NOTES OF A SURGEON.[1]

NOTES OF A SURGEON.[1]

NUMBER ONE.

THE DISLOCATION.

The reduction of a dislocated limb, in a person of muscular frame, is one of the most fearful and difficult operations in surgery; and in a lad or a female, there is much in the attending circumstances to excite the liveliest interest of the spectator. To hear the bone click, as it returns to its place; to behold the relief which is instantly experienced; the happiness so vividly depicted in the countenance; the inclination to immediate repose—every feather seeming to be a pillow to some over-strained and exhausted muscle—one cannot help cordially uniting in the feelings of the restored sufferer; nor can he restrain the smile which mantles his features, and is reflected in the lineaments of the surrounding surgeons.

In a strong man, where the muscles are rigid, and every fibre seems to be converted into a wire to resist the force exerted on them, the ceremony is one of distressing cruelty. The inquisition can scarcely furnish any thing more appalling, and certainly not the practice of surgery. The pain of an amputation may be more acute; but its very acuteness assures you that it will soon be over. The edge of the knife itself is an index, keen as the scythe of Time, and faithful as his march, of the progressive succession of the moments of trial; a fiëry monitor, which every instant sinks deeper, and will soon, very soon in the reality, but late, as it always must be, in the reckoning of the sufferer, reach its unswerving limits, the bone. And here the pain of the operation in a great measure ceases; for it is hardly necessary to state, that the sawing of this structure is not actually attended by any of the horrors with which vulgar apprehension has invested it. The ligature of the arteries, the dressing of the truncated member, etc., may each occasion a momentary anguish. But as to the mere pain of the operation, it is trivial, in comparison with that which an athletic man experiences in the reduction of a dislocated limb, which has been any length of time displaced.

It was a luxation of the thigh. The patient was a remarkably stout man, and bade fair to put in requisition the whole retinue of the hospital.

'Remember. Mr. F——,' said the attending surgeon, on leaving in the morning, 'be careful and have every thing ready—every thing. There must be no delay in seeking instruments while we are engaged with the patient.'

'I had better bleed him, probably?' replied I, inquiringly.

'Yes; an hour or so before twelve; and have him kept in the bath until then.'

I selected a double set of apparatus, consisting of very little else than a good strong block-and-tackle, and some padded buck-skin girths, and soon had them in their proper place in the 'theatre' of operations. This is an apartment of the hospital having very much the appearance of an ordinary theatre, but differing from it in being more especially appropriated to the enactment of tragedies; the play generally consisting in the lively representation of suffering on the part of the patient, and the exhibition of the coolest nonchalance by the officiating surgeons. If sometimes enlivened by an interlude between the chief actors and the subs, their sallies are wholly spontaneous, and usually fail to receive that applause which is the customary reward of such improvisations on other boards. The room is small, and ranges of boxes extend on the three sides of an ovoid, to the ceiling, forming an incommodious but commanding observatory for spectators. The pit is separated from the boxes by a thin partition. In this little space, lies the chief difference between the theatre of the hospital and more strictly dramatic edifices. The floor is the stage, on which those weekly representations take place, that seldom fail to draw crowds of students from the neighboring college, during its session; though it is not often that the spectacle of misery, (too purely unpoetical,) draws a tear from the lachrymal sac of the ardent and enthusiastic disciple of Hippocrates.

The audience are, in truth, mostly exceedingly phlegmatic in their manifestations of sympathy. They behold the struggles of a luckless wretch, in the clutches of the veritable Procrustes, who endeavors to make him conform to the measure of his bed, by a few inches of stretching, in the reduction of a luxated thigh, without apparently any fellow-feeling for his pitiable situation. They behold one of the lower limbs severed quite up to the hip-joint, and rivulets of blood streaming from the divided vessels of the stump, without a tremor, or a groan, or an exclamation, to evince the simultaneous racking of their own nerves; although it is true, that some youthful spectator will occasionally betray a tendency to deliquium, when he is immediately transported to a more kindred atmosphere.

The person to be operated on, was a man of vigorous constitution, and evinced great anxiety to have his body restored to its symmetry, and his limb to its usefulness. Though, as is usual in such cases, the probable severity of the operation, its duration, and the uncertainty of success, were laid before him in their true light, he was firm in his determination to have it done. Poor man! he could not bring himself to believe that there was a possibility of failure; nor did he suspect that, as strong a man as he was in resolution and bodily powers, he would be compelled, before the ceremonials of reduction were gone through with, to cry out, 'Give me some drink, Titinius, as a sick child.' Yet that such should be the case, shows that necessity is stronger than mortal resolution; and the same individual who asks you to reduce his limb, and then bids you cease your harrowing attempts, will in turn rebuke you if you obey his orders, given in the wildness of despair, and the limb thereby remain indissolubly locked in its distorted posture, an enduring monument of his own weakness, and of your culpable pliancy.

The patient was placed in a warm bath, and bled until faint. The object was to make him a sick man, as a preparatory step to rendering him whole. While superintending this necessary process, I hailed the nurse of ward No. 13, whose duty it was to attend to the regulation of the theatre.

'Nurse, have you seen that every thing is in order in the theatre?'

'I just came from there, doctor. I believe nothing is wanting.'

'We still need a bowl or two, and some warm water. You have the key?'

'Oh yes; I always carry the key of the side-doors. I shall not let any of the students in, doctor, until you say the word?'

'It will be as well to keep them out till the surgeons come. You must stand by, as we may want you to lend a hand.'

'There will be some occasion, I think, doctor, if I know any thing about a dislocation. I have been in this house fifteen years, and have seen Dr.—— try——'

'Well, be careful and have every thing ready.'

'Oh, I'll look out, doctor.'

His voice was soon heard at the farther end of the hall, summoning the nurse of one of the neighboring wards—a fellow whom Dr. D—— would have pronounced an O'Rang O'Tang, though he was neither an Irishman nor a monkey in appearance.

'I say, No. 14, have you carried that water in yet?'

'No, but I will directly,' replied the subaltern.

'Well, while I'm gone down to the old lady's after some fresh blankets, take care and have it done.'

How far this chain of rank extended downward, I can only conjecture. But it is probable that No. 14 did not consider himself the last link, and gave orders in an authoritative tone to one of his inferiors, and be d——d to him, to be careful and bring him a pail of water from the pump, while he stood on the steps to arrange his thoughts and shoe-strings.

I stepped down into the apothecary's shop, and procured a couple of drachms of tartar emetic. This I mixed up in a bowl of water, and gave a part of it to the patient, setting the remainder in a convenient place in the theatre. On a side-table, here, was spread out a pocket-case of instruments, containing scissors, scalpels, and every thing else that might be needed on an emergency.

The proper hour having now arrived, the disabled man was taken out of the bath, wrapped in a blanket, and supported into the theatre. On a table, in the centre of the pit, was placed the apparatus for reduction. The patient was extended on it, on his left side, and the young aspirants were called upon to exercise their ingenuity in attaching several silk handkerchiefs above the knee of the dislocated limb, (the right) with a clove-hitch. Surgeons are no sailors; and a knot which a cartman puts a hundred times a day over the front post of his cart, puzzles the juvenile professor exceedingly; and great is the honor bestowed on the fortunate achiever of the exploit. Phrenologists might find, in the retentive faculties of this knot, a desirable subject for investigation. The tighter you draw upon the two ends looped together, the more securely is the limb grasped; and a timber-head-hitch, as it is sometimes called, may be fixed to the tapering extremity of a slippery hacmetack log, and it will hold fast with the gripe of a drowning man, and allow you to drag it, for aught that can be averred to the contrary, half way round the globe. The mystery of this knot, unlike that of Gordian, is in the tying, not in the untying.

A broad belt was next passed along the os ischium, and up over the head, where it was fixed by a strong cord to the wall. Another was placed around the middle of the thigh. To the nooses in the end of the handkerchiefs, a small but strong pulley was attached, which was made fast at the other end to a staple on the side of the partition toward the patient's feet. In this situation, he seemed much as though stretched upon a rack, and waiting the application of the torture from his stern inquisitors; a resemblance which was more than justified in the progress of the operation.

The theatre was pretty well filled with students, and the arena of exhibition itself occupied by a sufficient number of persons either to assist, or to remain inactive spectators. The three chief surgeons stood about the feet of the patient, consulting as to the best mode of proceeding, and occasionally addressing a few words to the expecting patient. The walkers, house-surgeon, and one or two professional men, were arranged in convenient situations to afford aid. The nurse, par excellence, was also there, where his sailor-like promptness of hand in managing the rope was all important.

But as the reader does not, perhaps, know what a nurse is, hospitaliter et male loquendo, (that is, as applied to males, in hospital dialect,) it is proper that he should be made acquainted with him. I shall therefore peninsulate him briefly in this paragraph.

Nurse!—thy burly form would throw into inextricable confusion all ordinary notions of that soft and womanly occupation. To think of an advertisement like this: 'Wanted a wet-nurse, with a fresh breast of milk,' and of thy applying for it! Thy brachial extremities were far better adapted to embracing a cannon, than clasping an infant. Thou wert six feet three, leaving out the curve in thy shoulders, and wert called Featherbody, as if to show off thy unparalleled muscular development to better advantage. In fine, thy long chin, decisive mouth, nose of good magnitude, well-set eyes, rather superciliary eye-brows, low forehead, and matted hair, were sufficiently characteristic to have made thee remembered, had not thy extraordinary adaptation to thy office (so different from that which most conceive it to be) rendered thee an object of admiration to all who witnessed thy skill and prowess.

The patient thus extended upon the table, the bandages were taken from his arms; the bowl was held, and the flow of blood watched, to catch the first signs of failing strength. The vessel was already beginning to brim, when he sickened and vomited. It was now that the extension was put on. The sturdy, iron-armed nurse seized the stick around which the end of the pulley-rope was wound to give a firmer grasp to the hands, and began slowly and leisurely to bring the convolutions of the cord to a state of tension. His force, not trifling of itself, and now tripled, was not an eighth of it expended when its effects became apparent. The cord began to strain—the belt at the head tightened—the patient was lifted from the table, and became suspended between the two fastenings.

The surgeon, with his left hand upon the patient's ankle, and his right upon the upper end of the thigh-bone, while his knee, elevated by a stool, was placed under that of the culprit, as it hung over the end of the table, awaited the escape of the bone from its preternatural position. At the same time, a young Colossus stood upon the table, astride the unfortunate man, ready to lift up his thigh, and apparently tear it from his body, if it would not otherwise yield.

The man's groans now came thick and deep. He begged for a moment's intermission—rest, as he emphatically called it; and he never felt the full force of that word before, racked though his limbs had been, repeatedly, by the severest toil. The only consolation which they vouchsafed him, was in terms such as these:

'Do you feel sick—very sick?'

'Very.' His face was the picture of an emesis in embryo.

''Tis just what we want.'

The distressed man seemed to feel, gutturally, as if he could reject the comfort-drawing conclusion, ab imo pectore.

'Would you like to vomit?'

In the fulness of his stomach, he would have answered 'yes,' but restrained himself and his diaphragm after a moment's rumination.

'We don't want you to do that.'

'But I am exceedingly tired—wearied to death.'

'You will be better after it is over, my friend.'

'Give me a drink of water, doctor, for heaven's sake!'

'Take a little of this solution.'

'Do open the doors, and let in some air. I can hardly draw my breath.'

'Oh, never fear but you will breathe long enough.'

'I shall faint.'

'Faint away, and we shall soon have the bone in.'

'Doctor, I can't stand it!'

'Then lay it, friend,' a favorite expression with one of the distinguished surgeons who officiated on this occasion.

'Wont you loosen these straps, only for a moment, so that I can rest my leg?'

'One minute, my good man,' continued the speaker, while with double vigor he reiterated his efforts to pry the bone into its cavity; 'bear it a little longer—one minute—there—bear it only a little while longer——'

'O, doctor, you will break my thigh! Doctor—doctor!'

'Don't be alarmed, my man; if I do I will set it again.'

'Let me have that rope!' he exclaimed, as he made violent efforts to spring up and catch the cord that was straining his sinews; efforts ten times more hopeless and unavailing than those of Milton's giant,

'There, lie still; you must not exert yourself. Do not try to draw your thigh up; we will take care of that.' Let it go as if you had nothing to do with it. Mr. R——, lift up a little more, as you are a true surgeon.'

'Oh, I shall die!' gasped the cruciated wretch.

'My good friend, you came here to have your thigh put back in its place, and you must be patient. You cannot expect it to be returned without pain.'

'I know; but wait till to-morrow; or let me rest myself for an hour or two, and then I shall feel refreshed, and be better able to bear it.'

'You may go to sleep, if you wish, my good fellow. I should be glad to have you.'

'But he could not well go in stays,' observed one of the walkers, in a low tone, to his neighbor.

'The cord-drawer there should unlace,' replied the other. 'But he resembles an ox triced up to be shod, more than a lady in corsets.'

'That saying is rather too ox-umorious for the occasion,' returned the éléve.

'Do you chew tobacco, my friend?' said the chief operator to the almost exhausted patient.

'I haven't chewed any lately,' he groaned.

'So much the better then. Mr. Aster, let me have a little out of your box. There—ah!'

'Here, my good man, take that,' he continued, presenting the grateful boon to the patient. 'Eat it: if you have not been accustomed to chewing, I am in hopes it will make you sick.'

This weed, it is known, produces the most deadly nausea and exhaustion in those not addicted to its use. It is customary to employ it in cases of this nature, where habit does not intervene, to incapacitate the patient for making any voluntary exertion in opposition to the extension, which purpose it answers even better than bleeding.

The occupation temporarily relieved him by changing the current of his thoughts, and he reclined in a state of utter listlessness and évanouissement, only interrupted by occasional retchings. The surgeons perceived the favorable opportunity; but the moment a movement was made to seize it, his muscles were on the alert, and it became a struggle between the unaided energies of a desperate man, and the mechanically-exerted force of an equally hardy but less excited opponent.

'Come, be calm, and do not strain so.'

'I can't help it!' The surgeons knew it.

'Whisper to him, Parcels,' said Aster, one of the junior assistants, who made his brightness particularly apparent in perpetrating puns upon the Roman vernacular, 'whisper him, by way of consolation and encouragement,

'That is, I suppose, 'If you are ill now, it is no sign you will be sick by-and-by.''

'Yes; and nothing could be more inspiring.'

'Poor dog, it is true he is likely to be as much benefitted by that as any thing else; but I will not trifle with his sufferings, even in seeming.'

'Cur nodus—why not? What will you do?'

'I will help, and then——'

'Soothe him by mild language. No, let Nature speak out her agony in his cries, and let the surgeon utter his sympathy as best becomes him, and as the welfare of his patient demands.'

'In jests?'

'In imperturbable coolness and decision: or, as you say, in jests; for what is comfort, under these circumstances, but a jest?'

'I think his system will not endure much more,' said Parcels.

'It is possible,' replied the walker.

He was a brave man, and even in this painful situation, he took what was offered him to increase his prostration; he chewed up a cigar, and gulped it down; he drank swallow after swallow of tartar-emetic solution, a most nauseating and relaxing preparation. But still, though deadly sick, the sweat pouring out of his forehead in clear drops, and though seemingly stretched, on this Procrustean bed, at least three inches beyond his natural stature, his muscles showed no disposition to relinquish their grasp upon the bone. The surgeons again and again exerted all their strength upon the passive and suspended limb, but it was without effect. They spoke a few words to each other, and at length concluded to remit the extension for a few minutes, in order to rest themselves.

It was, indeed, not only necessary for them, but for the man also, whose frame, it was justly feared, would not bear such unremitted torture. He seemed reprieved, in truth, by even the trifling respite that they granted him, and looked at the Herculean tar, (that was, before he became a nurse, thinking that his tender forces might be better exerted in the sick-room than on board a ship,) as, in obedience to orders, he walked up toward the slender and elegantly-wrought brass block, with steps that might have been impressed by an infant, which yielded only inch by inch the play that he had been so long and diligently accumulating upon the rope; he regarded him, I say, with a grim satisfaction, not unmixed with a tiger-like expression about the eyes and corners of the mouth, which bespoke any thing but pure and cordial affection.

But far from gaining the so much-coveted disenthralment, to the full of his desires, the cords were only partially slackened, and he was barely allowed to catch a glimpse of that freedom which would have been to him

He might have lain about as much at his ease as Satan on the fiëry plains of ——, when bethinking him of his late discomfiture, and planning new schemes of vengeance.

I had seen many operations and exhibitions; but in none that I assisted at, was I ever so struck with the utter inefficiency of the measures resorted to, which yet seemed all of the most appropriate and potential kind. I knew that there was no fault in the operation, and that every expedient was strictly in accordance with the rules.

'He bears that stretching well,' said Parcels, one of the young éléves. 'The dislocation must be into the ischiatic notch.'

'It is,' replied Berry. 'The thigh should be pulled up more. Rhodes, instead of sending you up there again, to straddle over this poor fellow, we'd better put you at the halyards, and let Featherbody mount the rostrum.'

'It will take nothing less than the devil or a handspike to lift it out. My handkerchief around the upper end of the thigh was a point d'appui to the bodies of four mortal surgeons, and served as a pivot to balance two of them on his extremities, and two at his head.'

'Faith, you did resemble Jupiter, weighing the ponderous merits of the adverse parties; and 'long time in even scale the doctors hung;' but —— seemed inclined to kick the beam.'

'Do you observe,' said Berry, 'the doctor himself looks a little puzzled? J—— and D—— are no better off. I thought —— would break the femur more than once.'

'That bone is just at this time encased in an impenetrable mail of rigid muscles. If you broke that, you would break an iron bar of equal size,' replied Parcels.

'In truth,' said Berry, 'the relaxing medicines and bleeding seem to have had little effect in weakening them. How much blood did you take, Parcels, before he was brought in?'

'Two pounds.'

'He has lost two here, and I should think he might spare a couple more.'

'Yes, and two more added to them, before the bone would be in its place,' remarked Parcels.

'You have no faith in nauseating mixtures, and debilitating remedies?'

'No. While they apparently reduce the strength, they seem not to take a whit from the power of the muscles to resist extension.'

'You will certainly be expelled the church.'

'There is,' continued Parcels,'a kind of galvanism residing in the muscles, which emanates from the brain; and all bodily remedies, while they leave this organ in a state of intense action and excitement, can have no beneficial effect in subduing them.'

'Ego cycnus!' said Aster, in a kind of Latin, which must be taken literally to be understood, 'I swan! this is the most untractable member that ever came under my notice. We shall have to subscribe for a high-heeled boot for the other leg, if we carry this out much farther.'

'Another trial of doctoring, I think, will shortly break off the matter in debate,' observed Berry.

They now for a second time drew him into mid-air. The nurse, who had stood looking on with his hawk's eye, and wiping the sweat from his brow with one hand, while with the other he grappled the end of the pulley-rope, again applied his strength; the blocks drew nearer together; the surgeon, using the disjointed member for a lever, and his knee as a rest, exerted his whole force upon the limb, in one strong effort to pry it out; but it gave not, although it was anticipated that the bone might snap. The assistant upon the table, drawing upward with all his might, endeavored to entice (somewhat as the Irishman remonstrated) the upper end from its hiding-place. But it would have been easier, to all appearance, to have raised the world without Archimedes' fulcrum, than to have displaced this little globe from its new socket.

The surgeons regarded each other with evident indecision and inquietude, and began to remit or grow more abrupt in their exertions. The students looked incredulous, and exhibited a disposition to depart. But, resolved not to incur the mortification or disgrace of a failure, if it could be averted by any human means, the operators determined to carry their exertions, in a final attempt, as far as was consistent with the patient's safety. They loosed the bandages from the arms, and gave him an additional dose of the nauseating solution.

In this state of things, a young man leaped cautiously over the partition into the arena, stole his way unnoticed among the surgeons, and approaching the table stealthily, took from it a scalpel, or operating-knife, of large size. With this, passing in front of the man, he suddenly started up with it before his eyes, and seemed ready to plunge it into his body. As he made this gesture, the man roused up, in horror. Although pale from the loss of blood, he blanched still whiter, at this palpable demonstration of a design to slay him.

'It is necessary, my friend,' said the young man, steadily and clearly, 'to cut down to your back-bone, in order to get out the head of the thigh-bone, which is lodged there!'

Who can tell the terror that filled the sufferer's excited imagination, during the utterance of this awful ultimatum! 'The sense of death is most in apprehension;' and in the horror of that moment, he felt with King John:

The ready éléve now made as if he was about to lay open the bowels of the patient, at a single rash stroke, from the stomach to the hip. Every arm was raised to arrest him; but taken as they were by surprise, he had ample time to execute his purpose. Leaning over and pressing his hand upon the side of the abdomen, he drew the knife rapidly and violently along its naked surface, from one extremity to the other. Then hastily rising, and throwing the knife on the bloody floor, he darted from the midst of the attendants; contriving, in the course of the action, to cover up with a corner of the blanket the work he had committed.

The patient, who had at first struggled, sank back; the spectators ran to his side; the students started from their seats; and the bone slipped into its place, with an audible 'click!' They hurriedly drew off the blanket from the patient's body, when lo! there was no wound! They went up to his side, and endeavored to arouse him from his stupor, and make him sensible that he was not hurt. In this they soon succeeded. The straps, pullies, and bandages were undone, and he was laid at length upon the table.

The young operator had well observed the powerfully depressing effect of fear on the human system, and had been incited to the ingenious expedient just described, by witnessing the obstinacy with which the bone had resisted all the measures for its reduction. In a few days the patient recovered entirely from his fright, and was seen walking about the halls of the hospital.