Part 63

It has been said that men are more liable to cataract than women; the difference, however, if any, is probably very slight. Thus, in the first table, 61 were males and 60 females; in the second, 268 were males and 232 females.—ED.]

See Elements of Pathological Anatomy, vol. i., p. 489, for description of this fascia.

Boston Medical and Surgical Journal, Dec. 29th, 1841.

Mr. Bell thinks that the separation of the gum from the teeth, as a preliminary measure, is unnecessary; a view in which I must entirely disagree with him. That it materially facilitates the removal of the organ from its socket, ample experience has long since convinced me. The operation may be performed with a gum-lancet, or, what I have always preferred, a sharp penknife, which should be passed completely round the neck of the tooth, down to the alveolar margin of the jawbone. In the removal of the first teeth in children the previous separation of the gum is unnecessary.

The incisors of the upper jaw will require the use only of a small pair of straight forceps, the application of which is extremely simple. As the roots of these teeth are conical, and generally perfectly round, they will require merely a slight rotation, when they may be drawn downwards in the direction of the socket. The forceps should be placed as high on the root as the alveolar process will admit, and pressed so firmly as to prevent the blades from slipping, while at the same time care is taken not to crush the tooth.

The extraction of the lower incisors is effected in a very different manner. The roots of these teeth being very much flattened laterally, it is obvious that they cannot be dislodged upon the principle of simple rotation in the socket. When the tooth is even, or nearly so, with the others on each side of it, the best instrument will be the hawk’s-bill forceps, of very small size, and with narrow blades. The instrument being fixed as low on the neck of the tooth as possible, a gentle but firm movement is to be made forwards, so as just to separate the organ from the back part of the alveolar cavity, and then, continuously with this motion, the tooth is at once to be raised out of the socket.

The superior cuspid and bicuspid teeth may generally be removed by means of the same straight forceps as the incisors. The extraction of the former will be considerably facilitated, by giving a slight degree of rotation previous to its actual dislodgement from the socket. The bicuspids, on the contrary, having flatter sides, and less solid roots, will not allow of any degree of rotation; and must therefore be dislodged by first of all moving them a little outwards towards the cheek, so as to destroy the attachment to the inner alveolar plate, and then, by a perpendicular pull, they may be lifted directly from the socket.

The cuspids of the lower jaw are to be removed by the same means as the incisors. For the extraction of the bicuspids the key is the best instrument. The claw, placed in the usual position, should be rather small, and the fulcrum well covered with lint.

The removal of the first and second molars of the upper jaw will generally be best effected with a pair of large forceps, slightly bent at the blades. In applying this instrument to the teeth in question, the edges must be thrust as far under the border of the gum as possible, and a firm, steady hold taken of the tooth. It is then to be dislodged by first a steady, gradual bearing outwards until it is slightly moved, when, with a contrary motion into its former position, followed by a firm pull downwards, the tooth is removed with considerable facility. The corresponding teeth of the lower jaw may be extracted by the same means, or with a pair of hawk’s-bill forceps, the longer blade of which is to be placed on the inner gum. The operator standing on that side of the patient from which the organ is to be removed, and having taken a firm hold, first moves the tooth a little outwards towards himself, and then, with a steady and continuous movement, draws it almost straight from the socket; a motion which the inclination of the handle will greatly facilitate. The wisdom-teeth are best extracted with the forceps; their roots are small, and but little force is required for their removal.

When the crowns of any of the teeth are so entirely destroyed that the forceps and the key are alike insufficient to remove the roots which remain, the elevator, as it is called, will be found a very simple and efficient means to effect it. The edge of the instrument is to be inserted between the root and the alveolus, so far as to secure a sure hold, and the root is then to be lifted, as it were, from the socket, by resting the instrument upon the alveolar process, or even upon the side of a neighbouring tooth. There is not the least danger of injuring the latter if care be taken not to depend too exclusively, nor to bear with too much force upon it.—ED.]

Daniel Monday, a married negro, thirty-six years of age, of a stout muscular frame, and a brickmaker by occupation, consulted me, in February, 1841, for a circumscribed, pulsating tumour, produced by the recoil of the butt-end of a yager, and situated beneath the right pectoral muscle, extending from the clavicle down towards the cartilage of the fourth rib. It was of an irregular, conical shape, and about the volume of a large fist, measuring fully four inches at its base in one direction, by three and a half in the other. In its feel it was tense, as well as inelastic; the blood rushed into it with a whizzing noise, and the pulsation was so distinct that it could be seen at the distance of some feet from the patient. The clavicle was thrown above its natural level; the whole limb, from the top of the shoulder to the ends of the fingers, was benumbed, painful, and almost deprived of power; the pectoral muscle was much stretched; and the patient constantly inclined his head towards the affected side, keeping the elbow nearly at a right angle, and supporting it carefully with the opposite hand, to prevent tension of the tumour. The swelling of the limb, however, was slight; the temperature was also good, and the pulse at the wrist was nearly as distinct as in the natural state. For the last four weeks the pain was almost incessant; it was particularly severe at the chest and shoulder, and had become so agonizing of late as to deprive him of sleep, and even prevent him from lying down. The appetite was also much impaired, and the countenance expressive of the deepest distress. The tumour had grown with great rapidity during the last two months; and, as there was danger of its bursting, an operation was at once decided upon.

The patient was placed upon a narrow table of moderate height, the head and chest being elevated with pillows, and the face turned slightly towards the opposite side, while an assistant pulled at the wrist, to depress the affected shoulder. The integuments over the clavicle being stretched upon the chest, I made my first incision along the centre of that bone, beginning near the sternal origin of the mastoid muscle, and passing out towards the acromion process of the scapula for about three inches and a half; thus dividing at one stroke the skin, cellular substance, and fibres of the platysma-hyoid. The parts being allowed to retract, left the lower margin of the cut parallel, and on a level with the superior border of the clavicle. A second incision, about two inches in length, was carried along the posterior edge of the sterno-mastoid muscle, at a right angle with the preceding. The triangular flap thus formed was then dissected up and held away, care being taken not to interfere with the external jugular vein, or any of the smaller arteries of the neck. Having advanced thus far, the cervical aponeurosis was detached from the clavicle by cautious strokes of the handle of the scalpel, which laid bare the brachial plexus of nerves and the omo-hyoid muscle. At this stage of the operation a small vein, a branch of the subclavian, was divided, and, although it bled very little, it was immediately secured by a temporary ligature. Taking the omo-hyoid for my guide, I divided the loose cellular substance in the triangular space bounded above by the muscle just mentioned, by the clavicle below, and by the anterior scaleni muscle internally, and thus approached the artery as it passed over the first rib. The vessel here lay at some distance from the inferior branch of the brachial plexus of nerves, rather deeply behind the collar-bone; and with a common aneurism needle, armed with a double ligature of saddler’s silk, no difficulty was experienced in securing it, the instrument being carried from before backwards and from below upwards. The ligature was then drawn very firmly with the fingers, and tied with a double knot within a few lines of the anterior scaleni muscle: as soon as this was accomplished, all pulsation in the sac, as well as at the wrist, ceased. One end of the ligature being cut off, the other was left protruding at the inner angle of the wound, the edges of which were closed by three sutures and adhesive strips. Not half an ounce of blood was lost during the operation, which lasted twenty minutes.

The patient being put to bed, the limb was laid in an easy position, and wrapped in cotton wadding. In less than an hour the temperature, which had been considerably depressed, was thoroughly restored; the pain and numbness had greatly abated; and the poor fellow expressed himself more comfortable than he had been for a month. In less than twenty hours the tumour was quite solid; the ligature came away on the morning of the thirteenth day; and the patient was in all respects convalescent, the swelling having diminished fully one-half in size. No untoward symptoms of any kind occurred until the morning of the twenty-seventh day, when the patient was suddenly seized with intense pain in the right side of the chest, attended with short, hurried, and laborious respiration, quick and tense pulse, great anxiety of countenance, prostration of the vital powers, and entire subsidence of the aneurismal tumour. Being absent from town, he was kindly visited by my friends, Dr. T. L. Caldwell and Dr. S. B. Richardson, until he expired, early on the thirty-first day after the operation.

The body, carefully examined after death, was somewhat emaciated; the wound had completely cicatrised, and the pectoral muscles were a good deal wasted, though in other respects unchanged. The subclavian artery terminated abruptly at the outer margin of the scaleni muscle, where the ligature had been applied, its calibre being closed by a mass of solid fibrin, about one-third of an inch in length, which adhered firmly to the lining membrane, and thus presented an effectual barrier to the passage of the blood. Between this and the thyroid axis the vessel was occupied by a dark coagulum, which, as it was loose, was probably formed only a short time before death. Beyond the seat of the ligature the artery had a rough, ragged appearance, and was sufficiently pervious to admit of the ready passage of a small probe into the aneurismal sac. Superiorly the tumour was overlapped by the brachial plexus, while in front, at its lower part, was the subclavian vein, which, besides being thrown out of its natural course, was considerably diminished in size. No pus was anywhere perceptible, the structures involved in the operation being consolidated by plastic lymph. The aneurismal tumour, placed immediately below the clavicle, was of a conical form, and about the volume of a moderate-sized orange, being two inches and a quarter in diameter at its base. Its walls varied in thickness at different points, from half a line to the eighth of an inch; and its interior communicated, by means of an oval aperture, one inch and three-quarters in length by an inch and a half in width, with the pleuritic cavity: it was situated between the first and second ribs, nearly equi-distant between the sternum and the spine, and was the result obviously of ulcerative absorption induced by the pressure of the tumour. Both ribs were denuded of their periosteum immediately around the opening, and the serous membrane had a shreddy, ragged aspect. The aneurismal sac contained a few reddish clots arranged in a laminated manner, and closely adherent to its inner surface, especially at the part corresponding with the apex of the tumour.

The right thoracic cavity contained nearly three quarts of bloody-looking serum, intermixed with flakes of lymph and laminated clots; the latter of which were of a reddish-brown colour, and had evidently escaped from the aneurismal sac. The pleura exhibited signs of extensive inflammation; and the right lung was greatly reduced in volume, from the compression of the effused fluid. The left lung was considerably engorged, and at one or two points almost hepatized. The heart and pericardium were sound, as were also the abdominal viscera, and the larger arterial trunks.

From the description of this operation in the text, it will be seen that Mr. Liston recommends two incisions, as performed in the above case. Were I to be again called upon to tie the subclavian artery above the clavicle, I should certainly omit the vertical incision, from a conviction that it is altogether unnecessary: it does not expedite the operation, nor does it facilitate the application of the ligature.—ED.]

With the assistance of Dr. Drane, an incision, five inches in length, was made over the course of the humeral artery; and after much difficulty, owing to the confused state of the parts, a ligature was placed above and below the orifice, which was found to be at least six lines long! All the grumous blood, amounting to nearly a quart, was squeezed out, when the edges of the wound were brought together with adhesive strips and a roller extending from the wrist upwards. Very little sloughing took place; and, notwithstanding the exhausted condition of the patient at the time of the operation, he made a very speedy recovery.—ED.]

A most singular and instructive case of this disease is reported by my distinguished friend, Professor Parker, in the New-York Medical Gazette, for January, 1842. The woman, who was thirty years of age, was the mother of five children, the youngest nine months old, and had always enjoyed good health. The swelling occupied the right breast, and was first noticed about three months after her confinement: it was free from pain, and without tenderness on pressure. The skin was a little more vascular than in the sound state, the veins were enlarged, and there was evident fluctuation. The child had nursed from both breasts. With a trocar, not less than three quarts of milk were drawn off at one operation! Professor Parker requested the woman to wean her child, and to return to his clinique in a week. At the expiration of this period the fluid had reaccumulated to the amount of three pints. In a fortnight thereafter it was evacuated a third time, but in what quantity is not stated. Since then, as the professor has recently informed me, he has not heard from his patient; and it is, therefore, uncertain how much, if any, she has been benefited by the operations in the way of a permanent cure.

Small swellings of this kind rarely require any treatment beyond the application of some stimulating embrocation, to promote the absorption of the effused fluid. When the accumulation, however, is very large, as in the case above mentioned, it will be necessary not only to evacuate the milk, but to obliterate, if possible, the sac. This may be done, I conceive, either by stimulating injections, such, for example, as are used for the radical cure of hydrocele, by the introduction of the seton, or by laying open the tumour, and wearing a tent. In the former case, which, on the whole, I should prefer, assistance might be derived from methodical compression. Diminishing the quantity of milk by weaning the child would be an important preliminary step.—ED.]

Dr. Lotz, of Pennsylvania, succeeded a few years ago in curing a case of a similar kind, by means of an instrument which possesses some advantages over that of Dupuytren, and an account of which is published in the eighteenth volume of the American Journal of the Medical Sciences. It is composed of two blades, each six inches long, which are worked by two screws, and which terminate in front in two fenestrated branches, twelve lines in length by three in width. One blade being inserted into each extremity of the gut, they are carefully adjusted by tightening the screws, and are thus made to compress the intervening membranes. The pressure may be increased or diminished at pleasure. In the case treated by Dr. Lotz, the portion of the bowel corresponding with the fenestræ was excised with a gum-lancet on the fourth day from the application of the instrument, and in this manner a direct passage was created between the two ends of the tube.—ED.]

The ligatures which are employed in sewing up a wounded intestine are detached at a period varying from ten days to three or four weeks, according to the nature of the suture. When the extremities are cut off close to the knots, they invariably fall into the cavity of the bowel, and are finally discharged along with the feces; if, on the other hand, they are brought out at the external opening, they pass off in that direction instead of the one just mentioned.

When the opening in the gut is small, not exceeding three or four lines in extent, the margins may sometimes be advantageously encircled with a ligature, with the ends cut off close to the peritoneal surface. Sir Astley Cooper tied up an aperture in this manner in the human subject, in a case of strangulated hernia, and the patient recovered without a bad symptom. Professor Gibson, of the University of Pennsylvania, states that he has performed a similar operation with similar results. My experiments on dogs convince me that the plan is a good one. The ligature should be drawn pretty firmly, to prevent it from slipping, and the ends must be cut off close to the knot. It generally makes its way into the bowel in from eight to ten days.

When the bowel is completely severed, or mortified in its entire calibre, the edges, after being properly prepared, should be brought in contact, and retained by the continued or the interrupted suture. Cases of this kind, although apparently desperate, are not always of so hopeless a character as might at first sight be supposed. This is shown, not only by experiments on the inferior animals, but by what occurs in the human subject, in sphacelated hernia, and in intussusception. In the former, the greater part, or even the whole, of the circumference of the tube may be destroyed, and yet the patient ultimately recover, with perhaps the temporary inconvenience merely of an artificial anus; and in the latter, large pieces are not unfrequently detached without any serious suffering, save what is experienced during the antecedent and concomitant inflammation. In my morbid collection is a preparation of this kind, evidently a portion of the colon, nearly a foot long, which was discharged by a child six years old, who, notwithstanding, made a speedy and perfect recovery. Thirty-five cases of a similar character, collected from the writings of different pathologists, have been reported by Dr. Thompson of Europe. In a dog, from which I removed two inches and a half of the ileum, and treated the edges of the wound with six interrupted sutures, complete recovery took place, unattended with a single bad symptom. The threads were introduced at equal distances from each other, with a small sewing-needle, and the ends cut off close to the knots. Four months after the operation, being in good health, and the outer wound entirely healed, he was killed. Externally the bowel was perfectly smooth and natural, as if no injury had ever been inflicted upon it: the mucous membrane was of the same appearance as elsewhere, with the exception of a small depression corresponding with the edges of the wound.—ED.]

See the Editor’s Elements of Path. Anatomy, vol. ii., p. 260.

In the other variety, the tumour is situated within the bowel, from six lines to two inches above the external orifice. Consisting, as was before intimated, in a varicose condition of the capillary vessels, especially the venous: it is soft and compressible, of a deep purple colour, extremely liable to bleed, and of various sizes, from a small bean to that of an almond or upwards. It rarely occurs as an isolated swelling, but in groups or clusters, as many as six or eight being sometimes situated upon a surface not more than an inch and a half or two inches in diameter.—ED.]

Bushe on the Rectum, p. 220.

The principal objection to this method is, that it is not always successful, and that it requires, in some cases, to be repeated again and again before a sufficient amount of adhesive action is induced to obliterate the vaginal sac. Moreover, by carelessness on the part of the surgeon, the canula may slip out of the vaginal sac, and so allow the fluid to pass into the cellular substance of the scrotum, where, if it be not speedily evacuated by free incisions, it is sure to occasion gangrene. But this is not all. The operation, even when well performed, is sometimes followed by violent inflammation and suppuration; in one instance, indeed, I knew it to be productive of tetanus. The patient, a stout, robust mechanic, about twenty-six years of age, whom I saw twice in consultation, was doing apparently well during the first eight days after the operation; when, owing to exposure to cold, the symptoms of the disease in question manifested themselves, and in less than twenty-four hours the man expired. Upon examination after death, the vaginal tunic was found to be considerably thickened, and its cavity to contain several ounces of sero-sanguinolent fluid, intermixed with a small quantity of unhealthy-looking pus. No adhesions had taken place between the opposite sides of the sac. A case of a similar kind is alluded to by Sir George Ballinggall, in his “Outlines of Military Surgery.”

The operation by injection has, I know, many advocates, both in this country and in Europe; and, when well executed, is generally unattended with risk, if not always successful. The fact, however, that it may be followed by serious mischief, with occasional loss of life, should be sufficient to deter the practitioner from resorting to it, more especially when we reflect that we are in possession of another remedy, not only entirely devoid of danger, but always, so far as my observation extends, most effective. This remedy is the seton, which I have been in the habit of employing, in repeated instances, for some years past, and from which I have never experienced any other than the most happy results. The operation is perfectly simple, the amount of inflammation produced by the presence of the foreign body may be easily regulated, and there is no danger of sloughing of the scrotum, much less of the development of tetanus, or other mischief.