Part 87

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.]

[43] [I had occasion last winter to tie the humeral artery, for a wound inflicted upon it in bleeding at the bend of the arm, in a youth eighteen years of age, from one of the border counties of this state. The accident had occurred about six weeks previously with a thumb-lancet. It was soon followed by great swelling and discoloration of the limb, which gradually extended downwards nearly to the middle of the forearm and upwards as far as the axilla. The pain was excessive, the appetite much impaired, the sleep constantly interrupted, and the countenance blanched and expressive of great suffering. About the fourth week a large opening formed at the seat of the original orifice, from which upwards of a quart of thick grumous blood was discharged. He was brought to town on the 27th of December, and placed under the care of my friend, Dr. Drane. At this time his health was frightfully deranged; his strength was much exhausted; he had not slept for several nights; and the whole limb, benumbed and excessively painful, was swollen from the wrist to the shoulder. The parts pitted under pressure, two small foul-looking ulcers existed at the bend of the arm, the skin was discoloured, and fluctuation could be distinctly felt all the way up from below the elbow to the insertion of the deltoid muscle.

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

[44] [_Encysted tumours_ of the breast containing milk are sometimes met with. They are commonly produced by closure of one or more _lactiferous ducts_, either from the effusion of lymph, or some other accidental formation, or from external pressure. The swelling, which generally arises during the early months of lactation, may be globular, ovoidal, or pyriform, and rarely exceeds the size of an orange. It is almost always attended with a peculiar sense of distention, and distinctly fluctuates under the finger. On cutting into it the contents are found to be of a whitish colour, and of the consistence of milk, cream, or whey; the quantity ranging from a few drachms to several ounces.

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

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

[45] [In a case of artificial anus which came under the notice of the late Dr. Physick, in 1808, relief was afforded by the following procedure. A crooked needle, armed with a ligature, was passed from one portion of the intestine to the other through the contiguous sides, about one inch within their orifices. The ends of the ligature were then tied with moderate firmness at the external aperture, where they were left protruding. In this situation it gradually made its way through the parts which it embraced by ulcerative action, at the same time that it produced strong adhesion between the two folds of the bowel. After several weeks had elapsed, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature, thus establishing a direct communication between the upper and lower extremities of the gut.

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

[46] [When the wounded bowel protrudes, the aperture, unless it be very small, should be closed either with the continued or the interrupted suture, and then returned within the abdomen. This procedure is far preferable to the mechanical contrivances recommended by Reybart, Denans, and other surgeons; or even to the more ingenious but almost impracticable method of stitching the intestine, proposed by Mons. Lembert of Paris. From some experiments, upwards of forty in number, which I performed upon dogs last summer with a view of more fully elucidating the subject under consideration, I am led to infer that it does not matter what kind of suture be employed, provided we use the precaution of closing the opening so completely as to prevent the escape of fecal substance. This is undoubtedly the grand principle which should regulate the conduct of the surgeon in the treatment of injuries of this nature. Let him guard against fecal effusion, and the patient will be comparatively safe, or free from the danger of peritoneal inflammation. To attain this object the continued, or glover’s suture as it is termed, is unquestionably preferable to any other, especially when made, as I would suggest it should be, with a small sewing-needle, armed with fine silk, and passed between the muscular and mucous coats, or, what is the same thing, through the substance of the cellulo-fibrous lamella. After the suture has been applied, the protruded part of the mucous lining, if there be any, should be pared off with a sharp knife, to facilitate the process of reparation, the surface of the bowel should be cleansed with tepid water, and the whole carefully returned into the abdomen. If the interrupted suture be used, the intervals between each two respective threads must not exceed two lines, or the sixth of an inch, otherwise there will be danger of fecal extravasation, and the ends, instead of being brought out at the external aperture, should be cut off close to the knots. The reason why I prefer the continued suture, made in the manner above mentioned, is simply because we can thereby more effectually close the wound, at the same time that the parts are placed in the best possible condition for speedy reunion, from the want of protrusion of the lining membrane, and consequently the more perfect contact of the serous surfaces.

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

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

When the bowel is completely severed, or mortified in its entire calibre, the edges, after being properly prepared, should be brought in contact, and retained by the continued or the interrupted suture. Cases of this kind, although apparently desperate, are not always of so hopeless a character as might at first sight be supposed. This is shown, not only by experiments on the inferior animals, but by what occurs in the human subject, in sphacelated hernia, and in intussusception. In the former, the greater part, or even the whole, of the circumference of the tube may be destroyed, and yet the patient ultimately recover, with perhaps the temporary inconvenience merely of an artificial anus; and in the latter, large pieces are not unfrequently detached without any serious suffering, save what is experienced during the antecedent and concomitant inflammation. In my morbid collection is a preparation of this kind, evidently a portion of the colon, nearly a foot long, which was discharged by a child six years old, who, notwithstanding, made a speedy and perfect recovery. Thirty-five cases of a similar character, collected from the writings of different pathologists, have been reported by Dr. Thompson of Europe.[47] In a dog, from which I removed two inches and a half of the ileum, and treated the edges of the wound with six interrupted sutures, complete recovery took place, unattended with a single bad symptom. The threads were introduced at equal distances from each other, with a small sewing-needle, and the ends cut off close to the knots. Four months after the operation, being in good health, and the outer wound entirely healed, he was killed. Externally the bowel was perfectly smooth and natural, as if no injury had ever been inflicted upon it: the mucous membrane was of the same appearance as elsewhere, with the exception of a small depression corresponding with the edges of the wound.—ED.]

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

[48] [From my own observations and dissections I have long been convinced that there are two distinct and well marked varieties of hemorrhoidal tumours; one of which essentially consists in an enlargement of the capillary vessels of the mucous and submucous cellular tissue, the other in the formation of a small sac filled with fluid, coagulated, or organised blood. The latter, situated at the verge of the anus, or immediately within it, are composed partly of skin, partly of mucous membrane; they vary in size, from a pea to that of a small marble, are of a red florid complexion, hard and tender to the touch, and exquisitely painful when inflamed. The blood which they contain is at first fluid, but soon coagulates, and ultimately, if allowed to remain, becomes organised. Hence, in cases of long standing, the tumour is generally of a hard, gristly consistence, pale, and free from pain, producing no other than mechanical inconvenience.

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

[49] [Until recently it was the opinion of surgeons, almost universally, that the fistula opened into the bowel at the distance of from two to three inches from the anal outlet; an error which often led to severe and hazardous operations, by which the unfortunate patient was sometimes rendered miserable for life. Mons. Ribes of Paris, who was the first to investigate the subject in a careful and extended manner, ascertained that the internal orifice is generally situated immediately above the place where the lining membrane of the rectum unites with the skin, sometimes a little higher, but _never_ more than five or six lines. In eighty subjects affected with this malady it did not exceed this elevation, and in a considerable number it was not higher than a third or fourth of an inch. In my own operations and dissections I have rarely found the internal aperture more than a line or two above the internal sphincter muscle. The observations of the late Professor Bushe, of New-York, tend to a similar conclusion.—ED.]

[50] [This is undoubtedly the treatment which should always be adopted in the sacculated variety of the disease, as it is not only free from danger, but affords the most speedy and effectual relief. If the blood, upon the presence of which the irritation and swelling mainly depend, be allowed to remain, it finally becomes organised, and so incorporated with the walls of the tumour that it is impossible to dispose of it in any other way than by excising the whole excrescence.—ED.]

[51] [My own experience does certainly not accord, in this instance, with that of the distinguished author. I can recall to mind at least six or eight cases, several of them in delicate females in dilapidated health, in none of which I used less than two ligatures, and in some as many as three or four, without any serious consequences whatever. When the tumours are numerous, it can never be necessary to tie more than three or four at a time, since the inflammation thus induced generally extends to those around and effects their obliteration. It is always preferable, indeed, to repeat the operation, than to run the risk of producing too much irritation.—ED.]

[52] [Much may be accomplished in chronic cases by means of astringent injections, of which the best perhaps is a solution of alum in a decoction of oak-bark, in the proportion of two drachms of the one to a pint of the other. From two to three ounces of this should be thrown up the rectum twice a day; the bowels being at the same time kept in a soluble state by gentle laxatives, and the patient compelled to void his feces in the standing posture. In cases of an inveterate kind, in which the ordinary remedies prove unavailing, the operation of Dupuytren, which consists in cutting away some of the radiating folds of the skin around the anus, generally affords prompt and effectual relief. When the protruded part is large, it may be necessary to excise from four to six of these folds, and to prolong the incisions into the rectum as far as the junction of the skin with the mucous membrane. The object of this operation is to produce a diminution of the orifice of the anus, which it does by the cicatrization and contraction of the little wounds made in the operation.—ED.]

[53] Bushe on the Rectum, p. 220.