Elements of Surgery

by Robert Liston

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.]

[38] [I have been in the habit, for many years, of keeping the edges of incised wounds of the face, forehead, and eyelids, in contact with gold pins finer than the most delicate sewing-needle. They should be from an inch to an inch and a half in length, and be provided with heads of sealing-wax, by which they can be more easily carried across the skin than in any other way. From the materials of which they are composed they are entirely exempt from oxidation, which is not the case with the common needle; and I am convinced, from ample experience, that wounds thus healed are seldom attended with permanent deformity, from the formation of unsightly scars.—ED.]

[39] [In this country goitre is most common in the mountainous districts of Pennsylvania, Virginia, New-York, Connecticut, New-Hampshire, and Vermont. It is very rare in the natives of the western and southern states.—ED.]

[40] [I have in two instances succeeded completely, and in another partially, in curing goitre of long standing, by the internal and external use of iodine; and am disposed to place more reliance upon this remedy in the treatment of this affection than upon any other with which I am acquainted. To be beneficial, it should be administered in large doses, and be continued for at least three or four months. The local remedy which has best succeeded in my hands consists of equal parts of iodine and of camphorated mercurial ointment, rubbed thoroughly upon the surface of the tumour twice a day.—ED.]

[41] [To obtain a full stream of blood, the lancet should be carried obliquely upwards and outwards, by which means the fibres of the platysma-myoid will be cut across, instead of being divided vertically, and the edges of the incision will retract so as to form a much larger orifice. The pressure below the opening should not be removed until the wound has been closed, to avoid the introduction of air into the vein, an accident which may occur when this precaution is neglected.—ED.]

[42] [I am induced to subjoin the following example of axillary aneurism for which the subclavian artery was tied, in the belief that, from the unique manner of its termination, it will be interesting and instructive to the reader. The particulars of it, together with an analysis of twenty-six other cases reported by different surgeons, will be found in the Western Journal of Medicine and Surgery for June, 1841.

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.