SURGERY, rich as it is in sound information, well-established facts, and plans and means for the relief and cure of numberless injuries and diseases, to which the human body is liable, cannot be presumed to have yet reached all the perfection and efficiency of which it is susceptible. Were any doubt entertained upon this point, it would be immediately dispelled by the consideration, that scarcely a year passes away without new and improved modes of practice being suggested, and receiving the sanction of impartial experience. Besides, who can pretend yet to understand every thing relative to a long list of very difficult subjects which enter into the surgical department of the healing art; as, for instance, inflammation, suppuration, cancer, syphilis, scrofula, &c. &c.? Many questions, connected with these and numerous other affections, still remain in the deepest obscurity, presenting an extensive field, in which the diligent and faithful observer may gather immortal fame for himself, and confer infinite and lasting benefit upon the rest of mankind. The great deal that has been done for the advancement of surgery, in the course of the last fifty years, ought to furnish the assurance that much more will be done for its improvement in the half-century that is to come; particularly when the zeal, the emulation, and the ardent love of truth, now presiding over every useful scientific inquiry, are duly contemplated. The design of the present article is, to collect and place before the reader a few of the most interesting novelties in surgery; comprising those which have been produced subsequently to the period when the article upon this subject in the Encyclopædia was composed, and others which, though known earlier, escaped notice in that article. In performing this task, we shall take up the subjects in the order in which they present themselves in the original article, to which this is meant to be a supplement.
The first topic that seems to us to admit of a few additional remarks is that of encysted tumours, or wens, as they are popularly called. Though tumours and excrescences of various kinds form one of the most frequent classes of diseases, and, what is more, though they often afford convincing illustrations of the efficacy of surgery, the exact causes and manner of their origin cannot be said to have received hitherto any very successful elucidation. In the article referred to, some notice is taken of the interesting opinions of Bichat respecting the production of encysted tumours; and of his refutation of a common notion, that they are not new formed parts, but only dilated cells of the cellular membrane. At the same time, his own particular belief is mentioned, that their formation more probably depends upon laws, which regulate the growth of the different parts of our bodies; which laws, however, not being known and comprehended, leave us as much in the dark respecting the matter in question as if no reference to them had been made. But, what particularly claims
our attention here, is the great analogy which Bichat finds between the cysts of encysted tumours and serous membranes; because, if such analogy prevail, it is a strong fact against the correctness of an explanation of the origin of encysted tumours, lately promulgated in this country. Bichat says,—"The cysts, like serous membranes, form a species of sac, without an opening; they contain the fluid which they exhale, and they have a smooth and polished surface contiguous to the fluid, whilst the other surface is unequal, and connected with the adjacent cellular membrane." Now, this account is singularly at variance with the doctrine that has been recently proposed by an English surgeon of the highest reputation; who, in his description of the nature of encysted tumours, at least of those which are so frequently seen upon the head, face, and back, and sometimes under the skin of other parts of the body; instead of regarding the cysts as at all analogous to serous membranes, represents them as dilated cutaneous follicles, lined with cuticle, and, of course, partaking rather of the character of mucous membranes. Speaking of the origin of encysted tumours, Sir Astley Cooper expresses his conviction, that it depends upon "a follicle extremely enlarged, and incapable of discharging its contents, from an obstruction of the orifice by which it opens upon the surface of the skin." Then, adverting to the nature of follicles, he observes, that, upon superficial examination, they appear to be only pores in the skin; but that, when a small probe is introduced into them, they are found to proceed through the skin into the subjacent cellular membrane. "The first circumstance (says he) which induced me to believe that an encysted tumour was an obstructed follicle, was examining a tumour of this kind situated upon my own back. It had acquired a diameter of about two inches, and was situated at the lower part of the dorsal vertebrae. I thought of requesting a friend to remove it, but, on examining it by means of two mirrors, I saw a small black spot in the centre of the swelling, and by pricking this, I extracted a piece of sebaceous matter with a black head, like those seen in the follicles of the nose. I then squeezed the tumour, and through the orifice occupied by the black sebaceous matter, I emptied the tumour by squeezing out a large quantity of sebaceous substance. This was effected without pain, and without succeeding inflammation; but, gradually, the secretion became renewed; by frequent pressure, however, I have now for several years kept it empty, although the bag and its orifice still remain. A lady applied to me with one of these swellings upon her shoulder. It had a small black spot upon its centre, through which I could squeeze its curd-like contents. I removed it with the skin over it, and found that the opening was a follicle leading into the hollow of an encysted tumour, which contained sebaceous matter, was lined with cuticle, and had a cyst of the usual cha-
character. Often have I seen the follicular aperture over these swellings, by which the point of a tent-probe was readily admitted into the cavity of the cyst, and through which I could immediately squeeze its contents. The follicle is, however, generally obstructed at its orifice, and a depression only is seen (and not always even this) when the sides of the swellings are compressed." (Surgical Essays, Part II. p. 236.)
This experienced surgeon conceives, that an encysted tumour begins in the following way: a follicle becomes obstructed at its termination upon the skin, and the secretion, still proceeding, its sides are extended in the cellular membrane wherever this most readily yields. If it be inquired, how it is possible for a follicle to be thus extended, the answer is, that other membranes expand to a much greater comparative size. An ovary, that would not contain within its membrane more than two drachms of water, will expand to a magnitude capable of holding nearly a hundred. The same author also considers pressure, and a want of moisture in a diseased state of the secretions, as occasional causes of encysted tumours. When we first perused Sir Astley Cooper's explanation of the formation of these swellings, a difficulty presented itself to the admission of the doctrine, on account of many encysted tumours being found in situations, where any suspicion of their connection with the follicles of the skin cannot for a moment be entertained. Upon referring to his essay upon the subject, however, we find, that his observations are meant to apply only to the kind of encysted tumour, which is situated just under the skin, and that he acknowledges different species of these swellings. Such difficulty is obviated, therefore, in the particular cases spoken of by this gentleman, as far as the consideration goes upon which it was founded; yet, for various other reasons, the doctrine is not to us, by any means, satisfactory; and it may even be doubted, whether the same mistake may not here have been made respecting the enlarged follicle, as surgeons once made about the dilated cell of the cellular membrane. That there is a particular class of encysted tumours, having upon their centre a minute dark spot, through which a small probe can be introduced into them, is a fact, which Sir Astley has most correctly described, and he is entitled to the credit of having first made this original observation; but it does not follow, that because there is such a dark spot, or even an aperture, that it must be that of a cutaneous follicle. With respect to the sebaceous substance said to have been pressed out of the opening, some experiments would also be requisite to determine whether it were actually of the same nature as the secretion of the cutaneous follicles. Nor does the occasional presence of cuticle in the cyst prove the truth of the doctrine advanced; because, in the formation of wens, nature presents unaccountable irregularities, sometimes producing in the cyst a substance resembling cuticle, sometimes hair, and, in a few instances, even teeth. The inner surface of almost all the encysted tumours that we have examined, corresponded rather to that of a serous membrane, as explained by Bichat. If en-
cysted tumours arose in the mechanical way, above specified, we should expect them not only to be a much more frequent disease, than they actually are, inasmuch as the cutaneous pores are innumerable, and must very often be obstructed, as we see happen on the nose; but, when the disease is formed, we should expect its cure by the simple removal of the stoppage would be more commonly practicable, than experience shows. Even in the cases which take place near the eye-lids, and have an opening, out of which the contents may be completely pressed, a cure will not follow, unless the cyst be removed. These reflections, at all events, tend to the conclusion, that there must be some other important cause concerned in the production of encysted tumours, besides the mere obstruction of the cutaneous follicles. As the subject, however, is yet obscure, and the new observations upon it come from so high an authority, we have deemed it our duty not to pass them over in silence.
The following practice is adopted by Sir Astley Cooper: If the follicle can be seen only as a black spot, filled with hardened sebaceous matter, a probe is passed through it, and the sebaceous matter squeezed out of the tumour, which may be done with little inconvenience. But, when the contents cannot be pressed out without violence, the preference is given to the plan of enlarging the opening, in order to avoid bringing on inflammation. When an encysted tumour is to be removed, the plan of first making an incision into it is preferred; and the sides of the skin are then pressed together, by which means the cyst, it is said, may be easily everted and removed. This way of operating was recommended for particular cases in the Encyclopædia; but doubts may be entertained concerning the advantages of the plan as a general practice.
The removal of encysted tumours is not altogether unattended with danger: Sir Astley Cooper has seen three instances of severe erysipelatus inflammation after operations of this kind upon the head, and one of them ended fatally; one or two other cases, equally unfortunate, have also been reported to us.
In the history of encysted tumours, the curious circumstance of the occasional growth of horny excrescences upon the human body deserves to be noticed: recent investigations prove, that the horny matter is, in fact, the secretion of the cysts of some of these tumours out of which it protrudes, and assumes various shapes, sometimes even that of a ram's horn, as happened in the remarkable case mentioned by Dr Roots of Kingston. This is a subject which has been particularly considered by Sir Everard Home, in the Philosophical Transactions for 1791. The case that fell under the observation of Dr Roots may be perused in the Article Horny Excrescence, in Dr Rees's Cyclopædia. Such horns will be reproduced, if care be not taken in the operation to cut away every particle of the cyst.
On the subject of erysipelas, the remarks of Mr Of Erysipe. Hutchison claim attention: he has found seafaring men particularly liable to phlegmonous erysipelas of the legs, frequently occasioned, as he supposes, by the exposure of these parts to the irritation of salt
water, and the friction of coarse trowsers. In such patients, the disease is said to proceed with extraordinary rapidity to the gangrenous state. Even when mortification is prevented, large abscesses very often form, and spread to a surprising distance between the muscles and under the skin. Now, according to Mr Hutchison's experience, the best way of hindering all these evils, is to make several free incisions into the inflamed surface as early in the disease as possible, the knife being carried through the integuments and down to the muscles. We fear many practitioners will consider this practice severe, more so, perhaps, than circumstances can ever justify in as early a stage as the author speaks of; because, at this period, who can predict, that the case will ever be serious enough to require the employment of the knife? However, as Mr Hutchison never had any unfortunate cases after he adopted the preceding method, and the contrary used to happen under the other plans, which he was formerly in the habit of trying, the proposal appears to deserve mature consideration.
In most works on surgery, little valuable practical information is to be met with respecting the best local applications for erysipelas; the sentiments of the late Dr Bateman, therefore, concerning this unsettled part of practice, may here not be unacceptable. In the early stage of the disease, Dr Bateman found powdery substances, like flour, starch, chalk, &c. increase the heat and irritation, by forming, with the concreted fluid, hard crusts upon the tender surface. In this gentleman's opinion, the only unobjectionable plan is that formerly advised by Dr Willan, which consists in fomenting, or washing the parts, from time to time, with milk, bran and water, or a decoction of elder-flowers. Great benefit is stated to result from tepid bathing, and sometimes from the application of the diluted liquor ammoniacæ acetatis.
With regard to the complaint termed gonorrhœa, it seems right just to notice a medicine that has been of late very much employed, and frequently with great benefit. Cubebs, a spice brought from China and Java, is the remedy here spoken of; it has been recommended (no doubt in terms rather too high) as a specific for gonorrhœa, equally proper in the early inflammatory stage, and in the later chronic form of the disease. The dose is a dessert spoonful of the powder, an hour before breakfast, a second six hours afterwards, and a third at bed-time. The powder is to be taken in water. If given while the discharge is copious, and the inflammation severe, the painful symptoms, it is asserted, will be removed in two days, and the discharge will generally cease on the third or fourth day. The antiphlogistic regimen is to be observed, and the powder continued a day or two after the stoppage of the discharge. (See Edin. Med. and Surgical Journ. Jan. 1819, p. 61, &c.) Cubebs appears to act upon the mucous membrane of the urethra very similarly to the balsam of copaiva, or turpentine medicines; that is to say, through the medium of the urine, to which it communicates particular qualities, and, amongst them, a powerful smell; its operation, however, is certain-
ly more potent, than that of the above mentioned Surgery. balsam, and, on this account, it may be sometimes more effectual.
As a supplement to the observations on strictures of the urethra, a short account of the manner of the Urethra. using bougies, armed with caustic potassa, as introduced into practice by the late Mr Whately, may not be uninteresting; and to the same subject we mean to annex a brief description of the way, in which a passage is sometimes forced through bad strictures by means of a catheter of a conical shape; as done at the present day by some surgeons of considerable eminence, particularly in France.
Our reason for introducing an account of Mr Whately's plan of treating strictures, is not that the practice seems to us by any means entitled to the reputation which it acquired, but because there are some surgeons, whose judgment and talents we respect, who think more highly of such treatment, than we could ever yet venture to do ourselves. Mr Whately regarded strictures of the urethra, not merely as contractions, but as really diseased portions of the membrane lining that canal, with a continued disposition to increased contraction. Hence, he conceived, that the remedy should be calculated both to remove the diseased affection, and to dilate the contracted part, without putting the patient to the inconvenience of wearing a bougie. Such a remedy he deemed caustic, when employed with skill and judgment. That to which he gave the preference was the caustic potassa, applied in a particular manner, as being, according to his description, more efficacious, and less painful and hazardous, than bougies armed with lunar caustic.
The following is the practice detailed and recommended by Mr Whately: Before the caustic potassa is used, the urethra should be rendered sufficiently capacious to let a bougie, rather above the smallest size, pass into the bladder, and the irritability of the strictures, if very considerable, should be lessened, in the first instance, by the use of common bougies.
A small quantity of the caustic potassa is to be put upon a piece of paper, and broken with a hammer into small pieces of about the size of large and small pins' heads. When thus broken, it is to be preserved for use in a phial closed with a ground stopper. A suitable curvature is to be communicated to the bougie, by drawing it several times between the forefinger and thumb of the left hand, and it ought to be just large enough to enter the stricture with some degree of tightness. It is to be gently introduced into the urethra, and when its point stops at the stricture, a notch is to be made on the upper portion of the bougie, precisely half an inch from the extremity of the penis. As soon as the bougie has been withdrawn again, a small hole, described as about the sixteenth part of an inch deep, is to be made in its rounded end. Then a bit of the caustic, less than the smallest pin's head, is to be selected for the first application. It is to be fixed in the hole of the bougie with a pocket knife, and pushed into it with the blunt end of a pin, rather below its margin. In order to hinder the caustic from slipping out, the hole is next to be contracted a little with the finger,
Surgery. and the remaining vacancy filled with hog's lard. The bougie, after being oiled, is to be introduced with its concavity upwards, as far as the anterior part of the stricture, the situation of which has been previously ascertained, and the bougie marked, as already noticed. The instrument should rest there a few seconds, for the purpose of letting the dissolution of the caustic begin to take place; it is then to be very gently pushed towards the bladder, about one-eighth of an inch, when it is again to be kept quiet for a second or two. The bougie is now to be introduced further, in the same gentle manner, until it reaches beyond the stricture. The next business is to withdraw it immediately, by a very gentle motion, to the part at which it was made to rest awhile. Then it is to be very slowly passed through the stricture a second time, but not allowed to stop in its passage. If pain or faintness arise, the operation is now to end, and the bougie to be removed; but if no such consequences occur, the instrument is to be moved backwards and forwards once or twice more.
The foregoing process is to be repeated once every seven days, and if the stricture be found to be dilated, the size of the bougie must be increased accordingly. This method of treating strictures having attained some celebrity, we deemed it worthy of brief notice in the present Work; but our experience leads us to regard the practice as very inferior to that executed with other armed bougies: to the particle of potassa, indeed, we can impute little certain effect, dissolved and blended as it may or may not be with the oil on the end of the bougie, and the mucus of the passage. Its regulation also, in the precise manner described by Mr Whately, so that it may operate exactly on the diseased portion of the urethra, and not upon the sound part, appears to us rather visionary, than really performed. How, then, has the method succeeded at all? Our answer would be, that it has effected cures principally by means of the mechanical dilatation of the bougies, without the potassa having any effect, or at least any that is not much more likely to do harm than good. The practice seems already to be on the decline,—a fact confirming the judgment here delivered concerning it.
We quit Mr Whately's suggestion to make a few observations upon another modern proposal relating to the cure of strictures. Every body, at all acquainted with the history of this disease, knows, that, in France, the use of armed bougies of any kind never met with much approbation, having been there, for the most part, represented as a very dangerous and harsh remedy. Yet, who would have anticipated in this same country, where caustic is abused on the principle of its being a harsh mode of treatment, the origin of another method of cure, in which every thing is to be completed by actual force? Mr Cross, a surgeon at Norwich, who visited the medical schools at Paris for the express purpose of ascertaining the state of the practice of surgery in France at the present day, gives a relation of what he saw there in reference to the treatment of strictures. He informs us, that, when he first went to La Charité, there were fifty-three male patients in the surgical ward, amongst whom were five with strictures of the ure-
thra. The caustic bougie, he says, is not used in any of the hospitals, and it was censured by all the surgeons whom he conversed with, as a perilous and harsh remedy. Mr Cross justly observes, however, that the Parisian method of treating many cases of stricture is not milder than the use of caustic. A case is then detailed, which this gentleman saw in La Charité. A man, who had had a permanent stricture a long while, had been repeatedly under surgical treatment for it. There was difficulty of making water, but not complete retention. For several days, unsuccessful attempts were made to pass an instrument into the bladder by gentle means. The patient was still able to void his urine, although with great pain and difficulty. M. Roux, the surgeon, now took a conical silver catheter, with a very slight curvature, and an almost pointed extremity, and by means of force, regularly applied, he passed the instrument into the bladder, notwithstanding all obstacles. Care was taken to keep the catheter in a central position, and the direction of its point was judged of by the lateral rings. The rule, laid down by M. Roux, for commencing the great depression of the outer end of the catheter was, when he could feel, by means of his finger in the rectum, that the point had reached the apex of the prostate gland. The patient was put to considerable pain; but the instrument really went into the bladder. The urine was not allowed to flow out immediately, the outer orifice of the catheter being stopped up with a bit of wood. In general, M. Roux suffers the conical catheter to remain in the urethra three or four days; but, the sufferings of this patient from it were so intolerable, that it was taken out in twenty-four hours. Rather a large elastic gum-catheter was then easily introduced, the end of which was fastened to the abdomen, while the orifice was closed with a stopper, and the urine permitted to flow occasionally. The next day, the patient was comparatively easy. On the fourth day, there was a swelling of the testicle, scrotum, and perineum. A poultice was applied, and the elastic catheter continued. In four days more, the swelling of the parts had subsided so considerably, that the poultice was unnecessary. A fresh gum-catheter of large size was now used, and, in about six weeks, one of the largest dimensions could be introduced.
The event of another case was less fortunate: The sonde conique had been employed for making a passage into the bladder, and a gum-catheter afterwards introduced; but, in less than a week, the patient, supposing he could make water without its assistance, withdrew it of his own accord. The next day, an effusion of urine in the scrotum had taken place, and it became necessary to let out the extravasated fluid by two free incisions. Unfortunately, the elastic catheter could not be introduced again. The incisions did indeed prevent sloughing of the scrotum; but the patient, who was in a very reduced state, died in a few days. It is but fair to add, that this case was so inveterate, that Mr Cross believes the patient would have sunk under any mode of treatment. On dissection, the bladder was found to be half an inch thick, the stricture cartilaginous, and extensive sinuses were traced, communicating with the once membranous part of the urethra.
The promptitude with which relief may be afforded in some very bad cases of stricture, where no bougie, nor elastic catheter, can be introduced, is the reason given for the foregoing practice; and M. Roux even assured Mr Cross, that he had never seen any inflammation or irritation produced by it, that did not readily yield to proper means. We suspect, however, that, by this declaration, M. Roux meant to refer all disastrous circumstances to the disease, when they happened, so as to screen the mode of treatment from all suspicion of being sometimes itself a source of dangerous consequences. Yet, we cannot understand, how he could hope to produce an universal conviction of the accuracy of such an insinuation; because, in his Clinical Lectures, he spoke of two fatal cases, which he dissected, where he found false passages, extravasation of urine, sloughing, &c. amongst other mischief. On the whole, without pronouncing this forcible use of catheters to be always bad practice, we shall venture to say, that it is generally so, and ought very seldom to be attempted. M. Ducamp, an intelligent writer on the present subject, differs altogether from some of his countrymen, by whom the treatment has been carried to a high degree of absurdity. "Surgeons (says he), who are ambitious of the title of operators, despise the slow progress and minute attention which the bougies require; nothing but what is prompt, great, and striking, is agreeable to their taste; they thrust a silver catheter through every obstacle into the bladder: at the end of three or four days, they exchange it for one of elastic gum; this last they withdraw every eighth or tenth day, and this they call practising good surgery on a grand scale!" The result is, in general, that a false passage is established, and inflammation of the urethra and prostate is produced by the presence of the instrument. In short, Ducamp clearly shows, from the nature of the stricture itself, that the operation, even when the instrument does not wander from the urethra, does not depend upon dilating the stricture, but upon tearing it; and as the stricture is more resistant than the rest of the canal, the chance is, that a false passage is made.
Having mentioned M. Ducamp, we shall not quit him without recommending to the attention of surgeons, his ingenious contrivances for the application of the lunar caustic to strictures; contrivances which are meant to regulate the action of the caustic more precisely than in the common mode: indeed, the whole of his work deserves, to be consulted. See Traité des Retentions d'Urine, causées par le Rétrécissement de l'Urethre, et des moyens à l'aide desquels on peut détruire complètement les Obstructions de ce Canal, Paris, 1822, 8vo.
While we are upon the subject of strictures, Mr Arnott's dilator occurs to us as a very ingenious instrument deserving to be mentioned, though we are not exactly acquainted with the degree in which it has yet been found to answer in practice. It was conceived, that, for the purpose of dilating strictures, an instrument was needed, calculated to pass through the obstruction with facility, then to admit of its diameter being increased to any size, and with any force, yet, when the surgeon wishes to extract it, to
be capable of being reduced to its primitive smallness. The dilator consists of a tube of oiled silk, lined with the thin gut of some small animal to render it air-tight, and then fixed upon the end of a small canula, by means of which it can be distended with air or water from a bag, or syringe at the outer end, while a stop-cock or valve serves to confine the air after it has been received. It is said generally to pass as easily down to the stricture as a small bougie; but Mr Arnott sometimes prefers introducing it through a smooth canula, especially when the urethra is irritable, and unaccustomed to the presence of instruments. As soon as the bag is sufficiently within the stricture or strictures, as much air as the patient can easily bear is to be injected into it. The dilator, it is asserted, can be made to act with more effect than a bougie, which, as soon as it yields, loses its power of distention, while the force of the dilator is concentrated at the stricture, and unceasing. In principle, it resembles Bromfield's contrivance for dilating the meatus urinarius.
Here the subject of diseases of the urinary passages must not be quitted, without mention being made of the success with which Mr Earle formed a canal, which answered perfectly as a substitute for a considerable portion of the urethra that had been destroyed. The details of this case, which appear to us very interesting, may be perused in the Phil. Trans. for 1821.
To what is delivered concerning hydrocele, in the Of Hydrocele. Encyclopædia, a few new and useful observations may be annexed. Since the article on Surgery in that work was written, Professor Scarpa has laid down in his valuable treatise upon Hernia some cautions, highly necessary to be recollected by surgeons in the operation of tapping a hydrocele. The analogy, existing between large scrotal hernie and hydroceles of considerable size, led Scarpa to suspect, that, in the latter disease, a displacement and separation of the vessels of the spermatic chord from each other might also happen. Careful investigations, afterwards made upon the dead subject, fully justified the conjecture. In fact, in all considerable hydroceles, he found the spermatic vessels so displaced and separated, that the artery and vas deferens were commonly situated upon one side of the tumour, and the veins upon the other. Sometimes all these vessels extended over the lateral parts of the tumour, as far as its fore part, principally towards the bottom of the swelling. Now, in numerous examples, the operation of puncturing a hydrocele has been followed by copious extravasation of blood within the tunica vaginalis; but, it was not until within the last few years that Scarpa became acquainted with a case of this kind, sufficiently well detailed and authentic to be quoted as an instance of the spermatic artery being wounded in the operation. Such a fact, however, was at length communicated to him by Gasparoli, an eminent surgeon at Pallanza; who, in introducing the trocar into the lower part of the swelling, wounded the spermatic artery, and the accident terminated in the patient's being obliged to submit to castration. As Scarpa justly observes, the accident may be avoided by taking care to puncture the tumour at a considerable distance from its bottom, that is to say, a little below
Surgery. its middle, and on a line that would divide the swelling longitudinally into two perfectly equal parts. Experience proves, that, for the purpose of completely emptying a hydrocele, there is not the slightest occasion to make the opening at the lower part of the swelling: the natural corrugation of the scrotum, and a little pressure made with the hand, will suffice for discharging all the fluid contained in the tunica vaginalis, even though the puncture be not lower than the middle of the tumour. These remarks upon the proper method of tapping hydroceles, which are amongst the most frequent cases in surgery, cannot fail to be highly interesting to every practical surgeon, and both on this account, and because they are modern, and perhaps not yet sufficiently known and understood, a short notice of them here appeared to us desirable.
The old method of curing hydroceles by the excision of a portion of the scrotum, and the greater part of the tunica vaginalis, has been very properly rejected from practice; as being an operation of an unnecessarily painful nature, liable to many severe ill consequences. This remark, however, should not be extended to the mode of excision, proposed a few years ago, and practised with success by Mr Kinder Wood: it is indeed a very different proceeding from that which was anciently adopted, inasmuch as it is perhaps the mildest of every plan hitherto devised for the radical cure of this disease, as it simply consists in puncturing the hydrocele with an abscess-lancet, drawing out a little piece of the sac with a tenaculum, and cutting it off. (See Med. Chir. Trans. Vol. IX.) If it prove as little subject to failure as the mode of cure by means of an injection, a point yet remaining to be settled in the extensive field of experience, we should say, that Mr Kinder Wood's simple and mild operation is as good a practice as any that has yet been suggested, with reference to the present disease. To us it seems not barely a transient novelty in surgery, but a proposal that may become a solid and lasting improvement.
The cure of an encysted hydrocele of the spermatic chord with an injection, is generally considered by modern surgeons less certain and advantageous, than the excision of a part of the cyst. That judicious and excellent practical surgeon, the late Mr Hey of Leeds, has left some useful observations upon this subject, though he does not appear to be aware, that his method of curing encysted hydroceles of the spermatic chord is substantially the same as that long ago recommended by Bertrand: it consists in cutting down to the cyst, and removing the fore-part of it, while the portion, closely attached to the cord, is not at all interfered with, by which means, all hazard of doing injury to the spermatic vessels is avoided, and the operation itself shortened.
Diseases of the Synovial Membrane. The next subject, on which we shall have to dwell a little, is that treated of in the article referred to, under the head of Diseases of the Synovial Membranes. From the observations of Mr Brodie, it appears, that the usual consequences of inflammation of the synovial membrane, or capsular ligament of a joint, are, first, a preternatural secretion of synovia; secondly, an effusion of coagulating lymph into the cavity of the joint; thirdly, a thickening of the syno-
Surgery. vial membrane, a conversion of it into a substance resembling gristle, and an effusion of coagulating lymph, and probably of serum, into the cellular substance, by which it is connected to the external parts. Mr Brodie has met with several cases, where, from the appearance of the joint and the symptoms, there was every reason to believe, that the inflammation had produced adhesions of the reflected fold of membrane, and in dissection, he has sometimes noticed adhesions, which might have arisen from inflammation at some former period. These effects of inflammation of the synovial membrane, he conceives, bear a strong resemblance to those of inflammation of serous membranes. There are, however, some points of difference. In the former, Mr Brodie thinks, that suppuration rarely takes place independently of ulceration, while, in the latter, this is a frequent occurrence. Some cases have fallen under this gentleman's notice, where there was extensive destruction of the cartilages, apparently in consequence of neglected inflammation of the synovial membrane; but, he believes, that, in most cases, where ulceration of the cartilage is combined with such inflammation, the former is the primary affection, and the latter takes place subsequently, in consequence of the formation of an abscess within the joint. According to the same writer, original inflammation of a synovial membrane seldom happens in young children; but is frequent in adult persons;—the reverse of what takes place in some other diseases of the joints.
Synovial inflammation frequently becomes chronic, and is then liable to be confounded with other more formidable diseases, under the general name of white swelling. The complaint is described by Mr Brodie as frequently proceeding from cold, and being on this account more common in the knee and ankle, than in the hip or shoulder. It may also arise from the immoderate use of mercury, and, in particular constitutions, from rheumatism and general debility. In such examples, it often leaves one joint, and attacks another; and it is less severe, and less disposed to produce an effusion of coagulating lymph, or a thickening of the membrane, than when apparently a local disease. In this last case, the disorder is more likely to assume a severe character, and may be of long duration, leaving the joint more or less impaired, and sometimes ending in its total destruction. The following are represented by Mr Brodie as the chief symptoms of inflammation of the synovial membrane: Though, in the beginning, some pain is felt over the whole joint, the patient complains principally of one point, and generally a week or ten days pass, before the suffering attains its greatest severity. Sometimes, even at this period, the pain is trifling; but, frequently, it is considerable, and every motion of the joint distressing. In a day or two after the commencement of the pain, the joint swells, the enlargement arising at first entirely from fluid within the capsular ligament, and where the joints are not covered by much flesh, an undulation may be distinguished. After the inflammation has lasted some time, however, the fluid becomes less perceptible, either in consequence of the synovial membrane being thickened, or lymph effused; and the more solid the swelling is, the more is the mobility of the joint impaired.
The shape of the diseased joint does not correspond to that of the heads of the bones; but, as the swelling is chiefly produced by the distention of the synovial membrane, its figure depends in a great measure upon the situation of the ligaments and tendons, which resist it in certain directions, and allow it to take place in others. Thus, when the knee is affected, the swelling is principally observable on the anterior and lower part of the thigh, where there is only a yielding cellular structure between the extensor muscles and the bone. It is also frequently considerable in the spaces between the ligament of the patella and the lateral ligaments, because at these points the fatty substance is propelled outwards by the fluid. In the elbow, the swelling occurs principally above the olecranon, under the extensor muscles of the fore-arm; and in the ankle, it is between the lateral ligaments and the tendons in front of the joint. In the hip and shoulder, where the disease is not so common, the fluid cannot be felt; but the swelling may be perceived through the muscles. In the beginning of this disease in the hip, a fulness both in the groin and nates may be remarked; but afterwards, the nates become flattened, and the glutei waste away, from want of exercise. The pain is usually confined to the hip; but Mr Brodie has seen cases, in which it was also referred to the knee. The disease may be discriminated from the case, in which the cartilages of the hip are ulcerated, by observing that the pain is more severe in the beginning than in the advanced stage of the complaint; it never amounts to the excruciating sensation felt in the other disease; and it is aggravated by motion, but not by pressing the cartilaginous surfaces against each other. The wasting of the glutei is also preceded by a fulness of the nates. After the subsidence of the inflammation, the fluid is absorbed, and the joint frequently recovers its natural figure and mobility; but, in the majority of cases, some stiffness and swelling remain, and the patient continues very liable to relapse, the pain returning and swelling increasing, whenever the patient exposes himself to cold, or exercises the limb much. When the synovial membrane is thickened, a slow inflammation sometimes continues in the part, notwithstanding the absorption of the fluid, and the subsidence of the principal swelling, the disease at length extending to the cartilages, suppuration taking place, and the articular surfaces being completely destroyed. In this advanced stage, the history of the disease, and not its present appearance, is the only thing, by which one can learn, whether the primary affection was inflammation of the synovial membrane, or ulceration of the cartilages. (See Brodie's Pathological and Surg. Obs. p. 21, &c.)
In cases where inflammation of the synovial membrane has arisen from an ill managed, or a tedious course of mercury, this gentleman recommends a trial of sarsaparilla; and, when it is connected with rheumatism, the medicines praised are opium with diaphoretics, preparations of colchicum autumnale, and other remedies usually prescribed in cases of rheumatism. When several joints have been affected, however, he has known benefit result from moderate doses of mercury.
We need not here enter into a description of the treatment of the acute stage of synovial inflammation; as soon as this is over, the surgeon's aim should be, to remove the thickened state of the capsular ligament; the rigidity of the joint; the pain on motion; the fluid remaining within the capsule, &c. The inflammation having abated, a blister may be applied, and kept open with the sative cerate, or a succession of blisters kept up, as preferred by Mr Brodie. The blisters, he says, should be of considerable size; and, if the joint be deep-seated, they may be applied as near it as possible, but otherwise, at a little distance. Mr Brodie thinks blisters have more effect, than any other means, in removing the swelling; but, excepting in very slight cases, he very rightly condemns their use, unprecedented by bleeding. After the inflammation has sufficiently subsided, exercise of the joint, and stimulating liniments, are recommended. The camphor liniment is to be strengthened with the addition of liquor ammoniacæ, or tinctura lyttæ. A very good liniment, much employed by the same practitioner, consists of three parts of olive oil, and of one of sulphuric acid. Mr Brodie has also a favourable opinion of the effects of the antimonial ointment. Plasters of gum ammoniacæ, he considers, as sometimes useful in preventing relapse. Issues and setons are said to be never serviceable, unless the cartilages are ulcerated. For the removal of the remains of the swelling and stiffness, friction and exercise are set down as the best means. The friction may be made with camphorated mercurial ointment, or with powdered starch; but it is to be adopted with caution, as otherwise it may produce a return of the inflammation. When this is the case, it must be left off, and blood taken from the part. On the whole, Mr Brodie seems to regard friction as more calculated for cases where the stiffness depends upon the state of the external parts, than for others, where it arises from disease in the joint itself. The plan of letting a column of warm water fall on the part is allowed to be sometimes beneficial; but it requires the same caution as friction.
In the article in the Encyclopædia, some account is given of the moveable bodies occasionally found within the synovial capsules, and the method of cure by an operation is mentioned. This practice, though generally successful, has sometimes brought on severe, and even fatal consequences. Hence, in addition to the observations made upon this subject in the above article, it seems right to state, that the plan of fixing and making pressure on the cartilaginous body has been tried by various surgeons of considerable eminence, as a means of relief. Here we shall only mention the late Mr Hey of Leeds, as an advocate for such practice. Duly impressed with the unfortunate event of some attempts that have been made to cure the disease by the extraction of loose cartilaginous substances from the knee-joint, this judicious practical surgeon preferred trying what relief might be obtained by the employment of a laced knee-cap; and the cases which he has published tend to prove that the plan answers extremely well, the benefit not being temporary, but lasting at least as long as the patient continues the bandage. One of Boyer's patients used a knee-cap a year, at the end of which it
Surgery. was discontinued, and the patient remained free from inconvenience. This practice appears to us to deserve notice, as a safer, though perhaps a less certain plan of relief, than the operation of extracting the substances which are the cause of annoyance.
Spina Bifida. With regard to spina bifida, treated of in the same article, some observations of considerable interest were published a few years ago by Mr Abernethy and Sir Astley Cooper. The first of these surgeons may be said to have the merit of suggesting the principles, on which a few successful attempts at relief have now been made. His reflections upon the nature of the malformation led him to think the trial of a gentle degree of pressure upon the tumour from its commencement extremely plausible; because it might have the effect of promoting the absorption of the fluid, and, at the same time, prevent the distention of the dura mater by keeping it supported. But, if this method were unavailing, and the fluid to increase, Mr Abernethy conceived that, as the disease, now left to itself, would unavoidably soon end in death, it might be a warrantable experiment to let out the fluid by means of a fine puncture, which could be immediately closed with sticking-plaster, and healed by the first intention. He proposed, that an endeavour should then be made to prevent another collection by bandages and topical applications; but, if the swelling returned, notwithstanding such means, he recommended the small puncture to be repeated, and the same mode followed again. We shall not here detail the case, in which Mr Abernethy put the plan to the test of experience, but shall merely state, that, though the child was not ultimately saved, there were circumstances in the case affording a degree of encouragement to future trials of the same kind. Sir Astley Cooper, proceeding on the principles already specified, tried the effect of puncturing spina bifida with a fine needle, letting out the fluid from time to time, and promoting the closure of the opening in the spine with a compress and bandage. In one case upon record, the treatment in this manner led to a complete cure. (Med. Chir. Trans. Vol. II. p. 326.) Sir Astley Cooper, however, follows two methods, according to the circumstances of the case, the one being palliative, the other radical. The first consists in treating the case as a hernia, and applying a truss to prevent its descent; the second in pricking the tumour with a small needle, and producing adhesion of the sides of the sac, whereby the opening in the spine is closed, and the disease altogether prevented. The first is attended with no risk; the second exposes the patient to a great deal of illness; but if successful, hinders the return of the disease. It deserves to be remembered, also, that, when the adhesive process cannot be effectually accomplished by the plan intended for a radical cure, the palliative treatment will yet admit of trial.
In order to be able to practise judiciously in these difficult cases, the surgeon should know, that there are particular examples, which afford not the slightest chance of a cure; they are unfortunately very frequent; for a statement of their nature, the profession is indebted to the last mentioned practitioner. If the tumour is connected with an unnatural en-
largement of the head, and hydrocephalus; if the lower extremities are paralytic, or the feces and urine come away involuntarily, there is no hope. Also, if the tumour is burst at the period of birth, or soon afterwards, little expectation of a cure can be entertained. The deficiency of the spine is sometimes so considerable, that the tumour, at the time of birth, is already very large; the nerves protrude from the spinal canal; the medulla itself is injured; and, under these circumstances, all surgical treatment must of course prove ineffectual.
Palsy of the lower extremities, from a diseased state of the spine, a case considered in the article referred to, has had, of late years, a great deal of attention bestowed upon it; and surely no disease, in the long list of those to which the human body is liable, has a stronger claim to be most carefully investigated, whether the difficulty of cure, or the degree of affliction brought on by the disorder, be contemplated. From Mr Brodie's observations, it would appear, that the affection of the spine is not always of one kind, but that the disease sometimes originates in ulceration of the intervertebral cartilages, and sometimes in a morbid condition of the cancellous structure of the bodies of the vertebrae. This gentleman concurs with Mr Pott, and other writers, respecting the fact, that the actual curvature of the spine must be preceded by disease of this part, unaccompanied with any visible deformity, and cannot take place until caries has made considerable progress. Hence, in the early stage of the case, when the diagnosis is of the highest importance, no information can be obtained from the appearance of the spine itself, the shape of which is yet unchanged; and frequently the symptoms, which do come on early, are rather ambiguous, being, according to Mr Brodie, a pain, and some degree of tenderness in that part of the spine, where the disease has begun; a sense of constriction of the chest; an uneasiness at the pit of the stomach, and over the whole abdomen; a disturbed state of the functions of the alimentary canal, and of the urinary bladder; a sense of weakness and aching, and occasional cramps in the muscles of the extremities. But, it is also acknowledged by the same writer, that very similar complaints may arise from other causes, and sometimes no particular ailments are mentioned previously to the curvature. Mr Brodie is inclined to think that the disease, which begins in the cancellous structure of the vertebrae, is more immediately followed by suppuration, than that which commences in the intervertebral cartilages; and that the first form of the disease seldom produces so extensive a destruction of the vertebrae as the last. But, with the exception of these circumstances, nothing which he has hitherto observed enables him to point out any differences in the symptoms of these different diseases.
The deformity of the spine, as Mr Brodie remarks, is generally of a peculiar kind, and such as nothing can produce, except the destruction of the bodies of one or more vertebrae. The spine is bent forward so as to form an angle posteriorly; and, although the destruction of the vertebrae may be to the same extent, the distortion is more obvious in some parts of the spine than others. For example, the spinous
processes in the middle of the back being long, and projecting downwards, the elevation of one of these must occasion a greater prominence, than that of one of the spinous processes of the neck, which are short, and stand directly backwards.
A curvature of the spine forwards may arise from other causes, as a weak condition of the muscles, or a rickety affection of the muscles. In such cases, it generally occupies the whole spine, which assumes the shape of a segment of a circle. At other times, however, it occupies only a portion of the spine, usually that which is formed by the superior lumbar and inferior dorsal vertebrae. But, in this circumstance, Mr Brodie finds, that the curvature is always gradual, and never angular; a circumstance distinguishing it from the curvature produced by caries. The cases, he thinks, have often been confounded, and some speedy and complete cures of carious spines on record, he infers, must have been cases of quite a different nature.
Besides the form of disease described by Mr Pott, the observations of the late Mr Wilson prove, that another form commences within the theca vertebralis, and thence extends to the bones. In his lectures at the College of Surgeons, the same gentleman also demonstrated what he called scrofulous tumours in the spinal marrow. Such diseases would create a loss of power in the parts below them, without any curvature of the spine.
We shall not here dwell upon the common treatment of diseased vertebrae, attended with a particular palsy of the limbs; it is already detailed in the former article, and consists principally in keeping open issues near the diseased bones. In France, it seems, the moxa is preferred to caustic issues, and cupping in the vicinity of the disease is often practised.
The great influence of the opinions of Mr Pott concerning the present distemper, has generally kept regular practitioners from making any trial of mechanical means for the support of the spine. It is questionable, however, whether Mr Pott may not have entertained prejudices against machinery, which, under some circumstances, may perhaps be useful. In these cases, mechanical contrivances are never now recommended, under the idea of there being any dislocation; an error sometimes prevailing in former times. We entirely coincide with Mr Brodie, and (we may say indeed) with the great mass of modern practitioners, that machines ought never to be employed with the view of elongating the spine, and correcting the deformity; but, if they be used merely for the purpose of taking off the weight of the head, chest, and upper extremities, from the diseased part of the spine, they may sometimes be of service. No doubt, Mr Brodie is fully justified in the observation, that they ought never, in the first instance, to supersede the constant maintenance of the horizontal position, though they may become advisable, when it is afterwards considered right for the patient to begin to sit up a part of the day.
The good which Mr Pott described as arising in these cases from issues, was imputed by the late Mr Baynton, not in reality to them, but to the long observance of the horizontal posture. Now, although
we fully agree, that keeping the patient as quiet as possible in the recumbent position is judicious practice, it does not follow that, because we entertain this belief, we must subscribe to the notion, that issues should be rejected, and that quietude will do every thing. Mr Baynton appears to us to have fallen into an error in supposing, that the process by which the diseased part of the spine is to be restored, and united, should be conducted exactly on the same principles as the union of bones free from disease. The truth is, there is an additional indication, namely, that of checking the progress of the disease, for which purpose experience proves, that issues, aided by rest, are the means affording the best chance of success. That issues frequently do render essential benefit is fully proved by the fact noticed by Mr Brodie, that many patients find themselves improved almost as soon as the issues are made; or regularly experience amendment each time the caustic is applied.
To the section on diseases of the bones, in the former article, we deem it right to add a few observations respecting the new and bold operation of removing the lower jaw; a proceeding which has been adopted several times in France by Dupuytren, Lallemand, &c. An interesting case of this practice was detailed a short time ago by the latter gentleman, who is Professor of Surgery at Montpellier. The patient, a robust man, aged 68, was received into the hospital St Eloy, on the 23d of May 1822. Nearly the whole of the lower lip, from one commissure to the other, extending downwards to the lower margin of the chin, was in a state of cancerous ulceration, in which disease the periosteum and bone itself appeared to participate. M. Lallemand began the operation with two semi-elliptical incisions, which commenced in the upper lip, about five or six lines from the commissure, and ended about the middle of the thyroid cartilage. The cheek on each side was dissected up to the front edge of the masseter. In this situation, the periosteum appeared perfectly sound; and here M. Lallemand sawed through the jaw, commencing with the left side. He then detached the muscles and soft parts on the internal side of the bone, and sawed through the right side from behind forwards, as he had done with respect to the left. The labial, submaxillary, and raninal arteries were successively tied, as well as a few less considerable branches. The lower angle of the wound was afterwards brought together with the twisted suture, and the branches of the jaw, and soft parts covering them, approximated by means of adhesive plaster. Soon after the operation, a considerable hemorrhage arose, which could not be suppressed without the actual cautery. In fifty days, the wound completely healed. There was then an interspace of nearly two inches between both ends of the jaw, through which the tongue passed, and the saliva dribbled away. For this last inconvenience, Lallemand contrived a silver chin, upon the concave surface of which was placed a sponge, secured by straps that passed back over the neck. (Journ. Univers. December 1822.) It is to be hoped that the successful instances of the removal of the lower jaw, now upon record, may not have the
Surgery. effect of leading young zealous admirers of every thing in the shape of a new and grand operation to repeat the practice in any cases, where the necessity for it is not clear, urgent, and unequivocal; for with the knowledge that we possess of the great deal that nature will do for the cure of necrosis of this bone, and of the bad, but temporary, disfigurement attending some stages of this disease, we would caution surgeons against any propensity to be too officious in such a case, which may even be erroneously considered as a cancerous affection. It is far from our intention, however, to insinuate, that the above case did not truly demand the bold measure which was put in execution.
Since the former Article on SURGERY was composed, a great many new and very interesting observations have been made upon aneurisms; and the share which English surgeons have had in the modern improvements that have taken place in the treatment of these formidable diseases, reflects such credit upon them, for science, judgment, and enterprise, that, in all works, devoted to the consideration of the diseases of the blood-vessels, their names must be inseparably connected with every successful attempt to meliorate this part of practice, and every praiseworthy effort to throw light upon the nature of the morbid changes to which the arteries and veins are liable. Whoever looks over Hodgson's valuable work on the diseases of the blood-vessels, will find the justness of this encomium completely established; and it is a book to which we refer with considerable pleasure, on account of the perspicuity and correctness prevailing in every part of it.
As an aneurism grows larger, its pulsations become weaker, and when the magnitude of the tumor is considerable, they are sometimes hardly distinguishable. This diminution of the pulsation has been accounted for by the coats of the artery losing their suppleness, in proportion as they become distended, and consequently the aneurismal sac no longer admitting of an alternate diastole and systole from the action of the heart. There can also be no doubt, that the fact is in a great measure owing to lamellated coagulated blood being deposited on the inner surface of the sac. This is an occurrence of great importance; for, when the disease undergoes a spontaneous cure, the deposition of lamellated coagula within the sac, is the mode by which this desirable event is accomplished. As Mr Hodgson remarks, one of the circumstances, which, in the most early stage, generally attend the formation of aneurism, is the establishment of that process, which is the basis of its future cure. The blood, which enters the sac soon after its formation, generally leaves upon its internal surface a stratum of coagulum, and successive depositions of the fibrous part of the blood, gradually diminish the cavity of the tumor. At length, the sac becomes entirely filled with this substance, and the deposition of it generally continues in the artery, which supplies the disease, forming a firm plug of coagulum, which extends on both sides of the sac to the next important ramifications given off by the artery. The circulation through the vessel is thus prevented, the blood is conveyed by collateral channels, and another process
is instituted, whereby the bulk of the tumor is removed. (On the Diseases of Arteries, p. 114.)
Surgery. External aneurisms, when they burst, give way by the sloughing of the extremity of a thin conical prominence that is previously formed upon them; but the bursting happens in a different manner in internal aneurisms. As Mr Allan Burns first noticed, these generally burst by actual laceration, and not by the sphacelation of the cyst. But the most correct account of this subject is to be found in Mr Hodgson's work. We are there informed, that when the sac points externally, it rarely or never bursts by laceration, but the extreme distention causes the integuments and investing parts to slough; and upon the separation of the eschar, the blood issues from the tumour. A similar process takes place, when the disease extends into a cavity, which is lined by a mucous membrane, as the oesophagus, intestines, bladder, &c. In such cases, the cavity of the aneurism is generally exposed, by the separation of a slough, which is formed upon its most distended part, and not by laceration. But when the sac projects into a cavity lined by a serous membrane, as the pleura, the peritoneum, the pericardium, &c. these membranes do not slough, but the sides of the tumour having become extremely thin from distention, at length burst by a crack, or fissure, through which the blood is discharged.
A few years ago, Professor Scarpa published a valuable treatise upon aneurism, maintaining the ancient doctrine, that no aneurisms consisted in a dilatation of all the arterial coats, but that they were all attended with a rupture of the proper coats of the vessel, the muscular and internal. Scarpa considers it an error to suppose, that aortic aneurisms, produced by a violent and sudden exertion of the body, or of the heart in particular, and preceded by a congenital relaxation of a certain portion of this artery, or a morbid weakness of its coats, ought always to be regarded as a tumour, formed by the distention or dilatation of the proper coats of the artery itself, that is, of its internal and fibrous coats. On the contrary, he deems it fully demonstrable, that such aneurisms are produced by a rupture of these tunics; and, consequently, by the effusion of arterial blood under the cellular sheath, or other membrane covering the vessel. At the same time, he does not deny, that, from congenital relaxation, the proper coats of the aorta may occasionally yield and be disposed to give way; but he will not allow that dilatation of the vessel precedes and accompanies all its aneurisms, or that its proper coats ever yield sufficiently to constitute the aneurismal sac. The root of an aneurism of the aorta, he observes, never includes the whole circumference of the artery: and the aneurismal sac arises from one side of it, in the form of an appendix, or tuberosity. But what is called a dilatation of an artery, he says, always extends to the whole circumference of the vessel, and therefore differs essentially from aneurism. Hence, he argues, that there is a striking difference between a dilated and an aneurismal artery, although the two affections are sometimes found combined together, especially at the origin of the aorta. It is also noticed, that the dilatation of an artery may exist, without any
organic affection, the blood being always within the cavity of the vessel; that, in an artery so affected, no lamellated blood is deposited; and that the dilatation never gives rise to a swelling of considerable size. In fact, no doubt can be entertained, that these circumstances fully warrant the inference, that aneurism differs essentially from one kind of dilatation of an artery.
According to the observations of Scarpa, the aneurismal sac never comprises the whole circumference of the vessel. Where the tumour joins the side of the artery, the aneurismal sac presents a kind of constriction, beyond which it is more or less expanded. This, he says, would never be the case, if the sac were formed by an equable distention of the tube and proper coats of the affected artery. In incipient aneurisms, at least, the greater size of the tumour would then be in the artery itself, or root of the swelling, while its fundus would be the smallest part. But whether aneurisms be recent and small, or of long standing and large, the passage from the artery is always narrow, and the fundus of the swelling greater in proportion to its distance from the vessel. Scarpa further explains, that the sac is always covered by the same soft, yielding, cellular substance, which, in the healthy state, united the artery to the surrounding parts. In aneurisms of the thoracic aorta, this cellular substance is covered by the pleura, and, in those of the abdominal aorta, by the peritoneum, which membranes include the sac and ruptured artery, presenting externally a continued smooth surface, just as if the artery itself were dilated. But Scarpa observes, that, if the aorta be opened lengthwise on the side opposite the constriction, the place of the rupture of the proper coats of the artery immediately appears within the vessel, on the side opposite to that of the incision. The margin of the fissure, that has occurred, is sometimes fringed, and often indurated, and through it the blood passed into the cellular sheath, which was itself converted into the aneurismal sac. If, as sometimes happens in the arch of the aorta near the heart, the artery, before being ruptured, has been somewhat dilated, it seems, at first, as if there were two aneurisms; but the constriction, which the nearest part of the sac and the artery presents externally, denotes precisely the limits, beyond which the internal and muscular coats of the aorta had not been able to resist the distention, and where, of course, they were ruptured. The partition, which Scarpa asserts may always be seen dividing the tube of the artery from the aneurismal sac, and is lacerated in its centre, consists of nothing but the remains of the internal and muscular coats of the ruptured artery.
Scarpa states, that, when an incision is made lengthwise in the side of the vessel opposite the rupture, its proper coats are found either perfectly sound, or a little weakened, and studded with earthy points, but still capable of being separated into distinct layers. On the contrary, in the opposite side of the aorta, where the rupture is, the proper coats are unusually thin, and not separable from each other without difficulty, or even not at all; they are frequently brittle, like an egg-shell, and are disor-
ganized and torn at the place, where they form the partition between the ruptured artery and the mouth of the aneurismal sac. Continuing to separate these coats from within outwards, we arrive at the cellular sheath surrounding the aorta. As in large aneurisms, this sheath is considerably thickened, and very adherent, at the constriction of the sac, to the subjacent muscular coat of the artery, it is liable to be mistaken for a dilated portion of the vessel itself. But even in such cases, it may at length be separated without laceration from the tube of the artery, above and below the injury, and successively from the muscular coat, as far as the neck of the aneurism. It then becomes manifest that the muscular coat does not pass beyond the partition between the cavity of the artery and that of the aneurismal sac, over which it is not extended, but terminates in a jagged manner at the edge of the rupture. The aorta and the sac being both covered by the pleura, or peritoneum, is a circumstance tending very much to lead surgeons into mistaken views of the real state of things.
As the portion of the aorta within the pericardium is covered only by a thin reflected layer of this membrane, such layer may also give way, when the proper coats of the vessel burst, and the consequence be an instantaneous effusion of blood within the pericardium itself. But every other part of the aorta makes long resistance to the fatal effusion, because there is between it and the peritoneum or pleura, a cellular sheath of a strong and elastic nature, which is capable of expanding into a sac, and while it is strengthened externally by the peritoneum or pleura, its strength is inwardly augmented in a very material degree, by the layers of coagulated blood.
Scarpa's doctrine, that all aneurisms are attended with rupture of the proper coats of the artery, great as the weight and influence of his opinion justly are, is far from having received general or even extensive sanction; for, in France, it is rejected by Richerand, Boyer, Dubois, Dupuytren, Sabatier, Breschet, &c.; and, in this country, every lecturer has continued to adopt the common division of aneurisms into true and false, or into some cases accompanied with dilatation, and into others attended with rupture of the arterial coats. The foundation for Scarpa's sentiments has now been very ably and impartially considered by numerous correct observers; and the love of truth obliges us to confess, that the mass of facts and authorities is decidedly against the doctrine which he maintains, without exceptions. As Mr Hodgson has remarked, the proofs of a partial dilatation of the coats of an artery, particularly of the aorta, are incontestably established by the possibility of tracing the coats of the vessel throughout the whole extent of the expansion, and by the existence of those morbid appearances in the sac, which are peculiar to the coats of arteries.
In the year 1811, this gentleman dissected an aneurism of the aorta. The sac was equal in size to a small melon, and the disease had proved fatal by bursting into the posterior mediastinum, and subsequently into the cavity of the thorax. This aorta exhibited the formation of aneurism in three distinct
Surgery. stages. The internal coat was throughout inflamed, and presented a fleshy and irregular appearance. At the arch of the aorta there was a dilatation, not larger than the half of a small pea. About two inches lower was a second dilatation, which would have contained a hazel-nut, and immediately above the diaphragm was the large aneurysm, which had proved fatal. Mr Hodgson removed that portion of the vessel which contained the smallest dilatation, and he then macerated it until its coats could be separated without violence. The dilatation was found to prevail equally in the three coats of the vessel, and, after being separated, each presented the appearance of a minute aneurysm. The second dilatation exhibited the same circumstance in a more advanced stage; the coats of the vessel being, however, more closely adherent to each other than in the natural state. Yet it was perfectly evident that the dilatation comprised all the coats of the vessel, the internal, middle, and external. In the large aneurysm, the disorganized internal and middle coats could be traced for some distance into the sac, and then the parts contained in the posterior mediastinum, and the vertebrae, formed the remainder of the cyst. Mr Hodgson has met with this partial kind of dilatation at the division of the carotids and iliacs, in the arteries of the brain, and in almost all the arteries which are subject to aneurysm. Partial, as well as general dilatation, he observes, frequently precedes the formation of aneurysm in the extremities. A gentleman had a large femoral aneurysm, which underwent a spontaneous cure. Upon examining the limb after death, the popliteal artery was found to be thickened and covered with calcareous matter. A small pouch, which would have contained the seed of an orange, originated from the side of this artery, and was evidently formed by a dilatation of the coats of the vessel; for the internal and middle coats could be traced in its circumference, and the former in that situation exhibited the same morbid appearances which it possessed in other parts of the vessel. A man died from the sloughing of an aneurysm in the ham: in the femoral artery there was a small aneurysm of about the size of a walnut. The external coat was dissected from the surface of the tumour to a considerable extent. The internal and middle coats were plainly dilated, and contributed to the formation of the sac. Their dilatation was gradual, and, after making part of the sac for a considerable distance, they were inseparably blended with the surrounding parts. (See Hodgson's Treatise on the Diseases of Arteries, &c. p. 70, &c.)
With respect to differences existing on the pathology of aneurysm between Scarpa and other modern writers, they seem to us to be reduced to one question, viz. Whether any of the dilatations on record, alleged to comprehend all the arterial coats, ought, or ought not, to receive the name of aneurysm? This eminent professor has always distinctly admitted, that the arteries may be dilated, though the kind of dilatation to which he refers is thought by him, as well as by Mr Allan Burns and Mr Hodgson, to require discrimination in a pathological point of view. Dissection shows, says Scarpa, that the morbid dilatation is circumscribed by the proper
coats of the diseased artery; and that the inner surface of the sac, formed by the partial, or total protrusion of the arterial tube, is never filled with polyous laminae, or layers of fibrine, disposed over each other, which layers never fail to be formed, in greater or smaller quantity, in the cavity of an aneurysm. The notion, that these layers of coagula are not met with in small dilatations of arteries, but are found in large expansions of them, he says, is contradicted by numerous careful observations, and especially by a specimen actually before him when he was writing, where a morbid dilatation of the arch of the aorta, in the vicinity of its origin from the heart, six inches in length and five in breadth, was completely free from the lamellated coagula always found in aneurysms. On the contrary, the sac of an aneurysm being formed of the parts surrounding the wounded or ruptured artery, and the blood never entering it as a natural receiver, the latter fluid always deposits in it these layers of fibrine, and this sometimes so copiously as to fill the whole cyst. At the same time, it is particularly explained by Scarpa, that, if accidentally furrows or fissures exist on the inside of the morbid dilatation, the fibrine may be deposited in these rough places, but only in them. Such fissures and inequalities of the inner surface of the morbidly dilated artery, he regards strictly as so many beginnings of another disease of the vessel, quite different from dilatation, that is, of aneurysm subsequent to dilatation.
Scarpa, in his first publication on aneurysm, repeatedly mentions, that the morbid dilatation of an artery constantly extends to the whole circumference of it. But this point seems from the appendix to be renounced; as he now observes, where the morbid dilatation is partial, or on one side of the artery, like a thimble, (for, very frequently, even in the arch of the aorta, this partial dilatation does not exceed the size of half a bean,) the entrance for the blood into this capsule is as large as the bottom of the sac. Where the dilatation occupies the whole circumference of the arterial tube, the swelling always retains a cylindrical or oval form; and if compressed, it yields very readily, and is found after death much smaller than during life. On the contrary, Scarpa remarks with respect to aneurysm, that, whether it be preceded by dilatation or not, it constantly originates from one side of the ruptured artery. The entrance for the blood is small compared with the size of the fundus of the sac; the tumour assumes an irregular shape; yields with difficulty to pressure; retains nearly the same size in the dead that it had in the living subject; and its sac, instead of becoming thinner as the swelling enlarges, or the coats of an artery do when they are simply affected with dilatation, grows thicker the larger the aneurysm becomes. According to Scarpa, cases of morbid arterial dilatations are positively incurable; which is not absolutely the fact with respect to internal aneurysms, difficult and rare as such an event may be.
The conclusions, justified by facts, seem to be those laid down by Mr Hodgson. 1st, That numerous aneurysms are formed by the destruction of the internal and middle coats of the arteries, and the expansion of the outer coat into a small cyst, which,
giving way from distention, the surrounding parts, whatever may be their structure, compose the remainder of the sac. 2dly, That the disease sometimes commences with a dilatation of a portion of the circumference of the artery. Such dilatation increases until the coats of the vessel give way, when the surrounding parts form the sac in the same manner as when the disease is, in the first instance, produced by destruction of the coats of an artery.
Whenever an aneurysmal sac beats strongly, and for a long while, against a bone, as the sternum, ribs, clavicle, and vertebrae, the bones are, in the end, always destroyed; so that the sac then lifts up the integuments of the breast, or back, and throbs directly under the skin. This effect is referred by all the best modern writers to the action of the absorbent vessels, which, under these circumstances, take away the particles of bone, against which the tumour beats. J. L. Petit found the condyles of the femur, and the upper head of the tibia, nearly destroyed by a popliteal aneurysm, and another case, in which the injury of the bone had proceeded to a great extent, is recorded by Rosenmüller. It is correctly noticed by Mr Hodgson, that the carious and corroded state of the bones in aneurysm is rarely or never attended with the formation of pus. In this respect, therefore, the morbid change differs essentially from common caries or ulceration of bones. Exfoliation also very rarely accompanies it, from which fact one important practical observation is deducible, namely, that if the aneurysm be cured, the bones will recover their healthy state, without undergoing those tedious processes which take place in the cure of caries or necrosis.
Mr Hodgson confirms the remark first made by Dr W. Hunter, and subsequently repeated by Scarpa and others, that cartilage is less rapidly destroyed by the pressure of an aneurysm than bone itself.
Aneurysms are much less frequent in women, than men. The following comparative Table, affording information on this point, is contained in Mr Hodgson's work:
| Total. | Males. | Females. | |
|---|---|---|---|
| Of the ascending aorta, the arteria innominata, and arch of the aorta | 21 | 16 | 5 |
| Descending aorta | 8 | 7 | 1 |
| Carotid artery | 20 | 2 | 18 |
| Subclavian and axillary | 5 | 5 | |
| Inguinal artery | 12 | 12 | |
| Femoral and popliteal | 15 | 14 | 1 |
| 63 | 56 | 7 |
A common notion amongst surgeons is, that an operation for aneurysm should not be undertaken until the disease has continued sufficiently long for the collateral arteries to enlarge, so that the circulation may be more sure of going on in the parts beyond the ligature, and the danger of mortification be lessened. Gangrenous mischief was formerly a very
frequent consequence of operations for the cure of aneurysm, and constituted the practitioner's chief dread; but, while his mind was anxiously directed to the risk of such an occurrence, and while he was even so much alarmed at it, that he, not unfrequently, recommended amputation of the limb, when the aneurysm might have been cured by the ligature, and the member preserved; yet, it never struck him, that the frequency of mortification was generally owing to the bad method of operating, formerly practised in cases of aneurysm, and not to the mere stoppage of the flow of blood through a part of the main artery of the limb. We here allude to the severe plan of opening the sac, and turning out the lamellated coagula, previously to the application of the ligature, which, after all, was generally put upon a diseased portion of the vessel; so that, if the patient escaped mortification, he rarely escaped the equally formidable consequence—secondary hemorrhage.
At the present day, operations for the cure of aneurysm have reached a great degree of perfection; and, generally speaking, they are mild proceedings, compared with what they used to be in the hands of the older practitioners. The result is, that mortification now much less frequently follows them, and surgeons entertain greater confidence in the powers of nature to supply the limb with blood. Hence, also, some of the most judicious practitioners condemn all delay of the operation, merely for the purpose of affording time for the enlargement of the collateral vessels. Certain it is, that delay often does a great deal of harm, by letting the tumour become so large, and the effects of its pressure so extensive and injurious, that, after the artery is tied, the swelling is frequently attacked with severe inflammation, supuration, and sloughing, and the patient sometimes falls a victim to what would not have taken place had the operation been performed sooner. Nay, delay may have an opposite effect to that expected by its advocates, with reference to allowing time for the anastomosing vessels to dilate; for, as Mr Hodgson has remarked, the large size of an aneurysm is in reality a circumstance which must materially prevent the establishment of a collateral circulation. When the tumour is of immense bulk, it has probably destroyed the parts in which some of the principal anastomosing branches are situated, or may prevent their dilatation by its pressure. Nor can it be doubted, that, where the tumour has been suffered to attain a large size, before an attempt is made to cure it, and where, from this cause, both the neighbouring soft parts and the bone are considerably altered, the completion of the cure, that is to say, the full restoration of the use of the limb, must be far more distant, than in other cases, where the cure is attempted in an earlier stage.
According to Scarpa, the complete cure of an aneurysm cannot be effected in whatever part of the body the tumour is situated, unless the artery, from which the aneurysm is derived, be obliterated, either by nature or art; and converted into a perfectly solid, ligamentous substance, for a certain extent above and below the place of the ulceration, laceration, or wound. Notwithstanding the general cor-
Surgery. rectness of this observation, we believe there are exceptions to it in a few aneurysms of the aorta, especially those of its arch, which seem to have been occasionally lessened and cured by Valsalva's treatment, repeated bleeding, very spare diet, &c. Here, we are not to suppose, that the aorta is obliterated at its very beginning; but that the diminution of the quantity of circulating blood, the reduced impetus of this fluid, the lessened distention of the aneurysmal sac, the general weakness induced in the constitution, and the increased activity of the lymphatic system, all necessary effects of Valsalva's treatment, have combined to bring about a greater or lesser subsidence of the tumour. Certain facts, recorded by Mr Hodgson, satisfactorily prove, 1st, That a deposition of coagulum may take place in an aneurysmal sac to such an extent as entirely to preclude the communication between its cavity and that of the artery, from which it originates; 2dly, That a sac, thus filled with coagulum, cannot prove fatal by rupture; and, 3dly, That the gradual absorption of its contents, and the consequent diminution of the sac, may proceed to such an extent, that the disease shall be cured without any obstruction taking place in the calibre of the vessel, from which it originates.
Both the spontaneous and surgical cures of aneurysm have generally two stages; in the first, the entrance of blood into the aneurysmal sac is prevented; in the second, the parietes of the artery approach each other, and, becoming agglutinated, the vessel is converted into a solid cylinder. In order that compression may be the means of uniting the opposite sides of the artery, and thus of producing a radical cure of aneurysm, the degree of pressure, according to Scarpa, must be such as to place these opposite sides in firm and complete contact, and such as to excite the adhesive inflammation in the coats of the artery. The point of compression must also fall above the laceration, or wound of the artery. Another condition is essential to success; the coats of the vessel, at the place where the pressure is made, must be sufficiently free from disease to be susceptible of the adhesive inflammation. When the arterial coats, round the root of an aneurysm, are much diseased, Scarpa considers them as unsusceptible of the adhesive inflammation, although compressed together in the most scientific manner, and even when tied with a ligature. This statement would appear to be corroborated by the following fact: Mr Langstaff amputated the thigh of a person seventy-five years of age; but the vessels were so ossified that they could not be effectually tied, and, in less than twenty-four hours, the patient died from loss of blood. It is generally supposed, says Mr Lawrence, that this condition of the arterial coats is incompatible with their union under the application of the ligature. The opinion should be received, however, with some limitation. In a man fifty-nine years of age, bleeding took place nearly a month after amputation, from an ossified femoral artery; and Mr Lawrence was, therefore, obliged to expose and tie that vessel again for the suppression of the hemorrhage, when he found a hard tube, which cracked immediately after the ligature was tightened; the bleeding, however, never returned. This case is mention-
ed, not with any view of encouraging surgeons to apply ligatures round diseased portions of arteries, a thing which should always be avoided when possible; but, to make them aware, that the ossified state of an artery, unfavourable as the circumstance may be, is not an absolute and constant prohibition to the successful application of the ligature.
Whenever the treatment by pressure is attempted, the plan should be promoted by repeated bleedings, spare diet, and strict repose in bed. Digitalis may also be prescribed, with the view of lessening the impetus of the circulation. Snow, or powdered ice, is sometimes applied to the tumour, with the design of facilitating the coagulation of the blood within the aneurysmal sac, and thus bringing about the obliteration of the cavity of the aneurysm and the artery. Ice should be employed, however, with some degree of caution. We learn from Breschet, that, when the swelling is large, the parts very tense, their texture changed, and the skin thin, the practice is likely to accelerate the formation of a slough; and he confirms a remark, made by Mr Hodgson, that some patients cannot continue this treatment longer than a few minutes, while others find it absolutely insupportable.
Modern experience has fully confirmed the fact, that the plan which can be most depended upon for the cure of external aneurysm, is that of tying the artery some way from the tumour, in the direction towards the heart. The following general instructions respecting the ligature, have received the sanction of many of the best surgeons in this country.
1. The cord should be thin and round, such a ligature being most likely to effect a clean division of the internal and middle coats of the vessel, and not liable to occasion extensive ulceration and sloughing.
2. The ligature should be tightly applied, in order to insure the complete division of the internal and middle coats of the artery, and to prevent its detachment; it being almost impossible, even with the thinnest ligatures, to cut entirely through a healthy artery.
3. The vessel should be detached from its connection, only so far as is necessary for the conveyance of the ligature underneath it.
4. The immediate adhesion of the wound should be promoted by all such means as are known to promote that process in general. (See Hodgson's Treatise on Diseases of Arteries, p. 225.)
The late Dr Jones, in his interesting experiments upon animals, performed with the view of ascertaining the effects of a ligature upon the blood-vessels, made out a fact, which at first raised the expectation that it would lead to a considerable improvement of the operation for the cure of aneurysms. After having assured himself of the correctness of an observation, first made by Desault, that, when a firm ligature is applied to an artery, it causes a division of the internal and middle coats, he discovered, that if such ligature be afterwards removed, an effusion of lymph takes place between the cut surfaces into the cavity of the vessel; and that, if several divisions of the internal and middle coats be thus effected in the vicinity of each other, the effusion of lymph was
Surgery. sufficiently extensive to obliterate the cavity of the vessel.
Here we see that Jones's experiments did not really justify any hope that a single division of the internal coats of the vessel with one ligature would lead to the obliteration of the tube at the tied part, though the cord were removed immediately after its application. On the contrary, his experiments proved that several ligatures, and several divisions of the inner coats of the vessel with them, were necessary, if they were to be taken away directly after being tightened. However, surgeons overlooked this difference, and their zeal allowed them to form hopes, which, in fact, had no foundation in any of the true results of Dr Jones's experiments. At the same time, it cannot be doubted, that if, immediately after tying the trunk of an artery for the cure of an aneurysm, the ligature could be altogether removed, and yet the vessel become obliterated, it would be highly advantageous; as no extraneous substance would then be left in the wound to prevent its union, or increase the chance of secondary hemorrhage, by causing the sloughing, or ulcerative process to extend too far. Suffice it here to state farther, with reference to this scheme, that the trials which have been made of it fully prove that it is ineffectual; a conclusion which might have been drawn from Dr Jones's own experiments. Still the fact of the ligature, though applied only for a moment, bringing on an effusion of lymph within the vessel, and a permanent constriction of it on the part operated upon, continued to keep the attention of surgeons fixed upon the subject; and their genius exerted itself in every possible way to render the new information the means of leading to some great and beneficial change in the operation for the cure of aneurysm. In particular, it appeared to Mr Travers, that the want of union was chiefly owing to the circumstance of the opposite sides of the vessel not being retained in a state of contact, so that they might have an opportunity of adhering together. This object is fulfilled by the ligature in the common mode of its application; and for the success of Dr Jones's experiment, it was conceived, it would be sufficient to let the ligature remain on the vessel only until the adhesion were strong enough to resist the passage of the blood through the tube. In short, Mr Travers thought, that if a ligature were applied to an artery, and suffered to remain only a few hours, the adhesion of the inner surface of the vessel would then be sufficiently advanced to insure the permanent obliteration of the cavity of the vessel. The early removal of the ligature, it was hoped, would prove highly advantageous by diminishing the chance of hemorrhage, and facilitating the union of the wound.
The trials which have been made of the temporary application of the ligature for the cure of aneurysm, we regret to say, have not had such decidedly favourable results, as to enable us to rank the practice as an established improvement. On the contrary, though some cases treated in this manner have been encouraging, the greater number has been of the opposite description. Sir Astley Cooper operated upon a popliteal aneurysm in this way; the flow of blood
to the tumour was completely stopped by the ligature for thirty-two hours, and the cord then removed; but the pulsations of the disease returned. A ligature was then applied forty hours longer, at the end of which time no pulsation followed the removal of the ligature; but, on the twelfth day, a considerable bleeding came on, and it was necessary to take up the vessel again. The careful consideration of this and various other cases, and, in particular, the perusal of Scarpa's examples of the practice, have perfectly satisfied us that, however flattering the suggestion deduced from Dr Jones's observations might at first be, the plan of removing the ligature, previously to its natural separation, will never answer in the operation for the cure of aneurysm, unless either an obliteration of the arterial tube follow, with reasonable certainty, the taking away of the ligature directly after it has been applied, and it has divided the inner coats of the vessel; or, at all events, unless the ligature can always be withdrawn at a determinate period, and the same obliteration either certainly ensue, or be already complete. All this, too, ought to be effected with such regularity and infallibility in every case, that there would be no chance of the surgeon being obliged to apply another ligature, do a second operation, or cause disturbance of the artery in any manner whatsoever.
Independently of the uncertainty of the period, when the arterial tube is closed by the adhesive inflammation in various patients, it appears that the disturbance of the vessel and wound by the steps necessary for the loosening and removal of the ligature, will ever form an insuperable objection to the practice. Scarpa has some apprehension of this kind himself; for he remarks, "In the act of removing the ligature, there can be no doubt, it is of great consequence that the artery be not rudely handled or stretched. And, indeed, if, on untying the running knot, the subjacent knot could be with the same facility untied, we could not wish for a better mode of performing this part of the operation. But the knot, although a simple one, is not so readily untied as the running knot; on account of the moisture with which the threads forming the ligature are soaked, or because the ligature has been previously waxed." These apprehensions lead him to suggest the scheme of placing a thread longitudinally on each side of the cylinder of linen, interposed by him between the knot and the artery. This he does before the knot is made; and at the time of removing the ligature, the threads are to be drawn in opposite directions, in order to undo the knot without displacing or stretching the artery. Thus, instead of one small ligature, which is all that an English surgeon leaves in the wound, Scarpa recommends his ligature of four or six threads, a roll of linen, and two other threads; a quantity of extraneous substances, which cannot fail to be a source of serious irritation and mischief. Were there, however, only the following single objection to this practice, it would never be established in this country; its advocates are necessarily obliged to renounce the infinite advantage of bringing the edges of the wound together directly after the operation. If it had been practicable to withdraw the li-
Surgery. gature as soon as the inner coats of the vessel had been divided by it, and the obliteration of the momentarily constricted portion of the artery followed as a matter of certainty, the case would have been very different, as there would then have been no foreign body at all left in the wound; the parts might have been immediately brought together, so as to leave the greatest chance of union by the first intention, and no future disturbance either of the artery or of the wound would have been incurred.
In the section upon the popliteal aneurysm, in the former Article, two things are recommended, which the experience of many of the best surgeons does not at present sanction. The first is the application of a double ligature, and then dividing the vessel at a point between the two cords; the second is using a ligature of sufficient thickness to hinder it from cutting through the coats of the vessel. With respect to the first of these proceedings, it seems to be of great antiquity, but had fallen into oblivion, when again brought into notice by Mr Abernethy. The reflections which led this gentleman to revive the practice were ingenious; for, when the artery was tied with two ligatures, and divided in the interspace between them, it was argued, that it would be quite lax, possess its natural attachment, and be as nearly as possible in the same circumstances as a tied artery upon the face of a stump. Strictly speaking, however, as Mr Hodgson first pointed out, an artery tied in two places, and cut through in the interspace, cannot be regarded as placed exactly in the same condition as an artery tied in amputation. In the latter case, the retraction of the vessel corresponds with that of the surrounding parts, which are divided at the same instant, and therefore its relative connections stand as before the operation. But, in the operation for aneurysm, the retraction of the artery takes place without being attended with a corresponding retraction of its connections. How far the retraction of the artery is beneficial or injurious, is by no means evident; and the advantages arising from it may be obtained in most situations by simply placing the limb in a bent position, without dividing the vessel. One important object, however, is gained by the division of the artery; namely, that in this case it is generally tied close to its connections, and it is very evident how liable the application of the ligature, in the middle of a denuded extent of the vessel, must be to produce ulceration, or sloughing of its coats. The same object, however, will be gained by tying the undivided artery close to its connections, at the end nearest to the heart; and the presence of a single ligature at the bottom of the wound will be less liable to give rise to suppuration, and the formation of sinuses, than the employment of two. When an artery is divided, the portions situated beyond the ligatures must slough, and be an additional cause of suppuration in the wound. Experience has amply proved, as Mr Hodgson correctly states, the safety of employing a single ligature, and it is at present preferred by many of the most experienced operators in this country.
The second thing recommended in the section upon the popliteal aneurysm; namely, the use of a largish
Surgery. ligature, with the view of not cutting the coats of the vessel, is a plan which by no means corresponds with the valuable doctrines inculcated by the late Dr Jones in his excellent work upon hemorrhage; nor is it found to be advisable on any practical grounds. On the contrary, the advantage of lessening, as much as possible, the quantity of extraneous substance in the wound, and the manner in which the dividing the inner coats of the vessel by the ligature insures the effusion of lymph within it, and the quick obliteration of its cavity, are considerations which dictate the propriety of always employing a round and slender, but very firm ligature, made of such materials as will combine these properties in the greatest degree. A larger ligature than is absolutely necessary, must ever be disadvantageous, not only by being less calculated, than a smaller one, to cut through the inner coats of the vessel, but by acting as a source of considerable irritation at the bottom of the wound; whereby the healing process, with respect to the wound itself and the tied part of the artery, must be placed in less favourable circumstances.
A few years ago, Mr Lawrence extended to operations for aneurysm the plan of tying the artery with a very firm, small, silk ligature; the whole of which is immediately afterwards cut off, with the exception of the noose and knot; and an attempt is then made to heal the wound by the first intention. When this plan is adopted, it is of importance to use a ligature made of dentists' silk, and not catgut, and other substances, which are less fitted for the purpose. Every case, in which any deviation in this respect is made from the directions given by Mr Lawrence, cannot be received as a fair trial of the practice.
Various pincers and compressors have been devised by different surgeons, as means well calculated to obliterate the artery; and, in the opinions of the inventors, they accomplish this business more certainly and securely, than a ligature. Some of these contrivances may, indeed, answer better than the large clumsy cords which are sometimes employed, accompanied with the further irritation and dangers of what are called ligatures of reserve; but all the best surgeons in this country unite in a decided preference to the ligature when of proper construction and skilfully applied. As Scarpa justly observes, metallic instruments, designed to be applied directly to an exposed artery, for the purpose of obliterating it by compression, are liable to all the inconveniences which are inseparable from the presence of hard bodies, introduced and kept for several days in the bottom of the wound; particularly of a recent wound, where they cannot be retained in a proper direction without difficulty, or precisely at such a depth as will not be attended with hurtful pressure upon the wound itself, and the important parts in its vicinity. And, with regard to Asalini's forceps, Monteggia has observed, that, if the obliteration of the artery is retarded, the forceps divides the artery just like the ligature, by causing the death of the included portion. In one case, the same surgeon also saw the extremity of the instrument resting at the bottom of the wound upon the subjacent
Surgery. femoral vein, the anterior half of which it ruptured, though such portion had not been taken hold of by it.
As a recent improvement in the operation for popliteal aneurysm, that of making the incision somewhat higher up the thigh, than was commonly the practice a few years ago, deserves to be noticed. For this suggestion, we are principally indebted to Scarpa, some of whose other measures in the operation seem to us far less deserving of imitation. "The surgeon," says Scarpa, "is to explore with his forefinger the course of the artery from the crural arch downwards; and, when he comes to the place where the vibration of the vessel begins to be less distinctly felt, this point is to be fixed upon for the lower end of the external incision. This angle of the wound will fall nearly on the inner edge of the sartorius, just where this muscle crosses the track of the femoral artery, and at the very apex of the triangle formed by the convergence of the triceps and vastus internus. A little more than three inches above the place here fixed upon, the surgeon is to begin with a convex-edged bistoury the incision through the integuments and cellular substance, and carry the wound down the thigh in a slightly oblique line from without inwards; so as to make it follow the course of the artery as far as the apex of the triangle already specified, or the point where the vessel passes under the inner edge of the sartorius muscle." Scarpa's reason for making the incision higher up in the thigh than Mr Hunter did, is to avoid the necessity of removing the sartorius muscle from its position, or of turning it back, in order to get at the artery. We have seen the best operators, and even professors of anatomy, perplexed by having the sartorius muscle immediately in their way after the first incision had been made; and, as the vessel is more superficial a little higher up, the place is farther from the diseased portion of the artery, and the method does not interfere with the profunda, which arises about an inch and a half, or an inch and three quarters, below Poupart's ligament, the practice seems to us on every account right and unobjectionable.
Subsequently to the period when the former Article on SURGERY was written, the operation of tying the external iliac artery, for the cure of femoral aneurysms, has been repeated with a degree of success, that the most ardent practitioners could scarcely have anticipated. Indeed, as far as our observations and inquiries extend, it is an operation attended with nearly, if not quite as much success, as that of taking up the artery in the thigh for the cure of popliteal aneurysm. Out of twenty-five cases, we know of only three in which the limb was attacked with gangrene. The proportion is not so much as one in eight.
The following is Sir Astley Cooper's method of performing this operation. A semilunar incision is made through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of this incision will be situated near the spine of the ilium; the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique
muscle having been exposed, is to be divided throughout the extent, and in the direction, of the external wound. The flap, which is thus formed, being raised, the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia, which lines the transverse muscle, through which the spermatic cord passes, is situated in the mid-space between the anterior superior spine of the ilium and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. Hence, if the finger be passed under the spermatic cord, through this opening in the fascia, it will come into immediate contact with the artery, which lies on the outside of the external iliac vein. The artery and vein are connected together by dense cellular membrane, which must be separated to enable the operator to pass a ligature by means of an aneurysm-needle round the former of these vessels. (See Hodgson's Treatise on Diseases of Arteries, &c. p. 421.) In this operation, as well as in all others for aneurysms, a single ligature is now mostly preferred by all the best surgeons of this country.
Perhaps, no branch of surgery has received so much attention and decided improvement during the last twenty years, as that which has for its object the cure of aneurysmal diseases. Cases formerly abandoned as certainly fatal, or in which the patient was saved only by amputation, are now cured, and this without any severe mutilation, or irremediable disfigurement. Nay, aneurysms, seemingly almost out of the reach of the surgeon's hand, are now not relinquished as a matter of course, but every possible means of checking and removing the disease is considered; and the boldest operations, conceivable by the most enterprising surgeon, are planned and undertaken. One proof of this advancement of modern surgery we find in an operation that has now been performed with success in two examples; we allude to that of tying the internal iliac artery for the cure of aneurysms of the gluteal artery. This proceeding, which was not before the public at the time when the former article came out, was first adopted by Mr Stevens, a surgeon at Santa Cruz. "An incision, about five inches in length, was made in the left side, in the lower and lateral part of the abdomen, parallel with the epigastric artery, and nearly half an inch on the outer side of it. The skin, the superficial fascia, and the three thin abdominal muscles, were successively divided; the peritoneum was separated from its loose connection with the iliacus internus and psoas magnus; it was then turned almost directly inwards, in a direction from the anterior superior spinous process of the ilium to the division of the common iliac artery. In the cavity which I had now made (continues Mr Stevens), I felt for the internal iliac, insinuated the point of my fore-finger behind it, and then pressed the artery betwixt my finger and thumb. Dr Lang now felt the aneurysm behind; the pulsation had entirely ceased, and the tumour was disappearing. I examined the vessel in the pelvis; it was healthy, and free from its neighbouring connections. I then passed a ligature behind the artery, and tied it about half an inch from
Surgery. its origin. The tumour disappeared almost immediately after the operation, and the wound healed kindly. About the end of the third week the ligature came away, and in six weeks the woman was perfectly well." (Med. Chir. Trans. Vol. V.) The operation is represented as free from any particular difficulty; and it is said, that not an ounce of blood was lost. The ureter was easily avoided, which followed the peritoneum, when this membrane was pushed inwards.
A second example of the performance of the same operation is recorded in the 38th volume of the Medical and Physical Journal, p. 267. The operator was Mr Atkinson of York, the disease a gluteal aneurysm, and the patient a stout bargeman, aged 29. This case, however, had not a fortunate result, as the patient sunk partly from the discharge, and partly from hemorrhage, about nineteen days after the operation. That the internal iliac artery was really tied, seems verified not only by the effect of the ligature upon the swelling, but by the still more positive evidence obtained by the examination of the body after death.
The possibility of tying the carotid artery in cases of wounds and aneurysms, without any injurious effect upon the functions of the brain, has been of late years repeatedly illustrated. Hebenstreit, in Vol. IV. p. 266, 3d ed. of his Translation of Mr B. Bell's Surgery, reports an instance in which the carotid artery happened to be wounded in the extirpation of a scirrhous tumour; and the hemorrhage would have been fatal, had not the surgeon immediately tied the trunk of the vessel. The patient lived many years afterwards. This is probably the earliest authentic case, in which a ligature was applied to the carotid artery. Mr Abernethy's case is perhaps the second, and that in which Mr Fleming, a naval surgeon, tied the common carotid in a sailor, who attempted suicide, and who was saved by the operation, is still later, not having occurred till the year 1803. (See Med. Chir. Jour. Vol. III.)
These were all cases of wounds. Sir Astley Cooper first tied the carotid artery for the cure of an aneurysm in the year 1805. An incision, two inches in length, was made at the inner edge of the sternocleido-mastoideus from the lower part of the tumour to the clavicle. This wound exposed the omo-hyoideus and sternohyoideus muscles, which were drawn aside towards the trachea, and the jugular vein presented itself. The motion of this vein produced the only difficulty in the operation, as in the different states of breathing the vessel sometimes became tense and distended under the knife, and then suddenly collapsed. This vessel was kept out of the way of the knife by the finger, and the carotid artery having been exposed by another cut, two ligatures were passed under it with a common aneurysm-needle. Care was taken to exclude the recurrent nerve, on the one hand, and the par vagum on the other. The ligatures were then tied about half an inch asunder; but the intervening portion of artery was left undivided. This case had not a favourable termination; and Sir Astley Cooper concludes his account of it with expressing his belief that, in future, the causes of failure may be avoided by operating before the tu-
mour is of such size as to make pressure upon important parts; or, if the swelling is large, by letting out its contents as soon as inflammation invades it. (Med. Chir. Trans. Vol. I.)
In another case of carotid aneurysm, operated upon by the same surgeon in 1808, success was complete. The patient was a man aged 50, and the aneurysm was attended with severe pain all over one side of the head, throbbing in the brain, hoarseness, cough, slight difficulty of breathing, nausea, giddiness, &c. The patient perfectly recovered, and resumed his occupation as a porter. The intellects remained perfect; the nervous system was unaffected; and the severe pain which, before the operation, used to affect the side of the head adjoining the aneurysm, never returned. In this example, two ligatures were applied, and the intervening portion of the artery divided: subsequent cases, however, have fully evinced the sufficiency of a single ligature, and the utility of applying two, and cutting through the vessel between them.
The carotid artery has also been several times taken up with the view of checking the progress of the disease well known to surgeons under the name of aneurysm by anastomosis. Of course, the complaint must be so situated as to afford a rational chance of such application of the ligature being capable of cutting off the main supply of blood to the tumour, to justify the practice. A very encouraging case is recorded by Mr Travers, who, by means of the operation, effectually cured an aneurysm by anastomosis in the orbit. (Med. Chir. Trans. Vol. II.) And another very interesting case of the same kind has been published by Mr Dalrymple of Norwich, in the 6th volume of those Transactions. These examples, however, should not lead surgeons to be too confident of being always able to cure aneurysms by anastomosis on the above principle; namely, that of tying the main artery, from which the swelling receives its supply of blood. The great cause of failure is the impossibility of preventing, in some situations, the transmission of a considerable quantity of blood into the tumour, through anastomosing vessels. For cases proving the caution, with which the prognosis should be made in attempts of this kind, see one published by Mr Wardrop in the Med. Chir. Trans. Vol. IX. p. 206; and another detailed by Breschet, in his translation of Mr Hodgson's work On the Diseases of Arteries, T. II. p. 296.
The carotid artery was tied by Mr Goodlad of Bury, in Lancashire, previously to the removal of a large tumour from the side of the neck, involving the parotid gland; this proceeding was adopted with the view of diminishing the danger of hemorrhage. (See Med. Chir. Trans. Vol. VII.)
There are two methods of operating for the cure of axillary aneurysms; in one, the axillary artery is taken up by cutting below the clavicle; in the other, the necessary wound is made above that bone, and the subclavian artery secured at the point where it emerges from behind the anterior scalenus muscle.
Mr Hodgson recommends the first mode to be performed in the following way: A semilunar incision through the integuments, with its convexity downwards, is to begin about an inch from the sternal
end of the clavicle, and to be continued towards the acromion to the extent of three or four inches, so as to terminate near the anterior margin of the deltoid muscle, without reaching into the space between the deltoid and pectoral muscle, in order to avoid wounding the cephalic vein. This incision will expose the fibres of the pectoral muscle, which are now to be divided in the direction and extent of the external wound. The flap is then to be raised by dividing the loose cellular membrane, which connects the pectoral muscle to the parts underneath it. The pectoralis minor will now be seen crossing the inferior part of the wound, and the surgeon, by introducing his finger between the upper edge of this muscle and the clavicle, may feel the pulsations of the axillary artery. Here one of the cervical nerves lies above, but in contact with the artery; the other nerves are behind it. In the dead subject the axillary vein is situated below it, but in the living the vein is distended, and conceals the artery. The cellular membrane connecting these parts is to be separated by careful dissection, or by lacerating it with a blunt instrument; then a ligature having been drawn under the artery with an aneurysm-needle, the ends of the cord are to be raised, and a finger passed down, so as to compress the part surrounded by the ligature. If the artery be included, the pulsation in the aneurysm will immediately cease. This precaution is highly necessary, lest one of the cervical nerves should be tied instead of the artery. The axillary artery has been tied with success below the clavicle by the late Mr Keate (see Med. Review, 1801), Mr Chamberlaine (Med. Chir. Trans. Vol. VI. p. 128), and others.
The subclavian artery may be tied at the place where it comes from behind the anterior scalenus muscle, and this plan indeed is necessary whenever the aneurysmal swelling extends beyond a certain distance towards the neck. It is observed by Mr Hodgson, that, when the subclavian artery has emerged from behind the anterior scalenus muscle, it passes obliquely over the flat surface of the first rib, with which it is in immediate contact. The cervical nerves are situated above, and a little behind, the artery; the subclavian vein passes before it, and underneath the clavicle. If the finger be passed down the acromial margin of the anterior scalenus muscle, the artery will be found in the angle formed by the origin of that muscle from the first rib. The shoulder being drawn down as much as possible, the skin is to be divided immediately above the clavicle, from the external margin of the clavicular portion of the mastoid muscle, to the margin of the clavicular insertion of the trapezius. No advantage whatever is gained by cutting the clavicular attachment of the mastoid; the exposed fibres of the platysma myoides are then to be divided, the utmost care being taken not to wound the external jugular vein, which lies immediately under them, near the middle of the incision; the fibres should be detached and drawn towards the shoulder with a blunt hook. The cellular membrane in the middle of the incision is then to be cut, or separated with the finger, until the surgeon arrives at the acromial edge of the anterior scalenus muscle. His finger is then
to be passed down its margin, until it reaches the part where it arises from the first rib; and in the angle formed by the origin of the muscle from the rib, the artery will be felt. The ligature is now to be conveyed under the vessel, either by means of an instrument, constructed on the principle of Desault's uiguille à ressort (see his Works by Bichat); or of the still better one lately invented by Mr Weiss, surgical instrument-maker, London.
As the difficulty of several operations for aneurysms chiefly consists in getting a ligature under the deeply situated artery, in consequence of the very little room afforded for turning the common aneurysm-needle; and even when the ligature is thus far introduced, an equal difficulty presents itself when the thread requires to be extricated from the eye of the needle; the ingenious instrument made by Weiss, and found completely to answer in practice by Sir Astley Cooper, Mr Travers, and Mr Brodie, deserves on every account to be made known to, and procured by, all operating surgeons. A particular description of it, illustrated by an engraving, may be seen in the Edinburgh Medical and Surgical Journal, No. LXXVI. p. 492.
Though the operation of taking up the subclavian artery at the point where it emerges from behind the anterior scalenus muscle, has now been very frequently performed, we believe only two successful cases are upon record; and these were operated upon by Dr Post of New York (see Med. Chir. Trans. Vol. IX.) and by Mr Liston of Edinburgh. (See Edinb. Med. and Surg. Journ., No. LXIV.) In some instances, the want of contrivances calculated to pass the ligature under the deeply seated artery, when the clavicle was much raised by the swelling, has prevented the completion of the operation; which unpleasant circumstance, it is to be hoped, will never happen again; the instrument constructed by Mr Weiss removing every difficulty of this kind. It should also be a maxim amongst surgeons always to recommend the operation before the swelling has attained a very large size, by which the operation is rendered more complicated, and the chances of recovery seriously lessened.
In America the arteria innominata has been lately tied by Dr Mott of New York, and in Germany by Professor Graefe of Berlin. The proposal was made several years ago in this country, but was never put in execution; owing to the common belief that such an operation would be almost necessarily fatal of itself, either from the inflammation likely to be excited by it in the neighbouring important organs; or from the danger of hemorrhage, in consequence of the adhesion of the vessel being exposed to be broken by the force of the circulation. In the case operated upon by Dr Mott, two incisions were made, one in the direction of the clavicle, and the other along the mastoid muscle. The carotid was laid bare, and traced towards the subclavian, which was found so diseased, that the only alternative left was to tie the arteria innominata. The incisions were accordingly carried more deeply, and Dr Mott having separated the recurrent and phrenic nerves, arrived at the division of the artery, and with a curved needle, passed the ligature above half an inch from this point. The
Surgery. wound was then closed with a suture. In the operation, a branch of the internal mammary artery, and two of the inferior and superior thyroid, were divided, but not more than three ounces of blood were lost, and the operation was completed in about an hour. It is said, that the patient immediately after it felt quite well; his pulse was 69; the temperature of the right arm was nearly the same as that of the left; and the breathing was undisturbed. Until the 22d day after the operation, he continued to improve; the suppuration went on favourably, the ligatures came away without accident, and the pulse, which, at one time, had risen to 120, was reduced by venesection to its natural standard; the cough was disappearing, cicatrization was going on properly, and the swelling diminishing. He was now in high spirits, and so far recovered, that he walked daily in the garden of the hospital. All on a sudden, however, on the 24th day, hemorrhage from the wound took place, and though it was soon stopped, and little blood was lost, it recurred twice the next two days, difficulty of breathing came on, and the patient died on the 26th day.
Upon dissection, no mark of inflammation was traced in the arch of the aorta, the origin of the arteria innominata, or the lungs. The inner coat of the arteria innominata is described as being sound, smooth, and soft, but the parietes of the vessel were so thick, that it would scarcely admit a crow-quill. It is to be regretted that various interesting particulars, relating to the state of the tied portion of the artery, are omitted in the history.
A similar operation was performed by Graefe at Berlin on the 5th of March 1822. The patient was laid upon his back, with his head hanging down over one side of the table. A longitudinal incision was made near the front edge of the mastoid muscle, down to the sternum. The carotid artery was thus exposed, and its course followed to the point, at which it unites with the subclavian, so as to form the trunk of the arteria innominata. When the latter vessel had been distinctly exposed, a ligature was passed round it with a bent needle, and then tied. No alarming symptoms followed the operation, and the ligature came away in about a fortnight. Some time afterwards, however, a considerable bleeding arose, which was stopped by means of cold water and pressure. The patient then complained of pain in the tumour, and as a fluctuation could be plainly felt, Graefe was led to make an incision into the aneurysmal sac. A large quantity of pus and grumous blood was thus discharged, and matter continued to be discharged daily from this opening, while the other granulated in the most favourable manner. The patient became feverish, however, spit blood, and died on the 65th day. Upon dissection, the lungs were found diseased. In the arteria innominata, a clot had been formed, extending from the origin of the vessel to the place where the ligature had been applied. When an injection was thrown into the aorta, the wax completely filled the arteries of the right arm, and right side of the head, proving that the circulation in these parts had been fully re-established by means of the anastomosing vessels.
As a conclusion to the remarks here introduced upon
Surgery. the subject of aneurysm, we deem it right to notice the memorable case, in which Sir Astley Cooper tied the aorta itself. He had often placed ligatures round the aorta in dogs, and found, that the blood was readily conveyed by the anastomoses into their posterior extremities. (Med. Chir. Trans. Vol. II. p. 158.) The case, in which he judged it warrantable to make the experiment of tying the aorta in the human subject, was one of inguinal aneurysm, on the left side, reaching so far upwards, that no operation was practicable without opening the peritoneum; and, at length, notwithstanding the trial of every means that could be thought of to check the disease, the tumour burst, and the patient was on the brink of the grave. In short, he was so reduced by repeated hemorrhages, that his feces passed involuntarily, and immediate death was only prevented by keeping up pressure upon the opening. In these desperate circumstances, Sir Astley Cooper made a small incision into the sac, above Poupart's ligament, and introducing his finger, tried if it were practicable to pass a ligature round the external iliac artery, within the cavity; but the thing was found impossible, as, instead of the vessel, "only a chaos of broken coagula" could be perceived. At the moment of withdrawing the finger, two students compressed the aorta against the spine, and the incision was then closed with a dossil of lint. It was now determined to apply a ligature to the aorta itself. An incision, three inches in length, was made in the direction of the linea alba, but slightly curved towards the left, so that the navel, which was in the centre of it, might be avoided. After the linea alba itself had been divided, a small aperture was made in the peritoneum, and the end of a finger introduced. This opening was now enlarged with a probe-pointed bistoury to nearly the same extent as the outer wound. Neither the omentum nor the intestines protruded; and during the progress of the operation, only one small convulsion projected beyond the wound. With his finger-nail, the operator now scratched through the peritoneum on the left side of the aorta, and then conducting it between the aorta and the spine, he again penetrated the peritoneum on the right side of the aorta. A blunt aneurysm-needle, armed with a single ligature, was next conveyed under that vessel, and tied, with the precaution of excluding the intestines from the noose. The wound was then closed by means of the quilled suture and adhesive plaster. During the operation, the feces were discharged involuntarily, and the pulse for an hour after the operation was 144. An opiate was given, and the involuntary passage of feces soon ceased. The sensibility of the right leg was very imperfect. In the night, the patient complained of heat in the abdomen; but no pain was felt on pressure being made upon it; and the lower extremities, which had been cold a little while after the operation, were now regaining their warmth, though their sensibility was very indistinct. At six o'clock, the following morning, the sensibility of the limb still continued imperfect; but, at eight o'clock, the right one was warmer than the left, and its sensibility beginning to return. At noon, the temperature of the right limb was ninety-four, and that of the left, or aneurys-
mal one, eighty-seven and a half. At eight o'clock on the second morning after the operation, the aneurysmal limb appeared livid and cold, more particularly round the aneurysm; but the right leg was warm; and between one and two o'clock of the same day, after a great deal of vomiting, involuntary discharge of the urine and feces, pain in the abdomen and loins, cold sweats, &c. the patient died. In the examination of the body, not the least appearance of peritoneal inflammation was found, except at the edges of the wound; and the omentum and intestines were of their natural colour. The ligature, which included no portion of intestine or omentum, was placed round the aorta, about three quarters of an inch above its bifurcation. When the vessel was opened, a clot, of more than an inch in extent, filled it above the ligature; and below the bifurcation, another clot, an inch in extent, occupied the right iliac artery, while the left contained a third, which extended as far as the aneurysm. As there were no appearances of inflammation of the viscera, Sir Astley Cooper refers the cause of death to the want of circulation in the aneurysmal limb, which never recovered its natural heat, nor any degree of sensibility, though the right limb was not hindered from doing so; and he believes, that, in order to have any chance of success in a similar case, the ligature must be applied before the swelling is very large. Here, however, some doubts may be entertained concerning the propriety and necessity of such an operation: indeed, even in the desperate circumstances of the above mentioned patient, there are many good surgeons, who consider, that it would have been better to have suffered him to meet his fate in tranquillity. Be this as it may, the case is highly interesting, both in a physiological and a surgical point of view, as proving, by what took place in the limb of the sound side, that where no other impediments exist, the circulation will continue in the lower extremities, though the abdominal aorta be suddenly tied, or obstructed. Obliterations of portions of this vessel by disease happen gradually, and though several instances of this kind upon record, also prove the possibility of the continuance of the circulation, notwithstanding the obstruction, they do not inform us, what would be the result of a stoppage suddenly made to the course of the blood, through such a vessel as the aorta. The particulars to be gathered from the preceding case, respecting the effects of this kind of change, cannot fail to interest the studious observer of the phenomena of the animal economy.
Following the subjects in the order in which they are arranged in the Article, in the Encyclopædia, we next find that of varicose veins; a disease sometimes very annoying and difficult to cure. The practice of tying veins for the cure of varices was well known to Pare and Dionis, who have correctly described the operation of tying and dividing the vein between the two ligatures. In modern times, Sir Everard Home has related many cases of varicose
veins of the leg; some of them accompanied with tedious ulcers, which, after the vena saphena major had been tied, where it passes over the inside of the knee, were readily healed, and the dilatations of the veins relieved. There cannot be a doubt that such practice frequently succeeded; but it is quite as certain that it had many failures. Amongst other evils, an inflammation of the tied vein has been observed, extending very far in the vessel, and succeeded by great constitutional disorder, symptoms very analogous to those of typhus fever and rapid dissolution. In some of these cases, previously to their termination, abscesses form in the direction of the vessel below or above the ligature; while, in other examples, such collections of matter are not observed.* In short, the dangers arising from an inflammation of the internal coat of the veins form the most serious objection to the old manner of operating for the cure of varices. The occasional subsequent attack of this membrane by inflammation, followed by a fever of a very serious nature, rendered several judicious surgeons doubtful of the propriety of continuing the practice. Certain reflections, however, induced Mr Brodie to suspect, that the same ill effects would not follow a similar operation upon the branches themselves. He remarks, that "where the whole of the veins of the leg are in a state of morbid dilatation, and the distress produced by the disease is not referred to any particular part, there seem to be no reasonable expectations of benefit, except from the uniform pressure of a well-applied bandage. But, not unfrequently, we find an ulcer which is irritable and difficult to heal, on account of its connection with some varicose vessels; or, without being accompanied by an ulcer, there is a varix in one part of the leg, painful, and perhaps liable to bleed, while the veins in other parts are nearly in a natural state, or, at any rate, are not the source of particular uneasiness. In some of these cases (says this gentleman), I formerly applied the caustic potash, so as to make a slough of the skin and veins beneath it; but I found the relief, which the patient experienced from the cure of the varix, afforded but an inadequate compensation for the pain to which he was subjected by the use of the caustic, and the inconvenience arising from the tedious healing of the ulcer, &c.
"In other cases, I made an incision with a scalpel through the varix, and the skin over it. This destroyed the varix as completely as it was destroyed by the caustic; and I found it to be preferable to the use of the caustic, as the operation occasioned less pain, and in consequence of there being no loss of substance, the wound was cicatrized in a much shorter space of time." Mr Brodie employed this method with advantage in several instances; but he afterwards improved and simplified it as follows: "It is evident (says he) that the extensive division of the skin over a varix can be attended with no advantage. On the contrary, there must be a disadvantage in it,
* See Travers On Wounds and Ligatures of Veins, Surgical Essays, Part I.; Oldknow, in Edin. Med. and Surg. Jour. Vol. V.; R. Carmichael, in Transactions of the King's and Queen's College of Physicians, Vol. II.
Surgery. as a certain time will necessarily be required for the cicatrization of the external wound. The improvement consists in this: the varicose vessels are completely divided, while the skin over them is preserved entire, with the exception of a moderate puncture, which is necessary for the introduction of the instrument, with which the incision of the veins is effected." For this operation, Mr Brodie has generally employed a narrow sharp-pointed bistoury, slightly curved, with its cutting edge on the convex side. Having ascertained the precise situation of the vein, or cluster of veins, from which the distress of the patient appears principally to arise, he introduces the point of the bistoury through the skin, on one side of the varix, and passes it on between the skin and the vein, with one of the flat surfaces turned forwards, and the other backwards, until it reaches the opposite side. He then turns the cutting edge of the bistoury backwards, and in withdrawing the instrument the division of the varix is effected. The patient is to be kept quiet in bed for four or five days after the operation, and the bandage and other dressings removed with the utmost care and gentleness. In none of the cases in which Mr Brodie had operated at the time, when he published an account of the plan, had the operation been followed by inflammation of the coats of the divided veins. The examples, for which the method is considered by him advisable, are not those in which the veins of the leg generally are varicose, or in which the patient has little or no inconvenience from the complaint; but those in which there is considerable pain referred to a particular varix; or in which hemorrhage is liable to take place from the giving way of the dilated vessels; or in which they occasion an irritable and obstinate varicose ulcer. (Med. Chir. Trans. Vol. VII.)
Of Amputations. Many useful additions might be made to what is stated concerning amputation, in the former Article; but we must confine our remarks to a few of the most interesting things, on which the genius and industry of modern surgeons have been beneficially exerted in this part of practice. Every person accustomed to see much of surgery knows very well, that it is frequently a matter of greater difficulty to understand precisely when amputation ought, or ought not to be performed, than how the operation is to be done; and certainly a more important question, with reference to the patient's safety, and his future crippled or unmitigated condition, cannot be imagined.
Compound fractures of the thigh from gunshot violence are injuries, in which the prompt performance of amputation is frequently the only chance of preserving life. However, in these examples, the urgency for the operation varies. According to Schmucker, all gunshot fractures of the middle and upper part of the femur are attended with very great danger. But, says he, if the fracture be situated at the lowest part of the bone, the risk is considerably less, the muscles here not being so powerful. In such a case, therefore, amputation should not be performed before every other means has been fairly tried; and very frequently he treated fractures of
Surgery. this kind with success, though the limb sometimes continued stiff. Of course, these remarks imply, that, in addition to the mere solution of continuity in the bone, the soft parts are not extensively contused and lacerated, nor the bone very much smashed; circumstances which, as far as our experience in military surgery extends, would form a just reason against any attempt to save the limb; as the delay would neither be attended with success, nor leave a second opportunity of amputating with an equal chance of rescuing the patient from danger. When the bone was completely fractured, or splintered by a ball at its middle, or above that point, Schmucker, very judiciously, never waited for the bad symptoms to commence, but amputated before they had had time to originate; and, when the operation was done early enough, most of his patients were saved. On the contrary, when the operation had been delayed some days, and inflammation, swelling, and fever had come on, the issue was much less fortunate. The correctness of the opinion of this experienced surgeon is confirmed by the valuable testimony of our army surgeons, who had opportunities, in the course of the late war, of seeing many of those severe gunshot injuries of the thigh. In particular, the following observations upon the point under consideration, delivered by Mr Guthrie in his Treatise on Gunshot Wounds, are entitled to the greatest attention. "The danger and difficulty of cure, attendant on fractures of the femur from gunshot wounds," says he, "depend much on the part of the bone injured, and, in the consideration of these circumstances, it will be useful to divide it into five parts. Of these, the head and neck, included in the capsular ligament, may be considered the first; the body of the bone, which may be divided into three parts; and the spongy portion of the lower end of the bone, exterior to the capsular ligament, forming the fifth part. Of these, the fractures of the first kind are, I believe, always ultimately fatal, although life may be prolonged for some time. The upper third of the body of the bone, if badly fractured, generally causes death at the end of six or eight weeks of acute suffering. I have seen few escape, and then not with an useful limb, that had been badly fractured in the middle part. Fractures of the lower or fifth division are in the next degree dangerous, as they generally affect the joint; and the least dangerous are fractures of the lower third of the body of the bone." With respect even to these, Mr Guthrie also admits, that, when there is much shattered bone, the danger is great; so that a thigh fractured by gunshot, even without particular injury of the soft parts, is one of the most dangerous kinds of wounds that ever occur.
The very important maxim in military surgery is now completely settled by the general assent of every experienced army surgeon, namely, that, when a limb is so injured as to leave no rational chance of ultimately preserving it, amputation should be performed without delay, before inflammation, fever, and other bad symptoms originate. This rule is parti-
* None of the cases of this kind which fell under our own observation lasted so long.
Surgery. cularly applicable to the cases of compound fracture of the femur above specified as requiring the operation.
Another kind of injury, urgently demanding the immediate performance of amputation, is that in which a considerable portion of the whole thickness of a limb has been carried away by a cannon-ball or bomb. The necessity of this practice was inculcated by M. Faure himself, in former days one of the chief opponents of operating in the early stage of gunshot injuries; and it is strongly insisted upon in the valuable writings of Schmucker, Larrey, &c.
When a body, propelled by the explosion of gunpowder, strikes a limb so as to smash the bones, and violently contuse, lacerate, and deeply tear away the soft parts, amputation ought not to be delayed. If the operation be put off, all the injured parts will soon be attacked with gangrene, and the constitution be so generally and severely disordered, that a second opportunity of removing the limb will hardly be afforded. It is but justice to the memory of Mr Faure to mention, that this was a kind of case, which he particularly pointed out, as requiring the operation without the least delay.
If a similar body were to carry away a great mass of the soft parts, and the principal vessels of a limb, without fracturing the bone, immediate amputation is proper. Mr Guthrie also lays it down as a rule, to operate without loss of time, when the artery and vein on the inside of the thigh are injured, even though there should be no fracture. This gentleman likewise approves of the same practice, when a wound of the femoral artery accompanies a fracture of the thigh-bone.
Another case, demanding the immediate performance of amputation, is where a grape-shot has struck the thick part of a limb, broken the bone, divided and torn the muscles, and destroyed the principal nerves, without interfering, however, with the main artery. Mr Guthrie says, that if a cannon-shot strike the back part of the thigh, and carry away the muscular part behind, and with it the sciatic nerve, amputation is necessary, even though the bone be unhurt. In this case, he would not make a circular incision, but save a flap from the fore part, or sides, to cover the bone.
If a spent cannon-ball, or one that has been reflected, should strike a limb obliquely, without producing a solution of continuity in the skin, as often happens, the parts which resist its action, such as the bones, muscles, tendons, aponeuroses, and vessels, may be crushed and lacerated. Here, if the bones should feel through the soft parts as if they were smashed, and a kind of fluctuation indicate the rupture of the large vessels, amputation should take place without delay. The real state of the parts under the skin, however, should first be examined by means of an incision, which, when the principal vessels and the bones have escaped injury, will be of itself adequate to afford relief, by letting out the large quantity of extravasated blood generally found in such cases under the integuments.
When the articular heads of the bones are much broken, especially those which form the joints of the knee or foot, and the ligaments are lacerated, imme-
diate amputation is the right practice. Fractures of the patella, without injury of the other bones, will sometimes admit of delay. Even extensive sword wounds of the elbow joint are alleged by Baron Larrey to demand immediate amputation.
The common doctrine in the treatment of mortification has always been, not to attempt amputation until the stoppage of the disorder is denoted by the appearance of a red line on the margin of the living skin. However, the observations of Baron Larrey tend to prove that this maxim, if acted upon in cases of mortification from gunshot wounds and external injuries, would be productive of the worst consequences, and leave the patient hardly a possibility of recovery. On the contrary, he strongly urges the speedy performance of the operation, even though the mortification be yet in a spreading state. It was formerly imagined that the stump would always be attacked with gangrene, if amputation were done under these circumstances; but modern experience contradicts this opinion, and some observations, made by Mr Lawrence on this point, will be found to corroborate the view of the subject given by Larrey. (Med. Chir. Trans. Vol. VI.)
The establishment of the propriety of the severe operation of amputation at the hip-joint; the determination of the circumstances under which this attempt to save the patient should be made; and the settlement of the best manner of performing the operation, are also some of the useful results of the attention and zeal, with which the practice of surgery has been cultivated in modern times. As there are unquestionably some descriptions of injury where life must inevitably be lost if this proceeding be rejected, and experience proves that it sometimes answers, an important consideration is, What cases are most proper for it? Here we fully agree with Dr Thomson, that the examples in which it is particularly called for, and where no delay should be suffered, are those in which the head or neck of the thigh-bone has been fractured by a musket-ball, grape-shot, or small piece of shell. Larrey thinks the operation proper where the thigh has been shot off high up, or where the femur and soft parts near the hip have been broken and extensively lacerated by a cannon-ball or shell. Under such circumstances, however, the operation, though perhaps the only chance, must almost always fail, because injuries of this description occasion a shock to the constitution, of which the patient mostly sinks either immediately or in a few hours. There have now been at least three successful amputations at the hip-joint; the first was done by Larrey, the second by Mr Brownrigg, and the third by Mr Guthrie. All the examples were gunshot injuries, the only cases, we believe, in which the operation is ever justifiable. For further observations on this subject, the reader may consult Cooper's Dictionary of Surgery, where will be found a description of the various methods of operating, and a detail of the reasons for or against all the different modes which have been proposed.
Amputations, in general, have been of late years much improved by the rejection of the large clumsy ligatures, which were formerly used; whereby considerable irritation was kept up, union by the first
Surgery. intention materially prevented, the formation of large abscesses promoted, and secondary hemorrhage rendered much more frequent, than at the present time. Mr Lawrence adopts the plan of tying the vessels with fine silk ligatures, and cutting off the ends as close to the knot as is consistent with its security. Thus the extraneous matter in the wound is reduced to the insignificant quantity, which forms the noose actually surrounding the vessel, and the knot by which that noose is fastened. Of the silk which he commonly employs, a portion, sufficient to tie a large artery, when the ends are cut off, weighs between and of a grain; a similar portion of the thickest kind weighs of a grain, and of the slenderest .
Mr Lawrence observes, that the kind of silk twist, which is commonly known in the shops by the name of dentists' silk, and which is used in making fishing lines, is the strongest material, in proportion to its size, and, therefore, the best calculated for the purpose, which requires considerable force in drawing the thread tight enough to divide the fibrous and internal coats of the arteries. This twist is rendered very hard and stiff by means of gum, which may be removed by boiling it in soap and water; but the twist then loses a part of its strength. The stoutest twist which Lawrence uses is a very small thread, compared with ligatures made of inkle. The quantity of such a thread necessary for the noose and knot on the iliac artery weighs of a grain; or, if the gum has been removed, about . This gentleman's experience fully proves, that there is no danger of these ligatures cutting completely through the vessel, as certain surgeons have apprehended. Some objections have been urged against the practice, on the ground of its giving rise occasionally to little festerings, and even to ill-looking abscesses; but, it is justly remarked by Mr Lawrence, in reply to these objections, that as they are not accompanied by any description of the materials, or size of the ligature, nor by any details of the unfavourable cases, we cannot judge whether the events alluded to are to be attributed to the method itself, or to the way in which it was executed. (Med. Chir. Trans. Vol. VI.) In a paper of later date, he says, his further experience has confirmed the usefulness of the method; that, by diminishing irritation and inflammation, and simplifying the process of dressing, it very materially promotes the comfort of the patient and the convenience of the surgeon; while it has not produced ill consequences, or any unpleasant effect in the cases which have come under his own observation. The small knots of silk generally separate early, and come away with the discharge; where the integuments have united by the first intention, the ligatures often come out rather later with very trifling suppuration, and, in some instances, they remain quietly in the part. (Op. cit. Vol. VIII.)
Syphilis. In relation to syphilis, the judicious and impartial investigations of modern surgeons have succeeded in dispelling a considerable number of erroneous doctrines formerly entertained respecting this intricate and perplexing disease. Amongst other things, Mr Hunter inculcated, that "the venereal matter,
when taken into the constitution, produces an irritation, which is capable of being continued, independent of the continuance of absorption, and the constitution has no power of relief; therefore, a lues venerea continues to increase." The same criterion was proposed by Mr Abernethy, who states, that the "constitutional symptoms of the venereal disease are generally progressive, and never disappear, unless medicine be employed." And, notwithstanding some dissent may be traced in both old and recent writers, from the belief that mercury was absolutely essential to the cure of syphilis, and an opposite conclusion might easily have been made from a review of the whole history of the subject, including the practice of former and present times; still the contrary hypothesis was what was always taught in all the great medical schools of this country, even till within the last few years. But this mistaken notion no longer prevails; and no facts are more completely established, than that mercury, however useful it may frequently be in the treatment of this disease, is not absolutely necessary for the cure either of the primary or secondary symptoms; and that the disease, so far from always growing worse, unless mercury be administered, ultimately gets well of itself, without the aid of this or any other medicine. If any man yet doubt the general truth of this statement, let him impartially consider the many facts and arguments brought forward in proof of it, in the writings of Dr Fergusson, Dr Hennen, Dr Thomson, Mr Rose, Mr Guthrie, Mr Bacot, and others. In short, if there be such a sceptic now living in this country, let him peruse the returns made by the surgeons of the whole British army; let him consider the evidence of the surgeons of other countries, especially that of Cullerier, who annually demonstrates to his class of pupils the cure of venereal ulcers without mercury; and the testimony and practice of the German surgeons, who were attached, during the war, to regiments of their countrymen in the British service. The fact is, therefore, indisputable, that the venereal disease, in all its ordinary and diversified forms, is capable of a spontaneous cure; and, consequently, that the question, whether a disease is syphilitic or not, can never be determined by the circumstance of the complaint yielding, and being permanently cured, without the aid of mercury. Yet, as Mr Rose has observed, the supposition that syphilis did not admit of a natural cure, and that mercury was the only remedy that had the power of destroying its virus, was of late so much relied upon, that, where a disease had been cured without the use of that medicine, and did not afterwards return,—such fact alone, whatever might have been the symptoms, was regarded as sufficient proof, that it was not a case of syphilis. And, as the same writer very judiciously remarks, the refutation of these notions is of considerable importance, "not so much in reference to the treatment of syphilis, under common circumstances (for the strikingly good effects of mercury will probably not render it advisable, in general, to give up the use of that remedy"), as to the change it will produce in our views of the diagnosis of the disease. The distinction, which has engaged such a share of attention of late years, and which is evidently so important be-
Surgery. tween syphilis and syphilitic diseases, has been made to depend so much on the former admitting of no cure, except by mercury, that, if this principle should be found to be erroneous, the difficulties which have attended it will be in a great measure explained. (Med. Chir. Trans. Vol. VIII.)
Dr Fergusson assures us that, in Portugal, the disease, in its primary state amongst the natives, is curable without mercury, by simple topical treatment; that the antisyphilitic woods, combined with sudorifics, are an adequate remedy for constitutional symptoms; and that the virulence of the disease has there been so much mitigated, that, after running a certain course (commonly a wild one) through the respective orders of parts, according to the known laws of its progress, it exhausts itself, and ceases spontaneously. (Op. cit. Vol. IV.) The conclusion to which the writings of Mr Pearson led, long before recent investigations began, was, that venereal sores might be benefited, and even healed, under the use of several inert insignificant medicines. But, amongst modern writers, we find Dr Clutterbuck one of the earliest in distinctly asserting, that the healing of a sore without mercury was no test of its not being venereal. (Remarks on the Opinions of the late J. Hunter, 1799.) It is curious to remark, that this important truth is rendered conspicuous in the treatises of Mr Pearson and Dr Clutterbuck, though both these gentlemen were, at the time of their publishing, as much advocates for full mercurial courses as can well be conceived. But, although the whole history of syphilis, and of the effects of various articles of the materia medica, if carefully reflected upon, must have led to the above-mentioned inference; the truth was never placed in such a view as to command the general belief of all the most experienced surgeons in this and other countries of Europe. It is not meant, that the truth was not seen and remarked by several of the older writers; for that it was so any man may convince himself by referring to their works. But it is to be understood, that a great deal of indecision could never be renounced as long as prejudices interfered with the only rational plan of bringing the question to a final settlement; we mean that of instituting experiments upon a large and impartial scale, open to the observation of numerous judges, yet, under such control, as insured the rigorous trial of the non-mercurial treatment. Nor could such investigation be so well made by any class of practitioners as the army surgeons, whose patients are numerous, and obliged to follow strictly the treatment prescribed, without any power of going from hospital to hospital, or from one surgeon to another, as caprice may dictate; or of eluding the observation of the medical attendants after a seeming recovery. To us it appears, that the most important and cautious document yet extant, on the two questions of the possibility and expediency of curing the venereal disease without mercury, is the paper of Mr Rose. For, let it not be assumed, that, because the army surgeons find the venereal disease curable without mercury, they mean to recommend the total abandonment of that remedy for the distemper, any more than they would argue that possibility and expediency are
synonymous terms. At the time when Mr Rose published his observations, he had tried the non-mercurial treatment in the Coldstream Regiment of Guards, during a year and three quarters, and had thus succeeded in curing all the ulcers on the parts of generation which he met with in that period, together with the constitutional symptoms to which they gave rise. "I may not be warranted in asserting," says this gentleman, "that many of these were venereal, but, undoubtedly, a considerable number of them had all the appearances of primary sores produced by the venereal virus, and arose under circumstances where there had been at least a possibility of that virus having been applied. Admitting that there is nothing so characteristic in a chancre as to furnish incontrovertible proof of its nature, it will yet be allowed, that there are many symptoms common to such sores, although not entirely peculiar to them; and whenever these are met with, there are strong grounds to suspect, that they are the effects of the syphilitic virus. In a sore, for instance, appearing shortly after a suspicious connection, where there is loss of substance, a want of disposition to granulate, and an indurated margin and base, there is certainly a probability of that poison being present. Amongst a number of cases of such a description, taken indiscriminately, the probability of some being venereal is materially increased, and must at last approach nearly to a certainty. On this principle, some of the sores here referred to must have been venereal. They were also seen by different surgeons, on whose judgment I would rely, who agreed in considering many of them as well-marked cases of true chancre." The men thus treated were examined almost every week for a considerable time after their apparent cure, "both that the first approach of constitutional symptoms might be observed, and that any deception from an underhand use of mercury might be guarded against." In Mr Rose's practice, all idea of specific remedies was entirely laid aside. The patients were usually confined to their beds, and such local applications were employed as the appearances of the sores seemed to indicate. Aperient medicines, antimony, bark, vitriolic acid, and occasionally sarsaparilla, were administered. Upon an average, one out of every three of the sores, thus treated, was followed by some form or another of constitutional affection; this was in most instances mild, and sometimes so slight, that it would have escaped notice, if it had not been carefully sought for. The constitutional symptoms were evidently not such as could be regarded as venereal, if we give credit to the commonly received ideas on the subject. Caries of the bones, and some of the least equivocal symptoms, did not occur. In no instance was there that uniform progress, with unrelenting fury, from one order of symptoms and parts affected to another, which is considered as an essential characteristic of true syphilis. The constitutional symptoms also yielded without the aid of mercury; and frequently, primary sores, corresponding to what has been called the true chancre with indurated base, were cured in this manner; yet without being followed by any secondary symptoms. We are also
Surgery. informed, that several cases occurred of a cluster of ill-conditioned sores over the whole inner surface of the prepuce, and behind the corona glandis; and also of a circle of small irritable sores, situated on the thickened and contracted ring at the extreme margin of the prepuce. These occasionally produced buboes. None of the sores of this description were followed by any constitutional affection. Mr Rose bears testimony to the ill effects of mercury and stimulants in cases of phagedenic ulcers, and confirms an opinion, not uncommonly prevailing, that they are seldom followed by secondary symptoms; which opinion, perhaps, ought to be qualified with the condition, mentioned by Mr Guthrie (Med. Chir. Trans. Vol. VIII.), that no mercury be given; for, in this circumstance, secondary symptoms are more frequent.
But, although the fact of the possibility of curing every kind of ulcer on the genitals without mercury is now completely established, and it is of great importance with regard to the removal of an erroneous doctrine concerning the diagnosis, and also in encouraging practitioners even not to be frightened into the use of mercury, when the patient's constitution is in an unfavourable state for its exhibition, or the case is of a doubtful nature; yet, the expediency of the non-mercurial practice must evidently be determined by other considerations; the principal of which are, the comparative quickness of the cures effected with or without mercury; the comparative severity and frequency of secondary symptoms; and the generally acknowledged fact, that a syphilitic sore is not indicated, with any degree of certainty, by its mere external appearance, or, indeed, any other criterion. For the consideration of the evidence on these, and various other points connected with the present subject, we must refer to the last edition of Cooper's Surgical Dictionary, from which many of the foregoing remarks are selected.
In the former article, a short section will be found upon inflammation of the iris; a disease upon which modern surgeons have bestowed all the attention which its importance required, and the results, as might be expected, have been greater accuracy in the discrimination of the complaint, and much improvement in its treatment. The iris, next to the conjunctiva, is found to be that texture of the eye, which is most frequently affected with inflammation. It often becomes inflamed in consequence of surgical or accidental wounds of the eye-ball. A peculiar and characteristic iritis is generally supposed to be one of the constitutional effects of syphilis. Scarcely any disease, to which the eye is subject, has a more immediate or rapid tendency to destroy vision.
In the idiopathic iritis, as Professor Schmidt has remarked, besides the common symptoms of ophthalmia, certain changes happen at the very commencement of the case, indicating the seat of inflammation. The pupil appears contracted, the motions of the iris are less free, and the pupil loses its natural bright black colour. The brilliancy of the colour of the iris fades, and the part becomes thickened and puckered, with its inner margin turned towards the crystalline lens. The change of colour
Surgery. happens first in the lesser circle of the iris, which becomes of a darker hue; and afterwards in the greater circle, which turns green, if it had been greyish or blue; and reddish, if it had been brown or black. The redness accompanying these changes is by no means considerable, and is at first confined to the sclerotic coat, in which a number of very minute rose-red vessels are seen, running in straight lines towards the cornea. In the words of Mr Saunders, the vascularity of the sclerotica is very great, whilst that of the conjunctiva remains much as usual, the plexus of vessels lying within the latter tunic. The inosculations of these vessels are numerous, and at the junction of the sclerotica with the cornea, they form a kind of zone. Here the vessels disappear, not being continued over the cornea, as in a case of simple ophthalmia, but penetrating the sclerotica in order to reach the inflamed iris. The irritation of the light is distressing, and the patient is much annoyed by any pressure on the globe of the eye, or by the rapid or sudden motions of this organ. Considerable uneasiness is felt over the eyebrow, and acute lancinating pains shoot through the orbit towards the brain. The pupil loses its circular form, becomes somewhat irregular, and presents a greyish appearance. When examined with a magnifying glass, this appearance is found to be produced by a substance very like a cobweb, occupying the pupil, and which can soon afterwards be distinguished, even without the aid of a glass, to be a delicate flake of coagulable lymph, into which the dentations of the irregular margin of the iris seem to shoot, and at these points adhesions are apt to be formed. In consequence of these adhesions, the patient, whose vision has been all along indistinct, now complains of being able to see only on one side, or part of an object. Lymph is next deposited on the anterior surface of the iris, and between the iris and the capsule of the lens, and often in such quantity, that it extends through the pupil, and hangs down to the bottom of the anterior chamber. If this process is not checked, the pupil becomes entirely obliterated, or the iris adheres to the capsule of the lens; a very small opening only being left, which is usually occupied by an opaque portion of the capsule, or of organized lymph, and the patient is quite blind.
Schmidt, Beer, and many English surgeons, believe one form of iritis to be syphilitic. The affection of the iris may be accompanied with other symptoms of lues venerea, or it may take place singly before any of these have appeared. A pale redness, all round the cornea, is the first symptom perceived in the syphilitic iritis: it is at first confined to the sclerotic coat, but the conjunctiva very soon participates in it, and afterwards is the reddest of the two parts. However few the vessels may be elsewhere, there is always a broad zone of them all round the cornea. The redness is also described as having a peculiar tint, being brownish, something like the colour of cinnamon; or, as Mr Travers expresses himself, having a brick-dust, or dusky red, instead of a bright scarlet hue. The lymph, he says, is compact and brown, and intimately adherent to the iris, instead of being curd-like, loose, and
Surgery. of a yellowish white colour. (Surgical Essays, Part I.) The whole of the cornea now grows hazy, without being at any point actually opaque. The pupil becomes contracted, and the iris limited in its motions, as in common iritis; but the pupil, instead of preserving its natural situation, is drawn in the direction upwards and inwards, towards the root of the nose, and is irregular. The iris also loses its natural colour, and projects forwards. An aggravation of the symptoms always takes place towards evening; the intolerance of light, and painful sensibility of the whole eye increasing, and a gush of tears following every change of light and temperature. At length, a regular nightly pain begins, which is extremely severe, and strictly limited to that part of the cranium which is immediately over the eye-brow. It reaches its greatest severity about midnight, and then diminishes till about four or five o'clock in the morning, when it ceases. Afterwards, one or more reddish-brown tubercles, of a spongy look, arise either on the pupillary or ciliary edge of the iris, or on both of them, and grow rather fast. Sometimes little ill-conditioned ulcers are produced on the cornea, conjunctiva, or skin of the eye-lids. Even when the case terminates in the most favourable manner, the eye remains, for a long time, peculiarly sensible to the influence of cold and moisture. In the iritis, which appears in conjunction with eruptions, supposed to be connected with the abuse of mercury, the inflammation is less active, than in the other forms of iritis. The pupil is not much contracted, and lymph is less apt to be effused.
The principal danger of iritis is ascertained to depend upon the effusion of lymph, its quick organization, the rapid formation of adhesions between the iris and other parts, and the closure and obstruction of the pupil. Now, in modern practice, the management of the disease is much more successfully effected than twenty years ago, when in truth the nature of the case was but incorrectly known; and the great thing that has led to the improved treatment is the discovery of the fact, that mercury is one of the most effectual means of stopping the effusion, and promoting the absorption of lymph in the adhesive inflammation; a fact which was first particularly insisted upon by Dr Farre.
In idiopathic iritis, before lymph is effused, the means most likely to do good are copious bleeding and cathartics, followed by nauseating doses of tartarized antimony. This plan is to be assisted with leeches applied near the eye, and repeated according to the urgency of the case. When the inflammation stops in this stage, Saunders states, that the cure may be completed by covering the eye with linen wet with a collyrium of acetite of lead, and keeping the patient for some time in a dark room. Schmidt, however, condemns all cold applications in iritis as quite useless; and he asserts, that the only admissible topical treatment consists in fomenting the eye with warm water. In the first stage of the disease, he says, blisters on the temple, or behind the ears, have little or no effect, though they are sometimes useful when put on the nape of the neck.
But no sooner is lymph effused, than the principal
aim of the surgeon should be to bring about its absorption. Of all remedies for this purpose, none answer so well as mercury, which is to be freely exhibited, so as to affect the constitution as quickly as possible. The ointment, or pil. hydrargyri with opium, may be employed, and, in very urgent cases, the medicine may be used both externally and internally. In the second, or adhesive stage of iritis, Beer prescribes calomel combined with opium; applies to the eye itself a collyrium, containing oxy-muriate of mercury, mucilage, and a considerable proportion of vinum opii; and, when this application ceases to be effectual, he has recourse to a salve, composed of two drachms of fresh butter, six grains of red precipitate, and eight grains of the extract of opium. Frictions over the eye-brow once a day, with mercurial ointment, containing mercury, he says, will also have great effect in producing the absorption of the effused lymph. The late Mr Saunders used to resist the tendency of the pupil to contract by means of the extract of belladonna; with which he smeared the eye-lids and eye-brows, or which he diluted with water, and then dropped between the eye and eye-lids.
In the syphilitic iritis, general bleeding is not considered so necessary as in idiopathic cases. When the pain in the eye and head is severe, leeches may be applied, and the bowels emptied. The nightly attacks of pain are to be prevented by rubbing a small quantity of mercurial ointment, with opium, just above the eye-brow, a short time before the pain is expected to begin, and then covering the eye with a folded piece of warmed linen. Mercury is to be employed so as to affect the system, either in the form of ointment, or of calomel pills joined with opium.
The form of iritis, conjectured to proceed from the abuse of mercury, or accompanying ambiguous eruptions of the popular sort, or such as are not syphilitic, also requires a combination of the depleting with the mercurial plan. This circumstance, in relation to the first of these cases, seems extraordinary, as involving the seeming inconsistency of mercury being both the exciting cause, and the antidote of the disease. But, though iritis does present itself, accompanied or connected with various suspicious symptoms, and in individuals who have used considerable quantities of mercury, it cannot be said that mercury alone, that is, without the agency of some other additional causes, is really an exciting cause of iritis; or, if such assertion be made, the clear proof of the fact is yet wanting; and here we should also be disinclined to receive, as such proof, any rare and solitary instance of an attack of iritis after the free use of mercury in a case of a totally different nature from syphilis, or syphilitic disease. Mercury cannot be supposed to render a patient insusceptible of iritis; and, therefore, a few uncommon attacks after its administration for liver complaints, or other disorders quite unconnected with lues venerea, or the many diseases resembling it and confounded with it, would prove little or nothing to the point. In the meanwhile, the good effect of mercury in the examples of iritis, supposed to arise from the