LECTURES ON SOME PRACTICAL POINTS OF SURGERY,

311

octtlar side of the bag. The commucica-

tion with the nasal duct is the inferior extremity of the sac, a slight constriction marking the distinction between the bag attdduct. The latter passes from above obliquely downwards, and a little backwards, enclosed in a bony canal, and opens in the inferior meatus narium, on the outer side of the inferior turbinated, bone, which must be cut away in the dead body to expose the aperture ; the latter is then seen as an oblique slit. The lachrymal sac and the nasal duct are lined by a thick pulpy mucous membrane, resembling in its structure the Schneiderian membrane of the nose, and containing, like that, numerous small muThe lachrymal canals, and cous cryptae. the puncta lachrymalia, are lined by a thinner and more compact membrane continuous with the conjunctiva. Thus these lachrymal passages establish a connexion, by continuity of surface between the eye and nose. The fluid taken up by the puncta lachrymalia is conveyed into the sac, and it then descends into the nose. We do not exactly understand the mode in which the circular orifices of the lachrymal canals suck np the fluid. A small space is seen in the inner angle of the eye, between the two lids, towards which the tears flow, and at which tne .small triangular canal formed between the closed lids terminates ; this is called lacus lachrymarum, and the prominent papillae, in which the pnncta lachrymalia are perforated, are turned towards this space. When the secretion of tears is much increased by any of the exciting causes which I have mentioned, the fluid is poured ont faster than it can be abby the puncta, and it flows over the surface of the cheeks. In the internal angle of the eye, near the puncta lachrymalia, is a small prominent body of a reddish colour, called the caruncula lachrymalis; this part you will observe better by looking at it in the living eye than by examining it in the colJapsed and shrivelled state which it exhibits in preparations. It is a congeries of.glandular substances, similar in strncture to the Meibomian glands. Between the caruncula lachrymalis and the globe of the eye, is a small fold of conjunctiva, called the semilunar fold, which appears to be a rudiment or imperfect exhibition of that structure which in quadrupeds constitutes what has been termed a third eye-lid, and which is situated vertically between the upper and lower lid.

sorbed

LECTURES ON SOME

PRACTICAL POINTS OF SURGERY, DELIVERED TO THE

Students

of the

late

Borough Dispensary,

BY MR. ALCOCK.

LECTURE IV. On the occasional ill consequences section.

of Vene-

Gentlemen,

Previously to entering upon the details of the occasional results of venesection, it may be well to recapitulate som points of the past Lecture. I alluded to the imperfection of our knowledge on the subject of inflammation, and the means by which that knowledge may be extended, namely, by reading, observation, and experimental research. The effects of loss of blood, whether accidental or remedial, whether general or local, were considered. The necessity of a strict knowledge of the surgical anatomy of the bend of the arm-the difficulties occasionally experienced-the requisites when complete, and the simplification of the means in cases of emergency-the precautions and steps of the operation were particularized. Mr. Benjamin Bell has illustrated the importance of bloodletting, in his system of surgery, in the following terms :" Bloodletting, whether we consider it its influence on the system, or with respect to the nicety with which it-ought as to

to be performed, is perhaps one of the most important operations in surgery.

From every

so frequently practised, and pretender to knowledge in the healing art being able to perform it th

being

public have been induced to consider it as trivial with respect to its execution ; but every practitioner of character will acknowledge, that in order to perform it properly, the greatest nicety, steadiness, and exactness, are required. Every other operation in surgery I have frequently seen well performed ; but I have seldom seen bloodletting with the lancet correctly done. When properly performed,

it is a neat operation ; but when not done with exactness, it is the very reverse." The difficulties occasionally experienced have been already noticed; the defects, some of which not unfrequently frustrate the intention for which the operation is per.

312 1st. The bandage too tight, may appertain to the operator ;—3rd the reverse; 2dly. The incision too the want of sufficiently accurate knowamall or too large ; 3d. The valvular ledge of the parts to be operated upon; form of the aperture ; 4th. The turning of -4the. want of skill, and this more frethe hand and fore-arm. quently arises from the deficiency of It may seem superfluous to point out accurate knowledge than from other the advantage, nay, the necessity of being circumstances; for when the ideas are able to bleed with neatness and certainty, clear, the hand is generally obedient to the will;-,5th. want of care, provided the whenever it may be essential to the welfare of the patient ; for it is of little mo- requisite knowledge and skill have been for the ment to be able to point out the appro- attained ; and, lastly, though honour of I believe the it to profession, priate remedy for a dangerous disease, if be of very rare occurrence, it has been that remedy be not carried into effect, of an operator has and in the inflammation of a vital organ, known, that the hand been unsteady owing to intoxication. it is not by any ordinary local bloodletThe accidents which may arise from ting that the disease can be subdued with bleeding are more numerous than may the same certainty as by general bloodbe generally supposed. One of the most Hence the loss the ot time, letting. by is the occurrence of syncope or use of inefficient means, sometimes allows frequent Often this does not depend fainting. disease to proceed to a fatal termination, the timidity of the patient, but when the malady might have been cut upon the physical effects produced by short by efficient treatment. Mr. Alcock upon the loss of blood. The brain, like the mentioned instances in which the repuother parts of the body, depends for the tation of medical men had suffered by undue performance of its functions upon successful attempts to open a vein, whilst an adequate supply of arterial blood, others had superseded them by observwithout which these functions iinmediof the the cause and failure, doing ing the organs of circuthat with certainty at once which had ately cease ; again, lation of and respiration depend upon been previously and repeatedly attemptthe influence of the brain and nervous ed in vain; and others in which the supand cease to perform their funcposed impracticability of the operation, system, if tions that influence be withdrawn, this after failure, had given way to trivial subalso happens to the muscles which give stitutes, till the disease had become irre- motion to the body; hence, if a quantity mediable. This Mr. A. stated he had of blood be lost or abstracted so frequently had occasion to observe in the or speedily that the vessels cannotlargely adapt diseases of children, such as croup, inflamthemselves to the diminished quantity mation of the larynx, &c. circulating within them, the blood is no The adaptation of any remedy requires longer propelled in sufficient quantity to discrimination and sound judgment, and support the energy of the brain, and loss the abuse of general bloodletting, when of power, of sensation and of consciouslocal abstraction would suffice, is to be ness are the immediate result: every one guarded against as carefully as the error knows that a person in a fainting fit is above noticed. like one apparantly dead. Sometimes Tbe accidents and ill consequences this condition is merely momentary, and resulting from bleeding are generally is immediately succeeded by the return of slight, but sometimes have proved fatal; consciousness and power; at other times it - not in a solitaiy instance or two, but continues so as to cause alarm for the paunfortunately on many occasions. It is tient’s safety, and I need not tell you, it in surgery as in common lite, important has happened that from this state of apeffects are produced by apparently trivial parent death the unfortunate patient has causes; and Franklin’s illustration ofnot revived. One instance of this kind, the loss of the rider from a trifling be- which came to my knowledge many years ginning, if homely, is as likely to be re- ago,led rne toobserve whether the more beneficial effects usually observed in the membered as any 1 can offer you. treatment of acute disease when bleeding « For want of a nail the shoe was had produced fainting than when that I effect had not been lost," &c. induced, might not be obtained without carrying the depletion’to The cattses of accidents and ill con- that extent which should, in any degree, seqnences may be referred to,—1st. endanger the patient’s safety ; and I have peculiar habit or state of health of the been long convinced that, particularly in patient ;—2nd. mismanagement on the those acute inflammations of parts espart of the patient; sometimes, however, sential to life, and which, when unconit is to be feared the mismanagement trolled by art, speedily run a fatal course,

formed, are, or

313

abstractingthe Aneurism, arising from wounding the by adapting the mode ofcircumstances ofartery in bleeding, is a more dangerous blood to the existing

accident. I have before stated my opinion that it may be certainly avoided bv adequate knowledge of the parts, and skill and precaution in the operator. I have seen several instances, but none occurring in competent hands; and, when to lating system, employed after a first this circumstance is added that in the efficient bleeding, may very generally extensive practice of a public institution supersede the necessity of repeated nb- during a series of years, by the simple straction of blood, or may render the less precautions demonstrated in describing debititating loss of a few ounces, locally, the steps of the operation, maniacs, equivalent to a full bleeding without these children, and others, who could not be remedies. But though these medicines influenced by reasoning or entreaty to are invaluable aids, when general bleed- keep the arm steady, have been bled, ing has preceded, yet, being more slow and such cases have not been rare, yet in producing their effects, it would not in no wound of the artery has occurred : if, the more severe cases be safe to trust to therefore, under these unfavourable cirthem alone in the first instance. cumstances it may be certainly avoided, A gentleman who enjoys in a high de- what should cause the danger under the gree the confidence of his professional more favourable condition of a rational brethren lately informed me that a rela- patient, capable of comprehending and tion of his, a surgeon in the country, had anxious to follow the directions of the bled a lady, who fainted and died upon operator? the spot. My informant, with that canAneurism may be diffnse or varicose. dour which becomes the members of a In the former the blood is driven among liberal profession, observed, he did not the surrounding parts; in the latter it know that any blame was deserved ; but escapes into the vein, but this is a comthe accident proved very detrimental paratively rare occurrence. When the to the practice of the unfortunate ope- artery is wounded in bleeding, the blood rator. flows in jets, and of a more florid colour What should be our treatment when than that issuing from the vein. It is fainting continues so long as to indicate impetuous, and restrained with difficnlty; danger to the patient? In slighter cases, pressure below the orifice does not prethe placing the body horizontally, and the vent the stream; but compression upon application of stimuli to the nostrils, face, the artery above the orifice stops it. If. &c. will suffice; but unless the patient by pressure upon the orifice, the blcod speedily revive, the most approved means is prevented flowing outwardly, it is for restoring suspended animation must driven into the surrounding parts, and be immediately carried into effect, taking produces a swelling more or less excare that the head and upper part of the tensive-this increasing, at length rebody be not too much elevated. The quires the performance of the operation for usual means for restoring suspended ani- aneurism, which consists in exposing and mation admit of much simplification ; but securing by ligature the wounded artery. this will come under consideration in a Other results, less likely to occur under future lecture. surgical care, are repeated haemorrhage Thrombus, ecchymosis, or diffusion offrom the wound, and inflammation someblood under the skin, is one of the slighter times terminating in mortification. The accidents from bleeding, though to the unfortunate patient, when in ignorant young operator, who has not been taught hands, has bled to death. Sir A. Carlisle how to avoid its occurrence, it may appear related a case which came under his own alarming. The cause may be either an observation:—a country blacksmith had oblique or valvular opening in the first bled a patient and opened the artery, but instance, or the skin may be moved so as did not succeed in stopping the flow of to cover the opening of the vein, by the blood ; surgical assistance was sent for, twisting of the fore-arm and hand, as is but ere it arrived the patient had expired. often by patients, when not cau- On questioning the operator as to the tioned to avoid it. When this is per. circumstances, he said that" he had bled ceived, let the opening in the skin be him in the thumping vein," and could not made to correspond with that of the vein, stop the blood. This was a case of high and the farther progress will be prevented. division of the humeral artery, and the The blood is generally absorbed within a more superficial trunk had been mistaken week or a fortnight, and this result may for a pulsating vein. be expedited by evaporating lotions. Suppose the artery actually wounded the case, a much less loss of’ blood will suffice than is often resorted to, by which a correspondent saving of the strength and vital powers of the patient is effected. Those medicines which act particularly in diminishing the powers of the circu.

done

314 in

bloodletting, what should be the treat- finger, it was probable

that the trunk of

The

securing of the wounded ar- the humeral artery was wounded. Bear. tery by ligature without delay, as in any ing in recollection an unfortunate case of

ment?

other accidental

wound, is the obvious wounded humeral artery, which, in

treatment, by which the

more

remote

one

of the metropolitan hospitals, had termi. nated fatally by secondary iiaemorrhage from the artery after a ligature had been applied to that vessel above the wound, I determined to guard against a similar accident by tying the artery both above and below the wound. On exposing the vessel I found that the ulnar artery had been severed from the trunk of the hu meral at the very point from which it was given off; I therefore tied the humeral artery above this point, and also the open mouth of the ulnar artery ; notwithstanding this precaution secondary hsemorrhage occurred, but, certain that both the hurneral and ulnar arteries were secnrely tied, it was an obvious induction that the blood must have flowed by the inosculating branches so freely, as to pass retrograde through the radial artery, and by distending that vessel, and passing through the side of the artery from which the ulnar had been severed, below the ligature on the trunk of the humeral.— The cause of the haemorrhage and course of the blood being thus ascertained, the

and painful consequences may be prevented. Another question occurs, should the person, by whose want of skill or attention the accident has taken place be suffered to attempt the more dangerous and intricate operation of laying bare and securing the artery, which he had not the knowledge and skill to avoid ? I should not like to trust my arm to such an operator; for if every greater contain the less, how can the person who has failed in the more simple operation be supposed competent to that which really calls for a high degree of skill and self-possession ? These qualifications are not very likely to characterise any one to whom such an accident, as to wound an artery in bleeding, might be a probable occurrence. Should such an accident occur, the safest plan both for the patient and the unfortunate operator would be, not to attempt by the inefficient apto stop theofbleeding plication cloths or compresses, nor by tight bandages, which might mask the danger, but, if long continued, might endanger the strangulation and subsequent treatment presented little difficulty; the mortification of the limb ; but simply to principles to be fulfilled were obviously place the tip of his finger or thumb upon to prevent the retrograde course of th· the orifice, and make there sufficient pres- blood in the upper part of the radial aresure, by which he may, without further tery, above the point where the recurrent injury to the patient, prevent the hoemor- branches entered, and at the same time rhage till adequate surgical assistance be to avoid any compression of the limb procured. generally which should endanger the d’ Some surgeons still entertain fears lest calation in the inosculating branches mortification should take place by the im- these were effected simply by applying &mid ot;, mediate ligature of the artery, before the graduated compress so as to act upon th inosculating branches have time to en- radial artery at its upper part, whilst, by large. I do not participate these fears, thus concentrating the pressure upon the and, were it my own arm, would submit point on which it was designed to act, to have the artery tied, whea the surround- the general pressure around the limb was ing parts were in a natural state, rather so slight as not in any degree to obstruct than when ’likely to pass into unhealthy the circulation. There was no recurrence suppuration from the long-continued con- of haemorrhage, and the patient recovered tact of extravasated blood. So far from without any untoward symptom. having fears of the want of support by the inosculating vessels, the very freedom of these inosculating vessels is more likely to give rise to secondary hæmorrhage by ERRATA in Mr. ALCOCK’s Third Lecture. the retrograde passage of the blood, if the artery have only been secured by a ligature above the wound. Several years Page 278, line 8 from the bottom, 1st for 11 detect," read direct. ago I was called to a patient who had received a wound at the bend of the arm, Page 280, line 29 from the bottom, 2d and who was stated to be bleeding to for " or," read nor. column, death. An assistant arrived before me, and restrained the haemorrhage till my arrival, by pressing with his finger upon the point from which it issued. From the situation of the wound, and the gush of blood which took placeon f6moving the

column,