, and wearing a tent. In the
former case, which, on the whole, I should prefer, assistance might be
derived from methodical compression. Diminishing the quantity of milk
by weaning the child would be an important preliminary step.—ED.]
[45] [In a case of artificial anus which came under the notice of
the late Dr. Physick, in 1808, relief was afforded by the following
procedure. A crooked needle, armed with a ligature, was passed from
one portion of the intestine to the other through the contiguous
sides, about one inch within their orifices. The ends of the ligature
were then tied with moderate firmness at the external aperture, where
they were left protruding. In this situation it gradually made its
way through the parts which it embraced by ulcerative action, at the
same time that it produced strong adhesion between the two folds of
the bowel. After several weeks had elapsed, Dr. Physick divided with
a bistoury all the parts which now remained included within the noose
of the ligature, thus establishing a direct communication between the
upper and lower extremities of the gut.
Dr. Lotz, of Pennsylvania, succeeded a few years ago in curing a
case of a similar kind, by means of an instrument which possesses
some advantages over that of Dupuytren, and an account of which is
published in the eighteenth volume of the _American Journal of the
Medical Sciences_. It is composed of two blades, each six inches long,
which are worked by two screws, and which terminate in front in two
fenestrated branches, twelve lines in length by three in width. One
blade being inserted into each extremity of the gut, they are carefully
adjusted by tightening the screws, and are thus made to compress the
intervening membranes. The pressure may be increased or diminished at
pleasure. In the case treated by Dr. Lotz, the portion of the bowel
corresponding with the fenestræ was excised with a gum-lancet on the
fourth day from the application of the instrument, and in this manner a
direct passage was created between the two ends of the tube.—ED.]
[46] [When the wounded bowel protrudes, the aperture, unless it be very
small, should be closed either with the continued or the interrupted
suture, and then returned within the abdomen. This procedure is far
preferable to the mechanical contrivances recommended by Reybart,
Denans, and other surgeons; or even to the more ingenious but almost
impracticable method of stitching the intestine, proposed by Mons.
Lembert of Paris. From some experiments, upwards of forty in number,
which I performed upon dogs last summer with a view of more fully
elucidating the subject under consideration, I am led to infer that
it does not matter what kind of suture be employed, provided we use
the precaution of closing the opening so completely as to prevent the
escape of fecal substance. This is undoubtedly the grand principle
which should regulate the conduct of the surgeon in the treatment
of injuries of this nature. Let him guard against fecal effusion,
and the patient will be comparatively safe, or free from the danger
of peritoneal inflammation. To attain this object the continued, or
glover’s suture as it is termed, is unquestionably preferable to any
other, especially when made, as I would suggest it should be, with
a small sewing-needle, armed with fine silk, and passed between the
muscular and mucous coats, or, what is the same thing, through the
substance of the cellulo-fibrous lamella. After the suture has been
applied, the protruded part of the mucous lining, if there be any,
should be pared off with a sharp knife, to facilitate the process of
reparation, the surface of the bowel should be cleansed with tepid
water, and the whole carefully returned into the abdomen. If the
interrupted suture be used, the intervals between each two respective
threads must not exceed two lines, or the sixth of an inch, otherwise
there will be danger of fecal extravasation, and the ends, instead of
being brought out at the external aperture, should be cut off close
to the knots. The reason why I prefer the continued suture, made in
the manner above mentioned, is simply because we can thereby more
effectually close the wound, at the same time that the parts are placed
in the best possible condition for speedy reunion, from the want of
protrusion of the lining membrane, and consequently the more perfect
contact of the serous surfaces.
The ligatures which are employed in sewing up a wounded intestine are
detached at a period varying from ten days to three or four weeks,
according to the nature of the suture. When the extremities are cut off
close to the knots, they invariably fall into the cavity of the bowel,
and are finally discharged along with the feces; if, on the other hand,
they are brought out at the external opening, they pass off in that
direction instead of the one just mentioned.
When the opening in the gut is small, not exceeding three or four lines
in extent, the margins may sometimes be advantageously encircled with
a ligature, with the ends cut off close to the peritoneal surface. Sir
Astley Cooper tied up an aperture in this manner in the human subject,
in a case of strangulated hernia, and the patient recovered without
a bad symptom. Professor Gibson, of the University of Pennsylvania,
states that he has performed a similar operation with similar results.
My experiments on dogs convince me that the plan is a good one. The
ligature should be drawn pretty firmly, to prevent it from slipping,
and the ends must be cut off close to the knot. It generally makes its
way into the bowel in from eight to ten days.
When the bowel is completely severed, or mortified in its entire
calibre, the edges, after being properly prepared, should be brought
in contact, and retained by the continued or the interrupted suture.
Cases of this kind, although apparently desperate, are not always
of so hopeless a character as might at first sight be supposed.
This is shown, not only by experiments on the inferior animals, but
by what occurs in the human subject, in sphacelated hernia, and in
intussusception. In the former, the greater part, or even the whole,
of the circumference of the tube may be destroyed, and yet the
patient ultimately recover, with perhaps the temporary inconvenience
merely of an artificial anus; and in the latter, large pieces are not
unfrequently detached without any serious suffering, save what is
experienced during the antecedent and concomitant inflammation. In my
morbid collection is a preparation of this kind, evidently a portion
of the colon, nearly a foot long, which was discharged by a child six
years old, who, notwithstanding, made a speedy and perfect recovery.
Thirty-five cases of a similar character, collected from the writings
of different pathologists, have been reported by Dr. Thompson of
Europe.[47] In a dog, from which I removed two inches and a half of the
ileum, and treated the edges of the wound with six interrupted sutures,
complete recovery took place, unattended with a single bad symptom.
The threads were introduced at equal distances from each other, with
a small sewing-needle, and the ends cut off close to the knots. Four
months after the operation, being in good health, and the outer wound
entirely healed, he was killed. Externally the bowel was perfectly
smooth and natural, as if no injury had ever been inflicted upon it:
the mucous membrane was of the same appearance as elsewhere, with the
exception of a small depression corresponding with the edges of the
wound.—ED.]
[47] See the Editor’s Elements of Path. Anatomy, vol. ii., p. 260.
[48] [From my own observations and dissections I have long been
convinced that there are two distinct and well marked varieties
of hemorrhoidal tumours; one of which essentially consists in an
enlargement of the capillary vessels of the mucous and submucous
cellular tissue, the other in the formation of a small sac filled with
fluid, coagulated, or organised blood. The latter, situated at the
verge of the anus, or immediately within it, are composed partly of
skin, partly of mucous membrane; they vary in size, from a pea to that
of a small marble, are of a red florid complexion, hard and tender to
the touch, and exquisitely painful when inflamed. The blood which they
contain is at first fluid, but soon coagulates, and ultimately, if
allowed to remain, becomes organised. Hence, in cases of long standing,
the tumour is generally of a hard, gristly consistence, pale, and free
from pain, producing no other than mechanical inconvenience.
In the other variety, the tumour is situated within the bowel, from
six lines to two inches above the external orifice. Consisting, as was
before intimated, in a varicose condition of the capillary vessels,
especially the venous: it is soft and compressible, of a deep purple
colour, extremely liable to bleed, and of various sizes, from a small
bean to that of an almond or upwards. It rarely occurs as an isolated
swelling, but in groups or clusters, as many as six or eight being
sometimes situated upon a surface not more than an inch and a half or
two inches in diameter.—ED.]
[49] [Until recently it was the opinion of surgeons, almost
universally, that the fistula opened into the bowel at the distance of
from two to three inches from the anal outlet; an error which often led
to severe and hazardous operations, by which the unfortunate patient
was sometimes rendered miserable for life. Mons. Ribes of Paris, who
was the first to investigate the subject in a careful and extended
manner, ascertained that the internal orifice is generally situated
immediately above the place where the lining membrane of the rectum
unites with the skin, sometimes a little higher, but _never_ more
than five or six lines. In eighty subjects affected with this malady
it did not exceed this elevation, and in a considerable number it was
not higher than a third or fourth of an inch. In my own operations and
dissections I have rarely found the internal aperture more than a line
or two above the internal sphincter muscle. The observations of the
late Professor Bushe, of New-York, tend to a similar conclusion.—ED.]
[50] [This is undoubtedly the treatment which should always be adopted
in the sacculated variety of the disease, as it is not only free from
danger, but affords the most speedy and effectual relief. If the blood,
upon the presence of which the irritation and swelling mainly depend,
be allowed to remain, it finally becomes organised, and so incorporated
with the walls of the tumour that it is impossible to dispose of it in
any other way than by excising the whole excrescence.—ED.]
[51] [My own experience does certainly not accord, in this instance,
with that of the distinguished author. I can recall to mind at least
six or eight cases, several of them in delicate females in dilapidated
health, in none of which I used less than two ligatures, and in some as
many as three or four, without any serious consequences whatever. When
the tumours are numerous, it can never be necessary to tie more than
three or four at a time, since the inflammation thus induced generally
extends to those around and effects their obliteration. It is always
preferable, indeed, to repeat the operation, than to run the risk of
producing too much irritation.—ED.]
[52] [Much may be accomplished in chronic cases by means of astringent
injections, of which the best perhaps is a solution of alum in a
decoction of oak-bark, in the proportion of two drachms of the one to
a pint of the other. From two to three ounces of this should be thrown
up the rectum twice a day; the bowels being at the same time kept in a
soluble state by gentle laxatives, and the patient compelled to void
his feces in the standing posture. In cases of an inveterate kind,
in which the ordinary remedies prove unavailing, the operation of
Dupuytren, which consists in cutting away some of the radiating folds
of the skin around the anus, generally affords prompt and effectual
relief. When the protruded part is large, it may be necessary to excise
from four to six of these folds, and to prolong the incisions into the
rectum as far as the junction of the skin with the mucous membrane.
The object of this operation is to produce a diminution of the orifice
of the anus, which it does by the cicatrization and contraction of the
little wounds made in the operation.—ED.]
[53] Bushe on the Rectum, p. 220.
[54] [When the pain is considerable the camphorated liniment with
morphia, laudanum, or belladonna, will be of great service. It should
be rubbed upon the scrotum every four or five hours, avoiding of
course injury to the inflamed testicle and epididymis. When the acute
symptoms of the disease have subsided, under the treatment recommended
in the text, the most efficacious practice is compression of the
enlarged organ, by strapping it with the gum and mercurial plaster.
Dr. Fricke of Hamburg pursues this plan in the very commencement of
the inflammation, however severe, with the effect often of curing
his patients in a few days. The plaster should be cut into narrow
strips, not more than half an inch in width, and be applied in a
circular manner round the testicle, which is to be previously drawn
to the bottom of the scrotum. The first piece is to be placed round
the insertion of the cord, just above the epididymis, and after the
whole organ has been thus enveloped, another series of strips is to be
applied from below upwards, to confine the first, and more completely
equalise the pressure. Great care is to be taken not to pucker the
skin, which should be previously divested of hair. “If the pressure of
the plaster occasions pain or irritation, the strips are to be removed
till the inflammation and sensibility are diminished. In many instances
the patient experiences almost immediate relief from the application.”
This remedy, which has been recently claimed by a European writer
as new, appears to have been employed, with marked success, in the
Pennsylvania Hospital, in the early part of the present century.—ED.]
[55] The principal objection to this method is, that it is not always
successful, and that it requires, in some cases, to be repeated again
and again before a sufficient amount of adhesive action is induced to
obliterate the vaginal sac. Moreover, by carelessness on the part of
the surgeon, the canula may slip out of the vaginal sac, and so allow
the fluid to pass into the cellular substance of the scrotum, where, if
it be not speedily evacuated by free incisions, it is sure to occasion
gangrene. But this is not all. The operation, even when well performed,
is sometimes followed by violent inflammation and suppuration; in one
instance, indeed, I knew it to be productive of tetanus. The patient,
a stout, robust mechanic, about twenty-six years of age, whom I saw
twice in consultation, was doing apparently well during the first eight
days after the operation; when, owing to exposure to cold, the symptoms
of the disease in question manifested themselves, and in less than
twenty-four hours the man expired. Upon examination after death, the
vaginal tunic was found to be considerably thickened, and its cavity
to contain several ounces of sero-sanguinolent fluid, intermixed with
a small quantity of unhealthy-looking pus. No adhesions had taken
place between the opposite sides of the sac. A case of a similar kind
is alluded to by Sir George Ballinggall, in his “Outlines of Military
Surgery.”
The operation by injection has, I know, many advocates, both in this
country and in Europe; and, when well executed, is generally unattended
with risk, if not always successful. The fact, however, that it
may be followed by serious mischief, with occasional loss of life,
should be sufficient to deter the practitioner from resorting to it,
more especially when we reflect that we are in possession of another
remedy, not only entirely devoid of danger, but always, so far as my
observation extends, most effective. This remedy is the seton, which I
have been in the habit of employing, in repeated instances, for some
years past, and from which I have never experienced any other than the
most happy results. The operation is perfectly simple, the amount of
inflammation produced by the presence of the foreign body may be easily
regulated, and there is no danger of sloughing of the scrotum, much
less of the development of tetanus, or other mischief.