Elements of Surgery

58 [The least objectionable operation, in my opinion, is that of tying the affected veins, after having carefully separated them from the spermatic artery, vas deferens, and nerves of the testicle. The vessels may be ligatured at one or more points, according to the extent of the enlargement; and, by carefully excluding the structures just mentioned, there will be no danger of cutting off the nervous and vascular supply, as must necessarily happen, in some degree, in the proceeding recommended by Mr. Liston, and which must therefore lead to further wasting of the testicle; a circumstance which should be most sedulously avoided. The external incision need not exceed an inch and a half in length.

I am induced to subjoin the following account of a novel but harsh operation for the cure of cirsocele, lately devised by Mons. Breschet of Paris, not from any belief or hope that it will be generally adopted, but because it has made some noise in the surgical world. It is founded upon the anatomical arrangement of the part, or the facility with which the varicose vessels can be isolated from the spermatic artery and vas deferens, and afterwards compressed so as to obliterate their calibre. This is effected by means of a forceps with flattened plates, which are worked by a screw. The pressure is applied in a gradual manner, but with sufficient force to destroy the vitality of the scrotum and of the affected vessels. The instrument is usually removed in from six to eight days, during which the patient is left on his back, cold lotions are applied to the scrotum, and the case treated on general principles. When the sloughs are detached, the edges of the sore are approximated by adhesive strips, and the person is permitted to walk about. In this way Mons. Breschet is said to have operated successfully in more than a hundred cases; the average period required for a complete cure being twenty-three days. I have never performed this operation, the severity of which is such as to induce the belief that very few persons in this republican country would submit to it. An American surgeon, Dr. F. Hamilton, of New-York, has recently recommended castration for the relief of this affection, and has published several cases in which he performed the operation in illustration of its efficacy. This is certainly a radical mode of doing business, but in my opinion a very objectionable one.—ED.]

59 [Of 5376 calculous cases mentioned by Civiale,60 2416 were children, 2167 adults, and 793 old persons. Of these 1946 occurred before the age of ten, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty.

Children are more subject to this affection in certain districts than in others; and the same is true in regard to adults. The greater proportion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States, and some of the provinces of England, occur in young persons, from causes which have not hitherto been explained. In the United States a larger number of children are afflicted with this disorder in Kentucky, Tennessee, and Alabama, than perhaps in any other sections. In very warm or cold latitudes, on the contrary, adults, and, above all, old people appear to be most liable to it.

Whether this affection is actually hereditary or not is not yet fully decided. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity, whose mother had had the stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had laboured under the disorder. Prout speaks of a family of which the grandfather and father were affected with uric acid calculi, and who had a son, aged thirteen years, that was very much predisposed to the same disease.—ED.]

60 Treatise on Calculous Affections: MS. translation by Dr. Colescott.

61 [In comminuted fractures of the lower jaw, it sometimes happens, in spite of our best-directed efforts, that the ends of the fragments cannot be maintained in contact. Under these circumstances it may become necessary to tie the pieces together by means of a gold or silver wire, or to make the patient wear a thin metallic plate, adapted to the shape of the jaw, and interposed between the cheeks and dental arches; to the latter of which it should be immoveably fixed.—ED.]

62 [The bones, owing to falls, blows, or other external violence, are occasionally bent, with or without partial fracture. Within the last few years a considerable number of cases of this accident have been reported by American and European practitioners. The first regular account of it was published in 1810, by Professor Jurine of Geneva; and in 1821 a very able article on the subject appeared in the American Medical Recorder, from the pen of that distinguished surgeon, Dr. John Rhea Barton, of Philadelphia.

Simple bending is most common in the radius and ulna, though it is by no means confined to them. For obvious reasons it happens only in children, before the completion of the ossific process, or in whom there still exists a predominance of animal matter. In older persons the bones more readily break than bend. The diagnostic signs of the accident are, pain and deformity at the seat of the injury, loss of power in the limb, want of displacement of fragments, and absence of crepitation. The deformity consists in an unnatural curvature, which can be made to disappear under pressure and extension, but recurs, to a certain extent, when the limb is liberated. When attended with partial fracture, the symptoms are the same, excepting that, instead of a curvature, there is angular deformity opposite the seat of the accident. When the injury occurs in the forearm, and only one bone is implicated, extension generally produces no change in the appearance of the limb. The treatment, in both cases, is to be conducted upon the same principles as that of fractures. The attempts to remove the curvature by extension should neither be too violent nor long continued, otherwise they must prove injurious. Mr. Mantel of England, distinguished alike as an able surgeon and an accomplished geologist, thinks that the application of leeches and the usual antiphlogistic means should alone be trusted to when there is much pain and swelling, alleging that the action of the muscles will ultimately restore the limb to its natural form.—ED.]

63 [A comparison of the results of the different kinds of treatment of disunited fracture, furnished by Dr. Norris of Philadelphia, in an able and elaborate article in the American Journal of the Medical Sciences, for January, 1842, leaves no doubt as to their relative value. Of forty-six cases in which the seton was employed, thirty-six were cured, three partially relieved, five not benefited, and two died. In twenty-one the seton was introduced with, and in twenty-four without, previous incision: of the former seventeen were cured, two improved, one failed, and one died; of the latter eighteen were cured, one was benefited, five failed, and one died. In reference to the seat of the fracture, the cases stand as follows:—

The average period of the existence of the fracture in the above cases was nearly twelve months and a half, the longest ten years, the shortest six weeks. The mean period of the retention of the seton was seven weeks and three days. In one instance—that of a fractured humerus—it was left in thirteen months, notwithstanding which it finally failed. The average time required for the cure was nearly three months, the longest eight months, the shortest three weeks. Arterial hemorrhage occurred in two of the cases; in ten, severe fever, erysipelas, or profuse suppuration.

Of thirty-eight cases in which resection was performed, twenty-four were cured, one improved, seven failed, and six died. The seat of the injury was as follows:—

The longest period of the existence of the fracture in these cases was five years, the shortest ten weeks, the average thirteen months and nineteen days. The average time required for effecting a cure was four months, the shortest one month, the longest thirteen months. In seventeen of the cases other methods of treatment had been ineffectually tried: in six the resection was followed by erysipelas, in one by phlegmasia dolens, and in two by profuse suppuration and abscesses.

Of thirty-six cases healed by pressure and rest, twenty-nine were cured, one improved, and six failed. The seat of fracture was:—

The average duration of the fracture in the above cases was five months and twelve days, the longest twenty-two months, the shortest four weeks. The mean period required for a cure was nine weeks, the longest nine months, the shortest eighteen days. In one of the cases the treatment was productive of excoriations, in three of severe pain and inflammation.

Cauterization of the ends of the fragments, after free exposure of them by the knife, was successfully employed in six cases; in two others it completely failed. The article most frequently used was the caustic potash. Frictions succeeded in eleven cases.

From a careful analysis of all the circumstances connected with the preceding cases, one hundred and thirty-nine in number, and of which the above is an abstract, Dr. Norris has deduced the following conclusions:—1. That non-union after fracture is most common in the thigh and arm. 2. That the mortality after operations for its cure follows the same laws as after amputations and other great operations on the extremities, the danger being in proportion to the size of the limb and the proximity of the injury to the trunk. 3. That failures after operations are more frequent in the humerus than in other bones, and in middle-aged and elderly persons than in young ones. 4. That the seton, variously modified, is safer, speedier, and more successful than resection or caustic. 5. That incising the soft parts previously to introducing the seton augments the danger, but renders the cure more certain and expeditious. 6. That allowing the seton to remain in for a long time exposes to accidents, and does not facilitate the cure. 7. That the seton is least successful in the femur and humerus.—ED.]