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beautifully illustrated work of MM. Bernard and Huette, 
the editors flatter themselves that they have contributed 
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quently experienced heretofore, viz.: a complete and con- 
cise picture of the science and art of Operative Surgery, 
in its present advanced and perfected condition, in a port- 
able form. The admirable and extensive works of Bourgerv 
and Jacob, and Prof. Velpeau, with the translation of the 
latter under the auspices of Prof. Mott, and the equally 
excellent treatise on Operative Surgery by Prof. Pancoast 
of Philadelphia, can never be replaced by the present work. 
Yet its compactness and portability will render it more 
desirable to the student as a companion in the lecture and 
dissecting room, where its copious and graphic illustrations 
will assist him materially in acquiring correct general ideas 
as to the nature and objects of the individual operations 
of surgery; whilst for more minute and varied details with 
regard to their history and numerous modifications, the less 
accessible and more expensive treatises alluded to can be 
consulted at a more advanced period of study. In fact 
they are better calculated for works of reference to the 
practitioner of surgery, than as text books for the student, 
designed to set forth concisely the elements of the art. Onr 
manual, whilst it is intended mainly to illustrate the intern VI 
cacies of operative surgery by appealing to tlie eye as well 
as to the understanding of the student, and by familiarizing 
him with that most useful department of anatomy which 
immediately relates to surgical operations, will also be 
found, it is hoped, not entirely useless as a work of refer- 
ence to those already engaged in practice. 
It has been the object of the translators to Americanize 
the language of the work to as great an extent as possible, 
making use of the terms in ordinary use in this country by 
teachers of anatomy and surgery, in order that the Ameri- 
can student may not be annoyed by meeting with foreign 
modes of expression with which he is not familiar, and 
which, in their opinion, it is rarely desirable to introduce 
into common use. This almost invariable peculiarity of 
French translations has heretofore interfered both with their 
popularity and general utility; it has therefore been their 
endeavor to avoid it. 
The additions, in the form of notes, which it has been 
thought proper to append to the original text, will not, it is 
hoped, be found to detract from its value. 
New-York, October, 1851. PI. I. 
MODELES CHARRIERE IX 
Plate I. 
INSTRUMENTS REQUIRED FOR MAKING INCISIONS. 
Fig. 1. Straight bistoury. 
Fig. 2. Convex bistoury. 
Fig. 3. Probe-pointed bistoury. 
aaa back of the bistoury. 
bbb edge of the bistoury. 
ccc joint of the handle and blade. 
ddd end of the handle. 
Fig. 4. Ordinary dissecting forceps. 
aa jaws of the forceps. 
Fig. 5. Director. 
a groove of the director. 
b probe-like end of the director. 
// extremity of a director in which the groove is continuous 
to the end. 
Fig. 6. Straight scissors. 
Fig. 7. Scissors curved on their cutting edges. X 
Plate 11. 
INSTRUMENTS REQUIRED FOR LIGATURE OF ARTERIES. 
Fig. 1. Charriere’s forceps for continued pressure. 
Fig. 2. Graefe’s spring artery forceps. 
Fig. 3. Charriere’s curved forceps for continued pressure. 
Fig. 4. Amussat’s torsion forceps. 
Fig. 5. Tenaculum. 
Fig. 6. Deschamps’ artery needle. 
Fig. 7. Director, with an eye in its extremity. 
Fig. 8. Cooper’s artery needle. 
Fig. 9. Eyed probe. 
Fig. 10. Sottot’s knot-tightener. PL 11. 
MODELES CHARRIERE PI. 111. 
PI. IV. 
MODE LE S CHARRIE RE XI 
Plates 111. & IY. 
INSTRUMENTS REQUIRED FOR AMPUTATIONS. 
Figs. 1, 2, 3. Amputating knives of different sizes. 
Fig. 4. Interosseous knife, or catlin. 
Figs. 5 and 6. Bone forceps. 
Fig. 7. Charriere’s tourniquet. 
Fig. 8. Ordinary amputating saw. 
a extra blade. 
Fig. 9. Small amputating saw. 
b extra blade. 
Fig. 10. Chain saw. 
c needle to conduct it. 
d handle to be attached after the introduction of the saw. 
Fig. 11. Suture needles. 
Fig. 12. Charriere’s forceps for continued pressure. 
Fig. 13. Amussat’s torsion forceps. 
Fig. 14. Tenaculum. XII 
Plates Y. & YL 
INSTRUMENTS FOR EXSECTION OF BONES. 
Fig. 1. I ley’s saw. 
Fig. 2. Knife-shaped saw. 
Fig. 3. Small semicircular saw.—a, surface for a point of support to the 
index finger of the hand, holding the instrument, when it is desired to em- 
ploy force with precision of motion. 
Fig. 4. Larrey’s straight saw. 
Fig. 5. Martin’s saw.—This consists of a rod, a b, with a circular saw at 
its extremity, c. A rotary motion is given to the rod, ab, and to the saw 
at its extremity, by another rod, d e, which is connected with the first by 
a universal joint, /. This arrangement allows the saw to move freely at 
any angle which the two rods may form with each other. The extremity, 
h, of the rod, de, fits into the shaft of a trepan (fig. 5, bis) which is moved 
by an assistant, whilst the operator, holding the handle, i, which is traversed 
by the rod, a b, directs the action of the saw and graduates its force, using 
more or less pressure, as may be required. Saws of different diameters, j, 
or shaped like a mushroom, k, may be fitted to the rod, a b, according to 
circumstances. 
Fig. 6. Charriere’s rowel saw.—A crank, a, moves the wheel, b, the teeth 
of which, interlocking with those of the wheels, c d e, transmit a rotary 
motion to the saw,/. By means of this instrument, which is solid, firm, 
and of easy application, we can operate on bones which are very deeply 
seated. Saws of different diameters can be adapted to it. 
Fig. 7. Dupuytren’s perforator.—An instrument used for breaking up 
deeply seated sequestra, when they cannot be withdrawn whole on account 
of the narrowness of the external opening. Two serrated jaws, aa, which 
can be opened and closed at will, grasp the bony fragment, which is then 
acted upon by a central drill, put in motion by a bow, the string of which 
encircles the grooved wheel, c. 
Fig. 8. Liston’s bone forceps, used for dividing small bones at a single 
cut. 
Fig. 9. Strong forceps, for holding steadily a portion of bone whilst 
being sawn. 
Fig. 10. Forceps for the extraction of sequestra. 
Figs. 11 and 12. Chisel and gouge. 
Fig. 13. Leaden mallet. 
Fig. 14. Rasp. 
Fig. 15. Olive-shaped cautery-iron, in its handle, 
Fig. 16. Hatchet-shaped cautery-iron. 
Fig. 17. Nummular cautery. PLY. 
PI. VI 
MODELSS CHARRIERE SURGICAL OPERATIONS. INSTRUMENTS EMPLOYED 
IN 
SUEGICAL OPEEATIONS. PI. i Plate I. 
METHODS OF HOLDING THE BISTOURY. 
The positions in which the bistoury may be held are liable to infinite 
variety; nevertheless, for the purposes of operative surgery, these posi- 
tions may be reduced to three, and each of them subdivided into two 
varieties. 
First Position (fig. 1 and 2). The handle of the bistoury is held 
firmly in the whole hand, like a table knife. In this position, the end 
of the handle of the instrument always rests in the palm of the hand, 
whilst the cutting edge may be turned either downwards (as in fig. 1), 
when the index finger is extended upon the back of the blade ; or up- 
wards (as in fig. 2), when the index is placed near the junction of the 
blade with the handle, and on its side. The first position is the best, 
whenever great firmness or force is required in the use of the instru- 
ment. 
Second Position (fig. 3 and 4). The bistoury is held like a pen in 
writing, the cutting edge being turned either downwards (fig. 3), or 
upwards (fig. 4). This position of the instrument is suitable when we 
desire its movements to be at the same time delicate and precise. 
Third Position (fig. 5 and 6). The bistoury is held like the bow ot‘ 
a violin. In one of the varieties of this position, the point of the in- 
strument is carried forward with its edge downwards (fig. 6); in the 
other the point is carried backwards, with the edge upwards (fig. 5). 
This position is employed when we wish to use the knife with the ut- 
most delicacy and prudence.* 
* In this country, as in England, the ordinary scalpel is most generally employed 
by surgeons in operations upon the living body, in preference to the French bis- 
toury, as well as in dissections of the dead. And there is a manifest advantage in 
the employment of a similarly shaped instrument for both purposes, as that instru- 
ment which the operator is most in the habit of using will always serve his purpose 
best under circumstances of difficulty. The shape of the scalpel undergoes slight 
variations, according to the fancy of individuals, and the above rules with regard to 
position are entirely applicable to it.—Eds. 4 
In cutting tlie integuments with the bistoury, or scissors, the object 
ordinarily in view is to open a passage towards deeper seated tissues, 
either for their simple exposure, or their removal. Under different cir- 
cumstances, then, the incision may be made either from without in- 
wards, or from within outwards. 
INCISIONS. 
In cutting from without inwards, the skin should always be pre- 
viously put upon the stretch, in order to avoid its wrinkling, and to 
facilitate its division under the edge of the bistoury, which should 
always cut by being drawn across the tissues with a suitable amount of 
pressure, applied so as to leave the cut surfaces perfectly perpendicular. 
Ist. Simple Incisions. The skin being firmly drawn and stretched 
over the deeper parts by the left hand of the surgeon, or by his assist- 
ants, the operator takes a straight bistoury in the first or second position 
(fig. 1 or 3), plunges it at first perpendicularly to a sufficient depth, and 
afterwards inclines it to an angle of about 45°, until the incision has 
reached the desired length, when he brings it out again perpendicularly, 
in order to avoid making an oblique section of the skin at the end of 
the cut. The same rules are followed in making all simple incisions, 
whether straight or curved. 
Sometimes it is necessary to avoid with especial care the parts im- 
mediately beneath the skin. In such a case the incision should be 
made with a convex bistoury, held in the third position (fig. 6), divid- 
ing the tissues carefully, layer by layer. Or, by pinching up a fold of 
skin, one end of which is held by an assistant, the bistoury being held 
in the first position, the fold may be divided by cutting it downwards 
perpendicularly, or by transfixing its base and cutting outwards in the 
same direction, a simple straight incision being the result in either case 
(fig. 2). 
2d, Compound Incisions. These are formed by the meeting, or in- 
tersection, of two or more simple incisions. The principal varieties are : 
Ist, the incision resembling the letter Y, where two simple incisions 
meet at an acute angle; if they meet at a right angle, it is said to re- 
semble the letter L. 2d, the T incision, where one incision falls per- 
pendicularly upon the centre of another; when they intersect each 
other at a right angle, a crucial incision is the result; when several in- 
cisions converge towards a common centre, they form a star. When 
several incisions are to be made intersecting each other, it can be done 5 
to the best advantage, especially where the skin is loose and yielding, by 
making a long straight cut in the first place, and then, whilst firmly 
stretching its borders by a hand at either end, making the others 
rapidly across it. 
3d. Incisions from within outwards. These are effected either with, 
or without, the assistance of a director. By one method, the bistoury, 
held in the second or third position, is inserted obliquely beneath the 
skin, or aponeurosis, or into the sinus which is to be laid open, and 
then brought up into a perpendicular position, by which movement the 
parts covering its edge are freely divided, the knife cutting from its heel 
towards its point. In a second method the instrument, in its first posi- 
tion, is introduced under the skin, with or without a director, to the 
point where the incision is to be terminated; then thrusting its point 
through the integuments, from within outwards, the incision is com- 
pleted by lowering the wrist and cutting out, from the point towards 
the heel of the knife. Plate 11. 
UNION OF WOUNDS. 
The different methods of promoting the union of wounds vary accord- 
ing to the nature and condition of the solution of continuity, and the 
ultimate object which the surgeon has in view. When a wound has 
commenced to suppurate, we simply, by means of different modes of 
dressing, endeavor to prevent the gaping of its edges, and the unneces- 
sary retention of the purulent discharge, whilst watching the process of 
cicatrization. But when immediate union of the wound is sought after, 
union by the first intention, as it is called, it is necessary that its edges 
should be retained very accurately in contact, in order that the adhesive 
inflammation about to develop itself shall effect their permanent agglu- 
tination. When wounds are not very irregular in their form, or when 
they are situated on the extremities, or on a convenient part of the 
body, it is sometimes possible to keep their edges in accurate apposition 
by means of position, and the judicious use of adhesive plasters and 
bandages; but in a great many instances it becomes absolutely neces- 
sary to resort to a regular operative procedure, viz.; the application 
of sutures. 
Eia. 2, 3, 4, 5, 6. sutures. 
The object of the application of sutures is to retain in accurate con- 
tact the lips of a wound, when, from its form or position, plasters or 
bandages will not answer the purpose. 
The instruments required for the introduction of sutures are needles 
and ligatures. The flattened needle of Boyer, curved in the form of an 
arc of a circle, a a, and that of Velpeau, with its eye on the side, curved, 
but flattened only on its anterior half, b b, are in most general use ; for 
particular operations, needles of other shapes are employed—these will 
be described in their proper connection.* The needle-carrier (fig. 7) is 
* The straight round needle with a triangular point, of different sizes, is much 
used in this city. It answers fully as well in the great majority of wounds as the old- 
fashioned curved needles, and is unquestionably managed with more facility.—Eds. PL 2 . 7 
only used when the nature of the tissues requires the employment of 
much force in the introduction of the needle. 
In regard to their mode of application, and the manner in which 
their purpose is effected, sutures are divided into three species. Ist, 
The simple, or Pelletier's suture (fig. 2 and 3), which approximates 
the lips of the wound, edge to edge; 2d, The zig-zag, or hasting su- 
ture (fig. 5), hy which the deeper portions of the cut surfaces are 
brought in contact; 3d, The hoisted suture (fig. 6), which effects both 
of these objects, keeping the deeper portions of the wound together, 
whilst its cutaneous edges are also maintained in accurate apposition. 
Ist. Simple suture (fig. 3) is effected by passing a needle with its 
ligature through both of the lips of the wound which are to be kept in 
contact. To do this the operator passes the needle from without in- 
wards through the right border of the wound at a distance of two to 
three lines from its edge; its point is then pushed forward in such a 
manner as to perforate from below upwards the left border of the wound 
at the same distance from its edge; the convexity of the needle always 
presenting towards the bottom of the wound. Sometimes the irregular 
shape of the wound, or the separation of its lips from each other, ren- 
ders it impossible for both of them to be perforated at the same time by 
the same needle; in this case a ligature armed with two needles may 
be employed, each of which is passed through a lip of the wound, from 
within outwards. 
The first point of suture being thus effected, the rest are applied in 
like manner, until the edges of the solution of continuity are in contact 
throughout. When several sutures are thus introduced without cutting 
the thread, the continued, or glover's suture is the result (fig. 3). On 
the contrary, when the thread is cut and tied over the wound between 
each point of suture, it is then known as the interrupted suture (fig. 2). 
Finally when, in place of tying together the ends of each of the threads, 
they are all brought together in a single bundle, and fastened at a dis- 
tance, so as to keep up their tension, we have Ledrans’, or the looped 
suture, sometimes applied to wounds of the intestines (v. Enteroraphy). 
2d. Zig-zag, or basting suture (fig. 3). This is commenced exactly 
in the same manner as the simple suture, that is to say, a single needle 
is inserted through both lips of the wound, but its thread, instead of 
passing back again across the wound, is carried along, and parallel with, 
its border, until the next point is reached, from which it is passed again 
through both of its lips to the side from which it was at first introduced. 8 
The needle being thus inserted alternately from either side of the wound, 
without the thread being cut, a species of zig-zag is described by it 
from which the suture takes its name (fig. 5). The quilled suture 
(fig. 4) is evidently a variety of this latter; it tends also to bring toge- 
ther the deeper portions of a wound, only the loops of the ligature 
which produce this result in the zig-zag suture are here replaced by a 
piece of a gum elastic catheter, or the barrel of a quill. The manner 
in which it is done is by passing, in the first place, through the lips of 
the wound, as many double ligatures as it is wished to make points of 
suture; the quill or bougie is then introduced, parallel to the edge of 
the wound, through the loops formed by the doubling of the ligatures, 
whilst their free ends are tied, with the necessary degree of tightness, 
over another quill at the opposite side of the wound. 
3d. Twisted suture. This species of suture combines the results of 
both of those previously described, only it is done in a different manner; 
instead of an ordinary ligature, a metallic pin or needle is passed 
through the lips of the wound—either an ordinary pin, a, or the insect 
pins, which Dieffenbach prefers. By the first step the deeper portions 
of the cut surfaces are brought in contact, and to produce the same 
effect upon the cutaneous edges of the wound, a ligature is applied 
around each pin in the form of the figure 8, its ends being crossed in 
passing to the next pin, where the process is repeated. The operation 
is finished by cutting off the points of the pins, and placing a longitu- 
dinal strip of adhesive plaster between their extremities and the skin, to 
prevent the latter from being irritated by the cut ends, ff. PI. 3. Plate 111. 
OF THE SETON. 
The object of the seton is to establish and keep up a drain, or issue, by 
means of a strip of cotton, or linen tape, introduced beneath the skin. 
It is most frequently made use of in the nape of the neck, but may be 
applied with advantage in many other localities. 
EIG. 1. SETON IN THE NAPE OP THE NECK. 
Having pinched up the skin of the back of the neck in a vertical 
fold, one end of which is held by an assistant, the operator transfixes 
the base of the fold by a straight bistoury held in the first position, 
and enlarges the incisions thus made to the requisite extent; then by 
means of the eyed-probe, a 6, the strip of linen, c, previously greased 
with cerate, is passed through the wound made by the bistoury, and the 
fold of skin is allowed to resume its natural position. 
The dressing consists of a piece of linen in which a number of small 
holes have been cut, spread with cerate and placed upon the wound; 
over this is a small wad of lint for the purpose of absorbing the dis- 
charge which escapes through the holes in the linen, covered by a com- 
press, in the folds of which the excess of the seton is coiled. A circular 
turn of a bandage around the neck retains the dressing in position, and 
it should not be renewed until the fourth or fifth day, by which time 
suppuration will have been established. At each dressing a new por- 
tion of the seton, well greased, is drawn into the wound, and the 
soiled end cut off; when the seton is exhausted a new one is sewed to 
its extremity. 
Boyer’s suture needle (fig. 1 his), which carries the seton through at 
the same time that it makes the wound, may be substituted for the bis- 
toury and eyed-probe. This instrument, however, is not much used.* 
* The English seton needle, which differs slightly from Boyer’s, is a convenient 
instrument, and very generally employed in this country; it can be introduced 
more rapidly and with less pain than the bistoury and eyed-probe. 
The substitution of a strip of india-rubber cloth for linen or cotton, is also an ira- 10 
FIG. 2. VACCINATION. 
Ordinarily the upper and outer part of the arm is selected for the 
insertion of the vaccine virus. There are four methods of doing this : 
Ist, by friction; 2d, by a blister ; 3d, by scarification; 4th, by punc- 
ture. We will describe the latter only, which is the mode most in use. 
To vaccinate by puncture the ordinary lancet, or what is better, the 
vaccinating lancet, ab, is the instrument generally preferred. This is 
previously charged with the virus, either by inserting it into a mature 
vesicle, when we vaccinate directly from arm to arm, or by making use 
of preserved matter. The lancet is then introduced almost horizontally 
beneath the surface of the skin to the distance of about a line, the ope- 
rator endeavoring to make the instrument pass as it were between the 
epidermis and the true skin ; it is allowed to remain for a few seconds 
and then withdrawn in such a manner -as to wipe off the virus from the 
point of the instrument, the withdrawal of which is generally followed 
by a small drop of blood. In this manner three or four punctures are 
made in each arm, which must lie allowed to dry perfectly before the 
infant is dressed. 
NIG. 3. SCARIFICATIONS. 
The term bird-peck punctures, aaa, is applied to a number of su- 
perficial punctures rapidly made with a lancet-shaped needle, or- a well- 
pointed lancet, with the view of depleting inflamed or oedematous 
tissues. 
Scarifications are small superficial incisions, made close to each 
other for the purpose of causing a flow of blood; it is a very ancient 
method of effecting depletion of the capillaries. They may be made 
with a lancet, a razor, or even a bistoury, held in the third position. 
With a view of lessening the pain when made in this manner, the 
Germans have invented a scarificator (fig. 3 bis), in which, by means 
of a spring, some fifteen or twenty small blades, are made to cut at one 
stroke ; thus the duration of the operation is much diminished. 
FIG. 4. ACUPUNCTURE. 
The operation of Acupuncture consists in the introduction of needles 
made for the purpose, a, b, c, into different parts of the body. When 
provement, as it does not absorb the discharge from the wound; nor does it re- 
quire constant renewal and methodical dressing, but may be tied in a loop and 
allowed to remain, which, with children, is an advantage.—Eds. 11 
the needles are placed in communication with the poles of a machine, 
with the object of passing a current of electricity through a limb or a 
diseased part, the operation takes the name of electro-puncture. Of late 
electro-puncture has been employed, and in several instances with suc- 
cess, to produce the coagulation of the blood in arteries, and in this 
manner to effect a cure of aneurism. 
There are different modes of introducing the needles—either suddenly 
by a single thrust, or in a more gradual manner, by rolling the handle 
of the needle between the thumb and index finger, whilst pressing it 
gently onwards. Sometimes also it is driven forwards by a series of 
gentle taps upon its head. The pain is but trifling by either method. Plate IV. 
Ist. BLEEDING FROM THE ARM. 
FIG. 1. ANATOMY OF THE PART. 
The skin and adipose tissue which cover the veins at the hend of the 
arm have been removed by dissection, as well as the subjacent brachial 
aponeurosis, 2, in order to demonstrate the relation of the deeply seated 
parts with the superficial veins. 
These are, reckoning from without towards the inner border of the 
arm: 
A. The radial vein, accompanied by some small branches, a, of the 
musculo-cutaneous nerve. 
B. The median cephalic, crossed by the internal branch, b, of the 
musculo-cutaneous nerve. 
C, The cephalic vein, formed by the union of the two preceding; 
the main trunk of the musculo-cutaneous nerve, c, lies along its inner 
border. 
D. The common median vein, with branches from the musculo-cu- 
taneous and internal cutaneous nerves. 
E, The median basilic, accompanied by the anterior branch, e, of the 
internal cutaneous nerve. Larger and more superficial than the pre- 
ceding, the median basilic vein runs parallel, in its external half, with 
the brachial artery, from which it is separated by the aponeurotic ex- 
pansion given off by the tendon of the biceps, Gr, The median nerve, 
H, also lies behind it. 
I. Ulnar veins. M, basilic vein, formed by the union of the median 
basilic with the ulnar veins. A, Internal cutaneous nerve. 
FIG. 2. METHOD OF PERFORMING THE OPERATION. 
The patient being either seated, or lying down, the operator having- 
provided himself with a short bandage, places the centre of it upon the 
forepart of his arm, about three or four fingers’ breadths above the bend 
of the elbow, and bringing its two ends to the outer side of the arm, PI. 4- 13 
ties them in a bow-knot. Whilst the veins are swelling under the 
influence of this constriction, which, however, should never he carried 
so far as to control the heating of the pulse at the wrist, the surgeon 
prepares a small compress, folded in four, for the dressing, and makes 
ready his lancet, which is done hy opening the hlade until it forms a 
slightly ohtuse angle with its handles; this he places within his reach, 
or between the teeth, so that it can he seized at any moment hy the 
heel of the hlade. 
Then taking the patient’s arm, he rotates it outwards, and places its 
hand beneath his own left arm (if it is upon the right arm that he is 
about to operate, and vice versa, if on the left,); he now hy means of 
gentle friction pushes along the blood so as to distend the portion of 
the vein which he is about to pierce, to the utmost, and coniines it there 
hy the thumb of his left hand across the vein, whilst the four fingers of 
the same hand encircle the hack part of the patient’s arm and their 
ends put the skin upon the stretch in front. This done, the surgeon 
takes the hlade of the lancet between his thumb and index finger, and 
makes use of the other fingers as a point of support at the moment 
of piercing the vein, resting them upon the patient’s forearm. The 
opening of the vein should he made, in most instances, hy a simple 
puncture, obliquely to the general direction of the vein, a, aa11. ■ Im- 
mediately on the puncture being made, the stream of blood jets out 
with more or less force, and its force can he increased hy causing the pa- 
tient to grasp or squeeze in his hand a cane, lancet-case, or roll of ban- 
dage. When the requisite amount of blood has been obtained, it is ar- 
rested by applying the thumb of the left hand upon the opening in the 
vein, whilst removing the bandage from the arm. After having wiped 
away the blood from the arm, the small compress already prepared is 
placed upon the wound in the vein, under the thumb, and retained in 
its situation by a bandage applied around the arm in the form of the 
figure 8, the ends of which are tied in a knot over the wound, or 
fastened with a pin. 
In bleeding from the arm there are several points worthy of notice, 
both with regard to the selection of a vein, and the shape of the lancet. 
Blood can be obtained from any of the veins at the bend of the arm 
when they can be recognized beneath the skin. The median basilic, 
A, or cephalic, B, are, however, for the most part preferred. What 
has been said above, applies particularly to the median cephalic; but 
when the median basilic is the only vein to be found, it is necessary for 14 
the operator to ascertain accurately the position of the artery before 
opening the vein. It is better, as a rule, to make the puncture as low 
down in the vein as practicable, because, in this position, the aponeu- 
rotic expansion from the tendon of the biceps lies between the two 
vessels. If at the moment of puncturing the vein, the patient should 
throw his biceps muscle into a state of strong contraction, as he would, 
for example, in drawing the operator towards him with the arm, this, by 
throwing a stronger tension upon the aponeurotic expansion, would 
raise the median basilic vein, and separate it still farther from the artery 
which lies beneath it. 
The lancet wrhich makes an obtuse angle at its point, called a grain 
(Forge, from its resemblance in shape to a grain of barley, makes a 
large wound, and suits the great majority of cases (pi. 5, fig. 1) ; the 
more pointed pattern, known as the lancet a grain Favoine, from its 
shape being like that of an oat-grain (fig. 2), and that with a very 
acute point, called a langue de serpent (fig. 3), from its likeness to a 
snake’s tongue, are used when the vein lies very deep and is covered 
with a thick layer of fat; when using these it is recommended to en- 
large the opening in the integuments by making the point of the in- 
strument cut its way out by a lever-like movement succeeding the 
puncture. In this way a free Aoav of blood is secured, and the infiltra- 
tration of the cellular tissue, known as thrombus, is prevented. 
2d. BLEEDING FROM THE FOOT. 
FIG-. 3. ANATOMY OF THE PART. 
The internal saphoenous vein, A, which takes its origin on the dor- 
sum of the foot, B, passes from below upwards in front of the internal 
malleolus, C, upon the inner side of the tibia, accompanied by the sa- 
phoenous nerve, D, A thin layer of fascia separates it from the skin. 
FIG. 4. MODE OF OPERATING. 
The venous circulation in the foot is arrested, as in the arm, by 
means of a bandage placed around the ankle, about two fingers’ 
breadths above the malleoli; after this it is placed in a warm foot- 
bath, whilst the lancet and dressing are being made ready. When pre- 
pared, the surgeon, seated in front of the patient, takes the foot from 
the water, and having wiped it places it upon his knee ; he then secures 15 
the vein, A, in its place with the thumb, as it is very apt to roll in 
this locality, and proceeds to open it precisely as in bleeding from the 
arm. It is rarely the case that the blood flows from the foot in a jet, 
and the custom is to replace the foot in the vessel of warm water until 
its deepened color, or the length of time of immersion, indicates that a 
sufficient quantity of blood has been lost. 
The dressing consists of a small square compress over the wound, 
kept in place by a bandage in the form of the figure 8, around the 
foot and ankle. Plate V. 
Fig. I. Lancets.—1, a grain d’orge ; 2, a grain d’avoine ; 3, a 
LANGUE DE SERPENT, 
a, blade of the lancet; e, heel of the blade; g, sheath of the lancet; 
h, /k, the two portions of the sheath; /, joint of the blade and its 
sheath. 
Fig. 11. Bleeding from the external jugular vein, B ; arteriotomy 
in the temporal artery, A. 
BLEEDING FROM THE JUGULAR. 
PIG. 2. ANATOMY OP THE PART. 
The external jugular vein, which is sometimes solitary, and at others 
double in its origin, in the latter case commencing by two branches 
which unite in a common trunk about the middle of the neck, takes its 
course normally from the angle of the lower jaw to the middle of the 
clavicle. Passing obliquely backwards from its point of origin, it 
crosses the course of the sterno-eleido-mastoid muscle, and lies upon it, 
covered throughout by the platisma myoides and the skin. In the 
upper part of its course it has near it some small nervous filaments. 
MODE OP OPERATING, 
The patient being seated, or, still better, in reclining position, the cir- 
culation is arrested by a compress placed upon the vessel a short dis- 
tance above the clavicle. The compress, which should be somewhat 
thick, is kept in its place by a bandage, A, which is tied in the arm-pit 
of the opposite side. A simple piece of cord, rather tightly tied, might 
readily take the place of the compress and bandage, for the cord buries 
itself in the skin and compresses the vein very accurately at the point 
where it is crossed. The vein being by this means sufficiently distended, 
the surgeon steadies it with his index finger, and makes the puncture, 
B. The opening in the vein in this region of the neck should be full PL 5 17 
large, and directed obliquely across tbe fibres of the platisma muscle, 
for being thus divided the muscular fibres retract and keep the wound 
gaping. It happens very often that the blood will not flow in a jet, 
but trickles down the neck ; in this case a common card should be folded 
longitudinally, so as to form a gutter, by which the blood can be guided 
into a proper vessel. 
The flow of blood is stopped by removing the compression, and at 
the same time a finger should be placed upon the wound to prevent 
the entrance of air into the vein. The wound is dressed by bringing 
its edges together and applying a piece of adhesive plaster, or the com- 
mon court plaster. Sometimes this dressing, and even the addition of 
a circular bandage, does not succeed in stopping the flow of blood 
entirely; in such a case M. Magistel suggests the introduction of a 
point of suture. 
ARTERIOTOMY. 
SURGICAL ANATOMY. 
A' represents the course of the temporal artery; Z»', the section of 
the skin ; c', pyramidal compresses for compression of the artery. 
The temporal artery, a branch of the external carotid, when opposite 
to the condyle of the lower jaw, runs directly upwards behind the arch 
of the zygoma. About the middle of the temporal region it divides 
into two branches : the posterior, which passes backwards, and the an- 
terior, or frontal, which runs upwards and forwards upon the forehead, 
where it lies upon the epicranial aponeurosis, and immediately beneath 
the skin. 
MODE OF OPERATING. 
The patient being properly placed, either sitting or lying, the exact 
position of the artery is ascertained by its pulsations, and it is steadied 
by the thumb and index finger of the operator, the skin covering it 
being rendered tense at the same time. He then, with a straight bis- 
toury, held in the third position, makes a short incision directly across 
the course of the artery, by which it is divided. The blood issues some- 
times in a jet, though more frequently it only trickles ; in order to stop 
it, when necessary, compression is made on either side of the wound by 
means of the pyramidal compresses, c, c', which are retained in their 
places by a circular bandage around the head, knotted over the 
temples. Plate YL 
LIGATURE OF ARTERIES 
Ist. on the effects produced by the LIGATURE UPON an artery, 
Fig. 1, Arteries are composed of at least three membranes placed 
one upon the other, called coats: a, the external coat, possesses the 
most vitality, is tough and very resisting; h, the middle coat, is yellow, 
elastic, composed of circular fibres, possesses very little power of resist- 
ing force applied in the direction of the course of the vessel, and a low 
degree of vitality; c, the internal coat, thin, smooth, transparent, en- 
dowed with little strength and no vitality, is regarded as an analogue 
of the epidermoid tissues. 
Fig. 2. When a ligature, a, is applied to an artery, the internal and 
middle coats, b, c, are divided by the thread, and pushed aside, so that 
the internal surfaces, c, d, of the outer coat, the only one which resists 
the action of the ligature, are brought into forcible contact. 
Fig. 3. After the application of a ligature to an artery, the first col- 
lateral branch, a, above the ligature becomes dilated; in the space 
between the ligature and this first collateral branch the blood stagnates, 
and shortly forms a clot, 5, the office of which is to plug up the artery 
after the ligature has come away. 
Fig. 4 and 5. The process of torsion, a, produces an effect upon the 
arterial coats analagous to the ligature, that is to say, it effects a 
division of the internal and middle coats, h, b, which are forced to 
either side, whilst the external coat, c, alone offers resistance, and be- 
coming twisted, serves to obliterate the calibre of the artery. 
Fig. 6. After the circulation of the blood through an artery has 
been interrupted, by a ligature or any other means, it becomes re-esta- 
blished beyond the obstruction by the dilatation of the anastomoses 
between the collateral branches above and belowT the ligature. Fig, 6, 
taken from Dupuytren’s Museum, represents an aneurism, a, of the 
popliteal artery which was cured by the application of ice. We can 
readily recognize the very considerable dilatation of the articular arteries, PI. G 19 
6, b, b, b, through which the circulation in the limh below has been 
preserved. 
Fig. 7. a, an artery in a stump, transfixed by the point, 6, of the 
tenaculum; c, c', ligatures to be applied to the artery. 
2n. general rules for the ligature of arteries. 
To lay bare an artery for the purpose of placing a ligature upon it it 
is necessary: 
Ist. To determine the position of the vessel, by the requisite fami- 
liarity Avith its anatomical relations, assisted by the arterial pulsations 
—if the operation is performed upon the living body. 
2d. The skin being placed upon the stretch, an incision is made 
upon the vessel Avith a convex bistoury held in the third position; this 
incision, parallel with the course of the artery, should always divide 
both the skin and the subcutaneous cellular layer, and its length should 
be proportioned to the depth at which the vessel lies. 
3d. The aponeurotic layer which binds down the muscles is to be 
divided to the same extent, on a director, and the muscles beneath 
pushed to either side to expose the sheath of the vessel, Avhich con- 
tains the artery, in company Avith its corresponding veins and nerves. 
4th. After raising a fold of the sheath of the vessel with the dissect- 
ing forceps, it is to be opened with great care, the edge of the bistoury 
being kept parallel to the artery, and never turned towards it. 
sth. The bistoury is then relinquished, and the surgeon makes use 
of the director, held as a writing pen, to isolate the artery on either 
side, and endeaA7ors Avith its point to tear through the loose cellular 
tissue which surrounds it, so as to pass the instrument behind the vessel. 
In this stage of the operation there are tivo important precautions to be 
observed; in the first place, to lay bare the artery to as trifling an 
extent as possible, and secondly, to introduce the director betAveen the 
artery and the vein, so that the latter shall not be exposed to injury 
from the point of the director as it passes beneath the artery. 
6th. When the artery is well exposed and the director lodged be- 
neath it, the operator satisfies himself of its identity by recognizing its 
pulsations, and then passes along the groove of the director an eyed- 
probe, armed with the ligature. When the vessel is deeply situated, 
Deschamps’ or Cooper’s artery-needle is substituted for the eyed-probe.* 
* The highest American authority in regard to the mode of tying arteries. Prof. 
Mott, does not make use of the director as described above, but employs in its 20 
Finally, being assured of the identity of the artery, the first knot in 
the ligature is tied. If the vessel is deeply placed, the knot should be 
tightened by means of the two index fingers inserted into the wound, 
one of them pressing upon each end of the ligature, in order that the 
artery should not be too much dragged from its bed. The second knot 
is then tied, one of the ends of the ligature cut off, and the remaining 
one brought out at the most depending angle of the wound. 
place the smooth round point of the artery-needle which bears his name, and which 
is also known as the American needle. After opening the sheath of the vessels, 
and separating it from the artery with the handle of the scalpel, he insinuates the 
point of this needle, which he considers by far the best instrument of its kind, 
gently between the vein and artery, and passes it beneath the latter, always keep- 
ing the point from the vein, and disturbing the connections of the artery as little as 
possible. As there is probably no surgeon living who has operated upon the ar- 
teries more extensively, or more successfully, than Prof. Mott, we can do no better 
than to follow his method in this respect.—Ens. PI. 7. Plate VII. 
LIGATURE OF THE ULNAR AND RADIAL ARTERIES. 
FIG. 1. SURGICAL ANATOMY. 
A, Brachial artery, accompanied on its inner side by the median 
nerve, b. 
c, median basilic vein, crossing the course of the brachial artery and 
median nerve, from which it is separated by the aponeurotic expansion, 
d, given off by the tendon of the biceps. 
Incision No. 2 represents the ligature of the ulnar artery in its 
lower third, a, incision in the skin; b, edges of the divided aponeu- 
rosis ; c, ulnar nerve; d, tendons of flexor sublimes ; A, radial artery 
with the director beneath it. 
Incision No. 3. Ligature of the radial artery in its upper third, 
a, wound in the skin; h, edges of the aponeurosis; c, radial nerve; 
d, internal border of the supinator longus ; A, radial artery with the 
director beneath it. 
Incision No. 4. Ligature of the radial artery at the wrist, a, 
wound in the skin ; b, aponeurosis ; c, radial nerve ; A, radial artery 
on the director. 
MOLE OF OPERATING. 
§l. Ligature of the radial artery at the wrist (see incision No. 4). 
Ist, Along the external border of the tendon of the flexor carpi radialis, 
which is always easily recognized, make an incision from one and a half 
to two inches in length through the skin and sub-cutaneons cellular 
tissue. 2d, Divide the aponeurosis of the fore-arm upon a director; 
recognize, isolate, and place a ligature beneath the artery, which is si- 
tuated just external to the tendon of the flexor carpi radialis, always 
easily known by its pearly color. 
§2. Ligature of the radial artery in the upper third of the fore- 
arm—(see incision No. 3). 
Upon the internal border of the supinator longus muscle, if it can 
be recognized, and if not, along a line, representing the course of the 22 
artery, and drawn from the middle of the bend of the elbow, to the 
inner side of the styloid process of the radius, let an incision be made 
from two and a half to three inches in length, taking care to avoid 
the superficial veins. The deep fascia being laid open on the director, 
the inner edge of the supinator ongus muscle is to be sought for be- 
neath it. This landmark being determined, on drawing the muscle a 
little outwards with a spatula or blunt hook, the artery will be discov- 
ered enclosed in its sheath with its two venae comites, from which it is 
to be isolated and tied. 
§3. Ligature of the ulnar artery in the lower third of the fore- 
arm (see incision No. 2). Ist. Along the external border of the ten- 
don of the flexor carpi ulnar is, or if it is preferred, in the course of a 
line drawn from the internal condyle of the humerus to the prominence 
of the pisiform bone, let fall an incision from one and a half to two 
inches in length, dividing the skin and subcutaneous cellular tissue; 
2d. The deep fascia being then laid open upon the director, the tendon 
of the flexor ulnaris will be seen, and it must be pushed towards the 
inner side; 3d. The artery, which is beneath it, between its two accom- 
panying veins in their common sheath, is then to be isolated, and the 
ligature inserted beneath it. 
§4. Ligature of the ulnar artery in the middle of the forearm 
(see incision No. 1). Ist, Upon the imaginary line just indicated 
make an incision three inches in length through the skin and cellular 
tissue ; 2d, endeavour to find the first intermuscular septum which can 
be detected, going from within outwards ; 3d, divide it upon the direc- 
tor, and push the fibres of the flexor sublimis towards the outer side of 
the limb, when the artery will be discovered immediately beneath it, 
with its veins. After having laid open the sheath of the artery, it will 
be found most convenient to make use of Cooper’s or Deschamps’ needle, 
on account of the depth of the wound. PI. 8. Plate VIII. 
LIGATURE OF THE BRACHIAL ARTERY. 
PIG. 1. SURGICAL ANATOMY. 
AB, Brachial artery.—It extends from the inferior limit of the axilla 
to about an inch below the articulation of the humerus with the ulna. 
Situated on the inner side of the humerus above, it inclines gradually 
outwards in descending the arm, and at its lower part lies in front of the 
bone. 
In its upper fourth the artery is in relation with the inner edge of: 
the coraco-brachialis muscle 0 ; below, it corresponds with the internal 
border of the biceps, D, which slightly overlies it in its two inferior 
thirds. In emaciated subjects it is covered only by the integuments and 
deep fascia of the arm. Towards its termination, it lies along the inner 
edge of the tendon of the biceps, whilst about to pass beneath the 
aponeurotic expansion, a, given off by the latter, which separates it from 
the median basilic vein, h. 
E, The median nerve, which accompanies the artery thoronghont its 
course, enclosed with it in a common aponeurotic sheath. Above, the 
nerve is external to the artery; towards the middle of its course, it 
passes in front, and below, in its inferior third, it lies internal to it. 
The radial and ulnar nerves lie behind, and to the inner side of the 
artery, but only at its upper part. 
EG, Humeral veins.—The vein on the inner side of the artery is 
larger than that on the outer side ; in their course down the arm, they 
form frequent anertomoses with each other. 
H, The inferior profunda, branch of the brachial artery which passes- 
backwards in company with the ulnar nerve, K. 
Incision No. 1. Ligature of the brachial artery near the bend of 
the elbow, a, incision involving the skin and cellular tissue ; b, edges 
of the divided aponeurosis of the arm •, c, median basilic vein, situated 
between the skin and aponeurosis, and pushed out of its place towards 
FIG 2. OPERATION. 24 
the inner condyle; d, inner edge of the biceps muscle ; e, median nerve 
on the inner side of the artery; F, artery isolated from its sheath, with 
the director beneath it. 
Incision No. 2. Ligature of the brachial artery at the upper 
part of the arm.—a, incision through the integuments ;b, incision of 
the deep fascia; c, brachial vein; d, median nerve, external to the ar- 
tery ; E, artery isolated, and raised upon the director. 
§l. Ligature of the brachial artery at the bend of the elbow (see 
incision No. 1). Ist, Make out distinctly the tendon of the biceps, 
and the internal border of this muscle. 
MODE OE OPERATING. 
2. Make an incision at least two inches long, following the curve of 
the inner edge of the biceps. In this incision through the integu- 
ments, the precaution must be taken to push the basilic vein on one 
side, in order that it may not be wounded. 
3. The deep fascia, in this situation, is the aponeurotic expansion 
given off by the tendon of the biceps ; it is to be laid open on the 
director. 
4. Beneath it is seen the artery with its veins, and on its inner side, 
the median nerve; the sheath is to be opened by cutting upon it ob- 
liquely, and the artery carefully isolated and tied. 
§2. Ligature of the brachial artery in the upper part of the arm 
(see incision No. 2). Ist, after having distinctly recognized the inter- 
nal border of the biceps muscle, make an incision parallel to it about 
two Inches and a half in length, through the skin and cellular tissue. 
2d. Lay open the deep fascia on a director. 
3d, Look for the nervous trunk which lies nearest the inner edge of 
the biceps; it is the median nerve, beneath and to the inner side of 
which the artery will be found. 
4th. Open the common sheath of the vessels, by lifting a fold of it 
with the forceps and holding the knife horizontally ; then push the 
median nerve outwards, isolate the artery, and pass the director beneath 
it from without inwards. PI. 9 Plate IX. 
LIGATURE OF THE AXILLARY ARTERY. 
FIG. 1. SURGICAL ANATOMY. 
1, Pectoralis major muscle drawn upwards ; 2, pectoralis minor ; 
3, Latissimus dorsi and teres major muscles; 4, biceps muscle; 5, 
triceps extensor cubiti ; 6, deep fascia of tlie arm. 
a, Axillary artery. A continuation of the subclavian artery, it 
commences at the lower border of the first rib, and ends at the inferior 
boundary of the axilla (the lower border of the latissimus dorsi mus- 
cle) ; its course corresponds with a line dividing the anterior from the 
middle third of the axilla. In its inferior half it is in relation externally 
with the inner side of the humerus, against which it may be readily 
compressed; internally it is covered only by the integuments and deep 
fascia, and its pulsations can be easily felt. 
b, coraco-brachialis muscle, in contact with the artery throughout 
its course. The artery is always to be found at the internal and pos- 
terior border of this muscle, which serves as a reliable landmark. 
c, d 1 e, / branches of the brachial plexus of nerves. They surround 
the artery very closely below the pectoralis minor muscle ; c, the mus- 
culo-cutaneous nerve lies along the outer side of the artery; d, the 
median, the largest branch of the plexus, takes its origin by two roots, 
which meet in front of the artery, opposite the lower border of the 
pectoralis minor muscle; this nerve, skirting along the inner border 
of the coraco-brachialis muscle, lies in front and a little to the outer 
side of the artery; e, internal cutaneous nerve, a small branch which 
takes its origin from the innermost root of the median, lies in front and 
to its inner side. Finally, the ulnar nerve,/, and the radial, which is 
concealed by the axillary vein, are situated still farther within and 
behind. 
G, the axillary vein, is situated in front of the artery and nerves, 
which it partly conceals. 
The axillary vessels and nerves are surrounded and held together by 26 
a loose cellular tissue, which is interspersed with numerous lymphatic 
vessels and glands, h. 
K, brachial artery, continuation of the axillary, isolated from the 
nerves and veins which surround it. 
I, the subscapular, and inferior thoracic arteries and veins, 
FIG. 2. OPERATION. 
a, incision of the skin, cellular and adipose tissues; 6, deep fascia; 
c, median nerve, pushed upward ; d, axillary vein, depressed by a blunt 
hook; e, internal cutaneous nerve; /, sheath of the axillary vessels; 
G, axillary artery upon the director, which has been passed from 
within outwards, and from below upwards. 
MODE OF OPERATING. 
The operation of tying the axillary artery in the axilla, below the 
pectoralis minor muscle, is described as Lisfranc’s method; it is as 
follows : Ist, determine the position of the artery by drawing a straight 
line corresponding with the union of the anterior third with the pos- 
terior two-thirds of the axilla, or by feeling, if possible, for the internal 
edge of the coraco-hrachialis muscle, the guide for the artery. 2d, 
carefully divide the skin and cellular tissue on this line to the extent of 
two inches and a half. 3d, as soon as the fasciculus of vessels and nerves 
is in sight, lay aside the bistoury, and relax the parts by slightly low- 
ering the arm. 4th, endeavor then to recognize the coraco-hrachialis 
muscle, and make use of it as a guide to the position of the artery. 
sth, by the aid of the director, starting from the coraco-hrachialis 
muscle, first push the median and internal cutaneous nerves in front, 
and then the ulnar and musculo-spiral towards the posterior border of 
the wound; in the interval between them the artery and vein will be 
found. 6th, separate with care the artery from the vein, and pass the 
needle beneath it, from behind forwards, in order not to injure the vein, 
which in this locality requires more care than the nerves. PI. 10 Plate X. 
LIGATURE OF THE AXILLARY AND SUBCLAVIAN ARTERIES. 
(For the origin and collateral branches of the subclavian arteries, see pi. 11.) 
Fig. 1. 1, tlie clavicle and pectoralis major muscle, cut away par- 
tially, 2, in order to expose the axillary vessels; 3, the trapezius 
muscle 4, sterno-mastoid •, 5, omo-hyoid; 6, deltoid ; 7, pectoralis 
minor. 
FIG. 1 AND 2. SURGICAL ANATOMY. 
A, the axillary artery; in its upper half, it is covered successively by 
the insertion of the pectoralis minor, 7, higher up by the pectoralis 
major muscle, from which it is separated by a layer of adipose tissue, 
containing numerous small veins and arteries ; and finally by the fascia 
and the skin, a, The supra-scapular artery which crosses the base of 
the neck just above the clavicle. 
B, the axillary vein, situated in front and to the inner side of the 
artery, is not in immediate contact with it. The cephalic vein, c, passes 
upward in the interspace between the deltoid and pectoralis major 
muscles, crosses the axillary artery above the superior border of the 
pectoralis minor, and empties into the axillary vein. 
D, the nerves of the brachial fiexus, lie behind and above. A tho- 
racic branch often crosses the course of the arteiy, sometimes in front, 
and sometimes behind it. 
Fig. 1 and 2. A, the subclavian artery, taking its origin from the 
innominata on the right side, and from the arch of the aorta on the 
left, passes upwards, curves in the form of an arch over the first rib, a, 
and runs downwards and outwards to the first intercostal space, where 
it takes the name of axillary artery. On account of the difference m 
their origin it will be seen that the first, or ascending portion of the left 
subclavian, is somewhat longer than the corresponding division of the 
right, (See pi. 11, fig. 1.) 
The subclavian artery, after passing between the scaleni muscles, 
runs downwards upon the first rib, a (fig. 2), in a groove situated just 28 
outside of the tubercle into which the scalenus anticus muscle, 5, (fig. 
2,) is inserted, which tubercle Malgaigne pointed out as an excellent 
landmark in searching for the artery. Beyond the scaleni the arteiy 
lies in the supra-clavicular triangle, which is bounded below by the 
clavicle and the suhclavius muscle ; within, by the sterno-mastoid, 4, 
which often overlies it slightly with its external border; and on the 
outside by the omo-hyoideus. Here the artery is covered only by the 
deep cervical fascia, the platisma myoides muscle, and the skin ; still 
lower in its course it is covered by the clavicle and suhclavius muscle. 
In persons with long necks the first rib rises above the clavicle, and in 
this case the artery may be readily compressed directly against it by 
pushing the clavicle slightly downwards. 
B, the subclavian vein, situated somewhat lower down and in front 
of the artery, is separated from it by the insertion of the scalenus 
anticus muscle, b, fig. 2. The external jugular vein, e, may cross in 
front of the artery whilst passing down to empty into the subclavian 
vein. 
D, the nerves of the brachial plexus, lie above and behind the 
artery; they are only in relation with it below and posteriorly. 
FIG. 3. OPERATIONS. 
Incision Ho. 1. Ligature of the axillary artery.—a, incision of 
the skin ; b, deep fascia; c, upper border of the pectoralis minor; e, 
fibres of the pectoralis major cut across ; d, axillary vein ; A, axillary 
artery, below the point where the cephalic vein empties into the sub- 
clavian, with an artery needle passed beneath it. 
Incision No. 2. Ligature of the subclavian artery outside of the 
scaleni.—a, incision in the skin ; h, deep fascia; c, omohyoid muscle ; 
d, nerves of the brachial plexus; e, scalenus anticus muscle; f sub- 
clavian vein ; A, subclavian artery. 
§l. Ligature of the axillary artery below the clavicle. 
MODES OF OPERATING. 
1. Ordinary method.—The muscles of the shoulder being perfectly 
at rest, the elbow slightly separated from the trunk, and the head in- 
clined to the opposite side, the surgeon makes, from eight to ten lines 
below the clavicle, and parallel with it, an incision involving the skin, 
platisma and subcutaneous cellular tissue, and extending from the sep- 
tum between the pectoralis major and deltoid muscles, to a point two 29 
fingers’-breadth outside of the sterno-clavicular articulation. The mus- 
cular fibres of the pectoralis major being successively divided and 
pushed aside, the posterior fascial investment of this muscle (the coraco- 
clavicular aponeurosis) is brought into view. Then, to favor the sepa- 
ration of the edges of the wound, the shoulder should be depressed, 
and the fascia torn through with the point of a director. The finger 
being introduced into the wound to press downwards and outwards the 
pectoralis minor muscle, the following parts can be recognized: Ist 
the vein, distended with blood ; 2d, the axillary artery, farther on the 
outside and behind it ; 3d, the nerves of the brachial plexus, situated 
still higher up and farther behind. Whilst passing the ligature be- 
neath the artery, it is important that the vein should be pressed to the 
inner side by the finger, in order that it may be protected from injury 
from the point of the director, or needle, as it is introduced between 
the vessels. 
By this method, the artery is tied in a triangular space which is 
bounded above by the clavicle, below and on the outer side by the pec- 
toralis minor muscle, and below and on the inner side by the sternal 
portion of the pectoralis major. 
11. Desault's method.—This consists in making an oblique incision, 
about three inches in length, following the interspace separating the 
deltoid and pectoralis major muscle, which contains some cellular tisue 
and fat, as well as the cephalic vein, which must be carefully avoided. 
The object in this operation is to reach the axillary artery below the 
pectoralis minor muscle. 
111. Chamber lay ne's method.—Make an incision three inches in 
length below the clavicle, and join it by another of the same extent, 
corresponding to the interspace between the deltoid and pectoralis major 
muscle. This method, as is seen, unites the incision employed by 
Desault, with that of the ordinary method. The result is a triangular 
flap which is to be turned downwards in proceeding with the operation. 
The ligature of the axillary artery above the pectoralis minor muscle 
can be effected with much more facility by the double incision of 
Chamberlayne, than by the ordinary method, and is therefore prefer- 
able to it. 
§ 2. Ligature of the subclavian artery.—A ligature may be applied 
to the subclavian artery at three different points in its course: Ist, on 
the outside of the scaleni muscles, upon the first rib; 2d, between the 
scaleni, behind the insertion of the scalenus anticus; 3d, within the 30 
scaleni. In the first two of these operations the artery is sought for in 
the supra-clavicular triangle already described. 
I. On the outside of the scaleni.— Velpeau's method.—lst, The pa- 
tient being situated conveniently, a transverse incision is to be made 
above the clavicle, and parallel with its posterior border, extending 
from the sterno-mastoid muscle to the anterior edge of the trapezius. 
The skin, platisma, and cellular tissue are to be divided, layer by layer, 
and the external jugular vein, if it cannot be avoided, must also be cut 
across, after being tied.above and below; 2d, the cellular and fatty 
tissue is now to be torn and pushed aside with the point of the direc- 
tor, until the finger can detect, at the bottom of the wound, the tubercle 
on the first rib, into which the scalenus anticus is inserted ; 3d, this 
landmark being well recognized, introduce upon the finger the point of 
an artery needle, from before backwards, and slightly from without in- 
wards, so that it may pass beneath the artery, preventing, at the same 
time, with the point of the finger, the artery from being pushed by the 
needle towards the first trunk of the brachial plexus. In order to 
facilitate this manoeuvre, the shoulder should be depressed as much as 
possible.* 
11. Between the scaleni;—Dupuytreris method.—l This operation 
differs from the latter only in the situation of the ligature, which is to 
be placed on that portion of the artery which lies between the two 
scaleni muscles. To accomplish this, after the operator has recognized 
the situation of the tubercle on the first rib, and has felt distinctly the 
insertion of the muscle into it, he passes a director beneath the latter, 
between it and the artery, and on the director divides the muscle across. 
Thus, by the retraction of its muscular fibres, the artery is exposed, and 
a ligature is readily carried around it. The objections are urged against 
Dupuytren’s operation: that in it the phrenic nerve, which lies along 
the inner margin of the scalenus anticus, is exposed to injury, as well 
as the subclavian vein, and the origin of the internal mammary artery, 
which lie in its immediate vicinity.j 
* This operation was first performed by Mr. Kamsden, of St. Bartholomew’s 
Hospital, London, in 1809 ; his patient died on the fifth day. It was first success- 
fully performed by Prof. Wright Post, in this city, in 1817. 
f The successful termination of this operation in Dupuytren’s case as well as 
more recently in the hands of Dr. J. C. Warren, of Boston, renders it desirable to 
obviate these objections if possible, especially as in some cases it may be substituted 
for the ligature of the artery within the scaleni, which is such a desperate resource. 
Prof. Mott proposes to avoid some of the dangers enumerated above, which, by the 31 
111. Within the scaleni.—Colles, Mott, and Liston have each placed 
a ligature upon the artery in this situation, hut thus far it has not been 
followed by success. The operation presents so many serious difficul- 
ties, on account of the great depth of the artery, its numerous branches, 
and the importance of the parts by which it is surrounded, that it is at 
present hardly considered a justifiable undertaking.* 
way, are not alluded to by any of the surgeons who have successfully performed 
the operation, by cutting through the scalenus anticus muscle vertically, in the 
direction of its fibres, to a sufficient extent, and passing a ligature around the artery 
through the opening thus made.—Eds. 
* The mode of operating adopted for the ligature of the right subclavian artery 
within the scaleni, is very much the same as that for the ligature of the arteria 
innominata, to be shortly described. A similar method was also employed by Dr. 
J. Kearny Rodgers, for the ligature of the left subclavian within the scaleni, an 
operation never before attempted until performed by him at the New-York Hos- 
pital in 1846, The result of the case was unsuccessful—Ecs. Plate XI. 
LIGATURE OF THE PRIMITIVE CAROTID, LINGUAL AND 
FACIAL ARTERIES. 
FIG. 1, 2 AND 3. SURGICAL ANATOMY. 
Fig. 1. Origin of the carotid and subclavian arteries; branches 
of the subclavians.—a, a, arch of the aorta; b, innominata ; d, c, 
right subclavian and carotid, arising from the innominata ; e, /, left 
subclavian and carotid. On the inner side of the scalenus muscle, g, 
on either side, the subclavians give off the following branches : the ver- 
tebral arteries, /t, h; the inferior thyroid and supra-scapular, arising 
generally from a common trunk, the thyroid axis, i, i; the internal 
mammary arteries, j, j. Beyond the scalenus arise ; the posterior 
scapular branches, k1 k ; and the acromio-thoracic artery, which, how- 
ever, is more frequently given off by the axillary artery, just above the 
pectoralis minor muscle. 
Fig, 2. Relations of the arterial with the venous trunks.—a, a, 
internal jugular veins, somewhat in front of and external to the carotids ; 
b, b, the subclavian veins, in front of, running parallel with, and some- 
what lower down than their corresponding arteries ; c, the vena inno- 
minata in front, and a little on the outside of the artery of the same 
name d, the left brachio-cephalic venous trunk, or vena innominata, 
crosses in front of the origins of the left subclavian and carotid, and 
the arch of the aorta; e, inferior thyroid vein ; f external jugular. 
Fig. 3. 1, sterno-thyroid muscle ; 2, omo-hyoid ; 3, 3, extremities of 
the sterno-mastoid muscle, which has been cut across ; 4, masseter. 
A, right primitive carotid. Extending from the bifurcation of the 
innominata to the upper border of the thyroid cartilage, it ascends the 
neck somewhat obliquely from before backwards, and from within out- 
wards, skirting along the outer side of the trachea and larynx, and 
lying upon the longus colli and rectus anticus major muscles. In its 
lower half it is covered in front by the sterno-hyoid and sterno-thyroid 
muscles, 1 ; near its middle it is crossed by the omo-hyoid muscle, 2 ; 
and below this point it is also overlaid by the sternal portion of the PI. 11 ster no-mastoid, by which it is separated from the platisma and integu 
ments, the platisma covering the artery only in its upper half. 
B, the internal jugular vein, which lies on the outside of the artery, 
and over-lays it slightly. 
C, the pneumogastic nerve, which lies behind the vein and artery 
and between them, in the same sheath; below, it passes between the 
subclavian artery and vein to enter the thorax. Several cardiac 
branches arise from it, which cross in front of the artery in its lower 
fourth. 
The great sympathetic nerve lies still further behind the vessels, in 
the loose cellular tissue between their sheath and the proevertebral mus- 
cles, in company with some lymphatic vessels and glands. 
D, the internal carotid, and D' the external carotid, are the terminal 
branches of the primitive trunk. The external carotid, lying in front of 
the internal, terminates opposite the articulation of the lower jaw, where 
it takes the name of temporal. Almost superficial at its origin, it is 
immediately afterwards crossed by the great hypoglossal nerve H, and 
stylo-hyoid and digastric muscles, when it enters the substance of the 
parotid gland. 
E, the facial artery, arising from the external carotid, a little above 
the cornu of the os hyoides, passes beneath the stylo-hyoid and digas- 
tric muscles, through the submaxillary gland, and by a flexuous course 
reaches the base of the lower jaw, over which it mounts, lying in the in- 
terspace between the triangularis oris muscle, and the anterior border 
of the masseter, whence it passes on to supply the face. 
F, the lingual artery, arising from the external carotid below the 
facial, and opposite to the os hyoides, over which it winds to bury itself 
in the tongue. At its origin it is crossed by the great hypoglossal 
nerve H. 
' FIG. 4. OPERATIONS. 
Incision NoJLigature of the facial artery.—a, incision in the 
skin ; b, edges of the platisma and deep fascia; A, facial artery, beneath 
which a ligature has been passed. 
Incision No. 2. Ligature of the lingual artery.—a, incision 
through the platisma and deep fascia ; c, incision in the genio-hyo-glos- 
sus muscle; A, lingual artery with the ligature beneath it. 
Incision No. 3. Ligature of the carotid in its middle portion.—a, 
incision of the skin; Z>, deep cervical fascia ; A carotid artery, with the 
director beneath it. 34 
§l. Ligature of the innominata. This artery takes its origin from 
the most anterior point of the arch of the aorta, and after ascending 
obliquely from an inch to an inch and a half, terminates opposite to the 
right sterno-clavicular articulation. Although so short and deeply situa- 
ted, this artery has nevertheless been tied in the living body, without 
excessive difficulty, by Mott, who employed the following steps in the 
operation. 
MODES OP OPERATING. 
Mott's method. Ist, The patient lying conveniently, with his head 
thrown backwards, an L shaped incision is made, the horizontal portion 
of which extends parallel with the clavicle, and about half an inch 
above it, from the median line of the neck three inches outwards, whilst 
the vertical portion follows the internal edge of the right sterno-mastoid 
muscle to the same extent. 
2d. The whole of the sternal portion, and the greater part of 
the clavicular insertion of the sterno-mastoid muscle, is then cut across 
and turned over the flap, and the sterno-hyoid and sterno-thyroid muscles 
thus brought into view, are divided in the same manner, and turned 
over upon the trachea; 3d, the carotid being now recognized, is fol- 
lowed down to its origin ; 4th, the innominata being laid bare to the 
necessary extent, carefully avoiding the pneumogastic and phrenic 
nerves, as well as the internal jugular vein and the pleura, pass the liga- 
ture in an appropriate . artery needle, from below upwards, and from 
without inwards. 
§2. Ligature of the 'primitive carotid artery at the middle of 
the neck. (PI. 16, fig. 2). Ist, The patient being placed in a recum- 
bent position, and the head turned to the opposite side, an incision three 
inches in length is to be made along the inner border of the sterno-mas- 
toid muscle, and carried through the skin, subcut cellular tissue, 
and platysma myoides. 2d, Divide upon a portion of the 
deep cervical fascia, which unites the edges of the sterno-hyoid and sterno- 
thyroid muscles, with the sterno-mastoid; 3d, flexing the patient’s head 
forward, and separating the muscles just named, the omo-hyoid is 
brought into view crossing the wound obliquely, this may be pushed 
upwards, or downwards, or cut across, if in the way; 4th, the sheath 
of the vessel is now visible, this is to be opened with care, upon a di- 
rector, whilst an assistant presses upon the vein at the upper angle of 
the wound, to prevent its extreme distention from interfering with the 35 
operator; sth, the cellular tissue connecting the vessels is then to he 
gently torn with the point of the needle, in order that it may he passed 
beneath the vessel, from without inwards. 
Ligature of the primitive carotid at the base of the neck.—Mal- 
gaigue's method,—Ist, Make an incision from two and a half to three 
inches in length, extending from a point one-third of an inch above the 
sterno-clavicular articulation, upwards in the direction of a line which, 
if produced, would meet the symphysis of the chin; 2d, the skin, 
cellular tissue, and deep cervical fascia being divided, the sternal 
insertion of the sterno-mastoid muscle is laid bare ; 3d, divide this in 
the direction of the external incision, and beneath it will be found the 
sterno-hyoid and sterno-thyroid muscles, which are to be pushed in- 
wards towards the trachea; 4th, the sheath containing the vessels is 
now in view, and it should be opened, in the usual manner, as near to 
the trachea as possible, in order to avoid the vein. 
§ 3. Ligature of the lingual artery.—Malgaigne's method.—(Pl. 11, 
fig. 4.) Ist, Having recognized the position of one of the greater cornua 
of the hyoid bone, make an incision about an inch in length parallel 
with, and about two lines above it, through the skin, cellular tissue, and 
platysma; 2d, this incision will expose the lower border of the submax- 
illary gland, on lifting which slightly, the shining tendon of the digas- 
tric will be recognized; 3d, less than a line below this lies the great 
hypoglossal nerve, and at the distance of a line below the nerve, a 
transverse incision through the fibres of the genio-hyo-glossus muscle, 
will certainly expose the artery, which in this situation is accompanied 
by neither vein nor nerves. 
§ 4. Ligature of the facial artery as it crosses the lower jaw.—(Pl, 
11, fig. 4.) Ist, Let the patient close his jaws firmly, and feel with the 
finger for the anterior border of the masseter muscle, where the pulsa- 
tions of the vessel can generally be distinguished; 2d, make over this 
point a vertical an inch in length, down to the fibres of the 
masseter; 3d, at its anterior edge the vessel will be found, resting im- 
mediately upon the bone, in company with its vein, the artery being 
nearer the median line. In isolating the artery the cellular tissue 
around it will be found to be somewhat dense. Plate XII. 
LIGATURE OF THE RADIAL, AND DORSALIS PEDIS 
ARTERIES. 
FIG. 1. SURGICAL ANATOMY OF THE RADIAL ARTERY AT THE WRIST. 
1. Posterior annular ligament of the carpus; tendons of the extensor 
ossis metacarpi poll ids, 2; extensor primi internodii, 3; and extensor 
secundi internodii pollicis, 4. 
A, the radial artery (see pi. 7, fig. 1), opposite the radio-carpal arti- 
culation, winds around the styloid process of the radius to the bach of 
the wrist, and passes beneath the united tendons, 2, 3, of the extensor 
ossis metacarpi, and extensor primi internodiipollicis ; it then descends 
a little obliquely beneath the tendon of the extensor secundi internodii 
pollicis, and plunges through the first interosseous space of the meta- 
carpus to the palm of the hand, where it terminates by forming the 
deep palmar arch. 
In this course it is accompanied by its veins, and some small branches 
of the radial nerve; it is covered by the deep fascia of the limb, and 
the integuments. 
FIG. 2, OPERATION. 
a, incision in the skin; b, deep fascia ; A, radial artery. 
FIG. 3. SURGICAL ANATOMY OF THE ARTERIA DORSALIS PEDIS. 
1, Anterior annular ligament of the tarsus ; 2, tendon of the exten- 
sor proprius pollicis pedis; 3, tendons of the Sctensor longus digi- 
torum pedis; 4, extensor brevis digitorum pedis. * 
A, the arteria dorsalis pedis, a continuation of the anterior tibial, 
commences beneath the anterior annular ligament of the tarsus, 1, mid- 
way between the malleoli, and extends to the commencement of the 
first interosseous space, where it passes directly downwards to the sole 
of the foot, and anastomoses with the plantar arch. 
Covered by a layer of aponeurosis which binds it down upon the 
bones of the tarsus, and above this by the fascia of the limb, and the PI. 12. 37 
skin, the dorsalis pedis descends upon the instep, accompanied by its 
two vencß comites, and the anterior tibial nerve b, on its inner side. It 
runs along the outer edge of the tendon, 2, of the extensor proprius 
pollicis, an important relation, which offers an invariable guide to the 
artery by placing the great toe in the extended position. On its outer 
side it is in relation with the extensor brevis digitorum pedis, 4, 
which in muscular subjects overlays it to some extent. 
FIG. 4. OPERATION. 
a, incision in the skin; b, incision in the aponeurosis; A, arteria 
dorsalis pedis upon the director. 
MODES OF OPERATING. 
§l. Ligature of the radial artery at the wrist.— Ordinary method' 
—lst. By forced extension of the thumb determine the position of the 
tendon of the extensor secundi internodii ; 2d, make an incision about 
an inch in length along the inner border of this tendon and parallel to 
it, the centre of which shall correspond to the proximal end of the first 
interosseous space; 3d, incise the deep fascia in a slanting direction; 
4th, beneath this, in the angle at the extremity of the first interosseous 
space, the artery will be found lying upon the bone between its two 
veins ; isolate it with the point of the director, and pass the ligature be- 
neath it. 
§ 2. Ligature of the dorsalis pedis.—lst, Make an incision about 
two inches in length about the middle of the instep, in the course of a 
line drawn from midway between the two malleoli to the upper end of 
the interosseous space, between the first two metatarsal bones, along 
the external border of the tendon of the extensor proprius pollicis pedis, 
and parallel to it; 2d, divide the deep fascia upon a director; 3d, en- 
deavor to recognize the innermost division of the extensor brevis digi- 
torum, and lay open the aponeurotic sheath of this muscle; 4th, be- 
neath this, the artery will be found lying upon the bone, between its two. 
veins, from which it is to be isolated and tied in the usual manner. Plate XIII. 
LIGATURE OF THE ANTERIOR TIBIAL ARTERY. 
FIG. 1. SURGICAL ANATOMY. 
1. Patella; 2, external malleolus; 3, external aponeurosis of the 
limb; 4 and 5, tibialis anticus and extensor longus digitorum mus- 
cles, separated by blunt hooks, exposing the vessels deeply situated be- 
tween them; 6, peroneus longus and brevis cut across ; 7, fibula. 
A, the anterior tibial artery, the external and anterior branch of the 
poplileal, akes its origin beneath the tendinous arch uniting the two 
heads of the solceus muse e, and terminates in the dorsalis pedis, under 
the anterior annular ligament of the tarsus. Its direction, which is 
slightly oblique from above downwards and from behind forwards, 
would be represented by a line drawn from the centre of the space be- 
tween the head of the fibula and tuberosity of the tibia, to the centre of 
the inter-malleolar space on the front of the ankle. The artery passes 
through the interosseous ligament in the upper fourth of the limb, to 
its anterior surface, and lies upon it in the upper two-thirds of its 
course ; below this it lies upon the anterior face of the tibia. In the 
upper half of its course it lies deeply, between the tibialis anticus 4, 
and extensor longus digitorum, 5; in its lower half it is more super- 
ficially situated between the tibialis anticus 4, and extensor proprius 
pollicis 8, which latter muscle crosses it from without inwards, anteri- 
orly, as it passes to its destination; the artery then skirts along the 
outer side of its tendon, and passes beneath the anterior annular liga- 
ment, in the same tendinous sheath. 
The extensor longus and tibialis anticus muscles take their origin 
partly from the deep fascia in the upper part of the leg, 3, and this 
arrangement renders it difficult to recognise the intermuscular septum 
before dividing it freely, and also interferes with the ready separation of 
the muscles. 
B, B, the anterior tibial veins, which accompany the artery through- 
. out its course. PI. 13 39 
C, anterior tibial nerve ; at first it lies external to the artery, after- 
wards crosses it in its lower fourth, and lies internal to it under the 
anterior annular ligament of the tarsus. 
A', the peroneal artery, tire most external and posterior branch of 
the popliteal, runs down the posterior face of the fibula to the os calcis, 
covered above by the solans muscle ; lower down it lies between the 
flexor longus pollicis, 9, and the tibialis posticus muscles ; and in 
its lower fourth lies upon the interosseous ligament. 
FIG. 2. OPERATION. 
Incision No. 1. Ligature of the anterior tibial artery below its 
middle.—a, incision in the skin ; h, deep fascia; c, tibialis anticus ; 
d, extensor proprius pollicis pedis; e, anterior tibial nerve; A, artery 
upon Deschamps’ needle. 
Incision No. 2. Ligature of the anterior tibial in its upper half.— 
a, incision in the skin ; b, deep fascia ; c, extensor longus digit arum ; 
d, tibialis anticus ; e, anterior tibial vein; A, artery with the needle 
beneath it. 
Incision No. 3. Ligature of the dorsalis pedis.—a, incision in the 
skin; b, deep fascia; c, peronoeus longus; e, external border of the 
soloeus ; d, flexor longus pollicis ; A, artery upon the needle. 
MODES OP OPERATING. 
§ 1. Ligature of the anterior tibial below its middle.—lst, in the 
course of a line representing the direction of the artery, or, along the 
external border of the tibialis anticus muscle, the prominence of which 
can be generally recognised, make an incision through the Integuments 
about three inches in length ; 2d, lay open the deep fascia to the same 
extent upon a director ; 3d, separate with the index finger the two 
muscles until the artery is recognised lying upon the tibia, in company 
with its two veins; 4th, separate it from its connections and apply the 
ligature with a needle. 
§ 2. Ligature of the anterior tibial in its upper half.—Ist, about 
ten lines to the outer side of the spine of the tibia, and in the course of 
a line drawn from the external tuberosity at the head of the tibia to 
the middle of the instep, make an incision through the integuments 
from three to three and a half inches long; 2d, the inter-muscular 
space being difficult to recognise, it is better to lay open the deep fascia 
by a crucial incision ; 3d, the intermuscular septum will then be sought 40 
for by the finger In the wound, and will generally be recognised by the 
diminished resistance which it offers; when found, the muscles are to 
be forcibly separated down to the interosseous ligament, upon which 
the artery will be found with the nerve lying in front of it, and a vein 
on either side; 4th, the artery being isolated, the ligature is to be 
passed beneath it by means of a needle. 
§ 3. Ligature of the peronceal artery helow its middle.—Mal- 
gaigne’s method. Seek for the external border of the fibula, and 
about two lines behind it, and parallel with it, make an incision through 
the integuments from two and a half to three inches in length; 2d, 
divide the deep fascia to the same extent; 3d, the external border of 
the soloeus muscle sometimes lies over the fibula, detach this gently 
and push it inwards; then, commencing from the external border of 
the bone, ■which should be fairly in view, detach from its posterior sur- 
face the attachments of the flexor longus pollicis, which takes its origin 
from its lower two thirds ; 4th, push this muscle inwards, and at its 
inner border, near the insertion of the interosseous ligament, the artery 
will be found lying beneath a layer of the deep fascia derived from the 
investment of the muscle ; having divided this, the artery will be found 
immediately beneath it. PI. 14 Plate XIV. 
LIGATURE OF THE POSTERIOR TIBIAE ARTERY. 
FIG. 1. SURGICAL ANATOMY. 
1, patella; 2, internal malleolus; 3, internal surface of the tibia; 
4, internal aponeurosis of the limb; 5, solceus muscles, pulled back- 
wards by the blunt hook. 
A, the posterior tibial artery, arises from the popliteal on the inner 
side, and terminates beneath the internal annular ligament of the tarsus, 
where it divides into the internal and external plantar arteries. Its 
direction, somewhat oblique from without inwards, would be represented 
by an imaginary line drawn from the middle of the popliteal space, 
and terminating behind the internal malleolus. 
In its upper third, the posterior tibial artery is situated deeply be- 
neath the tibialis posticus, Y, and covered also by the deep aponeu- 
rosis, 4, the solceus, 5, and the gastrocnemius, 9 ; in its middle third, 
it lies nearer the surface, running parallel with the internal border of 
the tibia, and separated from that bone by the flexor longus digitorum 
muscle, 8, and covered by the deep aponeurosis and the internal border 
of the soloeus, 5 ; finally, in its lower third, lying immediately beneath 
the deep aponeurosis, it runs behind the tendons of the tibialis posticus 
and flexor longus digitorum, in relation posteriorly with the inner edge 
of the tendo Achillis, 6. 
88, the two venae comites of the artery, which anastomose frequently 
with each other ; 6, internal saphoena vein. 
C, the posterior tibial nerve, lying external to, and behind the artery. 
Incision No. 1, Ligature of the posterior tibial, in its lower third. 
FIG. 2. OPERATIONS. 
—a, incision in the skin; b, deep fascia ;c, posterior tibial nerve ;A, 
artery on the director. 
Incision No. 2. Ligature of the posterior tibial in its middle third. 
—a, incision in the skin; b, deep fascia ; c, external border of the so- loeus; d, flexor longus digitorum; e, posterior tibial nerve; A, artery 
on the needle. 
Incision No. 3. Ligature of the posterior tibial in its upper third. 
—a, incision in the skin; b, deep fascia; c, gastrocnemius, carried 
backwards by a blunt book; d, incision in tbe soloeus muscle; A, ar- 
tery with the needle beneath it. 
§ 1. Ligature of the posterior tibial artery in its lower third, or be- 
hind the malleolus.— Velpeau's method.—About one-third of an inch be- 
hind the posterior border of the internal malleolus, make a semicircular 
incision through the skin only, of an inch and three quarters in length, 
with its concavity looking towards the malleolus ; 2d, incise the apo- 
neurotic layer beneath cautiously upon a director, carefully avoiding the 
sheaths of the tendons which lie immediately behind the malleolus; 
3d, beneath the aponeurosis, and in front of tbe nerve, the artery will 
be found, between its accompanying veins. 
MODES OE OPERATING. 
§ 2. Ligature of the posterior tibial in its middle third.—lst, At 
the distance of three-quarters of an inch from the internal border of the 
tibia, or, in a line midway between the internal border of the tibia and 
the tendo Achillis, make an incision from two and and a half to three 
inches in length through the integuments; 2d, incise the deep fascia to 
the same extent, and push the edge of the soloeus muscle out of the line 
of incision; 3d, divide the deep aponeurosis upon the director, when 
immediately beneath it, the artery will be seen, between its two veins. 
§ 3, Ligature of the posterior tibial artery in its upper third.— 
Malgaigne’s method.—lst, At the distance of two thirds of an inch 
from the internal border of the tibia make an incision at least four 
inches in length, through the integuments and deep fascia ; 2d, carry- 
ing the index finger into the wound, detach and push outwards the inter- 
nal head of the gastrocnemius, and divide also the attachments of the 
solceus, thus exposed, from the posterior surface of the tibia; 3d, whilst 
an assistant keeps this muscle held backwards and outwards with a 
blunt hook, divide the deep layer of aponeurosis upon a director, and 
search for the vessel immediately beneath it; 4th, detach the artery, 
and pass the ligature beneath it with the artery needle. 
Manec’s method. Instead of detaching the solceus muscle from the 
tibia, this author directs that it should be divided, throughout its entire 
thickness, about an inch from the internal border of the tibia; this 43 
brings in view a thick, pearly, fibrous layer of tissue, into which its 
fleshy fibres are inserted, the anterior sheath of the muscle, which is 
perforated by several small arteries. Dividing this freely upon a direc- 
tor, the deep aponeurotic layer covering the artery is brought in view. 
In the first mode of operating it may happen in the living subject, as 
in the case of M. Bouchet of Lyons, that in consequence of the con- 
traction of the muscles interfering with the operator, it might become 
necessary to cut across the soltzus muscle. The object of Manec’s me- 
thod is to prevent the necessity of this step* 
* Mr. Guthrie proposes to substitute a perpendicular incision, six to seven inches 
in length, through the centre of the calf, for the ordinary modes of reaching the 
posterior tibial artery.—Eds. Plate XV. 
LIGATURE OF THE POPLITEAL ARTERY. 
EIG. 1, 2, AND 3. SURGICAL ANATOMY. 
Fig. 1. View of the -parts after removal of the integuments. 
Superficial vessels and nerves. 
1, 1. Deep fascia removed in the upper half of the popliteal region; 
2, semi-membranosus muscle; 3, biceps; 4, cutaneous vessels and 
nerves ; 5, internal saphoena vein. 
A, external, or posterior saphoena vein; it runs perpendicularly, 
following the median line of the limb to the middle of the popliteal 
space, where it perforates the deep fascia ; beneath the fascia it still as- 
cends, and winds around the popliteal nerve, to empty into the popli- 
teal vein. In the first part of its course, above the deep fascia, it is 
accompanied on its outer side by the external saphoenous nerve, b ; it 
frequently overlays the nerve, and is separated from it by a process of 
the deep fascia which forms a separate sheath for the nerve. 
C, popliteal nerve, lying immediately beneath the deep fascia, passes 
down the centre of the popliteal space, being situated superficial to, and 
slittle on the outside of the popliteal vessels, from which it is separated 
by a thin layer of adipose tissue. It gives off several branches, of which 
the principal is the external saphoenous nerve, b, which, after running 
a short distance beneath the deep fascia, emerges through the same 
opening which transmits the external saphoena vein. 
D, the peroneal nerve; more superficial and smaller than the pre- 
ceding, it is given off from it, at an acute angle, in the upper part of 
the popliteal space, and descends obliquely from within outwards, be- 
neath the deep fascia, to be distributed to the muscles on the outside 
and front of the Imib. In the popliteal space it gives off the communi- 
cans peronei, which is one of the roots of the external saphoenous 
nerve, and a branch, c, which pierces the deep fascia, and ultimately 
.anastomoses with the external saphoenous nerve. 
Fig. 2. View after removal of the deep fascia.—The popliteal  nerve being cut away in a part of its course, and tlie adipose tissue 
dissected out, the vessels are exposed to view. 
A, the 'popliteal artery, extending from the tendinous opening in 
the adductor magnus muscle to the lower border of the popliteus, runs 
a little obliquely from within outwards, covered in its whole course, 
and crossed about the middle of the popliteal space, by the popliteal 
vein, B, whose direction is vertical; in consequence of this relation the 
artery, always beneath the vein, is somewhat internal to it above, and 
external to it below. The two vessels are covered superiorly by the 
belly of the semi-membranosus, 1; below they pass between the two 
heads of the gastrocnemius, 2, 3. They are connected together, 
throughout their course, by dense cellular tissue which renders their 
separation difficult. 
Fig. 3. The popliteal artery, at first on the inner side of the femur, 
1, afterwards approaches the centre of its posterior face, and passes 
downwards between the condyles, 2, 3, in contact with the articula- 
tion, 2. In its course it gives off several branches, of which the princi- 
pal are ; the superior articular arteries, a, b, c ; the inferior articular s, 
d, e, which anastomose .with the preceding in front of the knee; the 
middle articular arteries, which enter the articulation, and the sural 
arteries, f g, which enter the gastrocnemius muscle. 
FIG. 4. OPERATION. 
Ligature of the popliteal artery in its superior half.—a, incision of 
the skin ; b, deep fascia; c, adipose tissue ; d, peroneal nerve ; e, ex- 
ternal saphcena vein ; f popliteal vein ; A, artery upon the needle. 
Ordinary method.—lst, the patient lying on his face with the limb 
extended moderately, make an incision from three to four inches in 
length through the skin and cellular tissue in the middle of the popli- 
teal space, and in the dissection of the length of the limb; 2d, divide 
the deep fascia to the same extent upon a director, taking care to push 
the external saphoena vein to the outside ; 3d, tear very carefully 
through the cellular tissue and fat, with the point of the director, at 
the same time flexing the leg slightly upon the thigh in order that the 
muscles may be separated with more facility ; 4th, push the popliteal 
nerve, which is encountered first in the wound, to the inside ; beneath 
this and a little to the inner side is found the popliteal vein, whose 
MODE OF OPERATING, 46 
connections are to be cautiously detached and the vein pushed also to 
the inner side, whilst the artery is sought for beneath it, in contact with 
the ligaments of the articulation. 
The popliteal artery may also be tied, both in the upper and lower 
half of the popliteal space, by the following method, with this difference 
only, that in order to reach the artery in its lower half j the external 
incision must be made three and a half inches long, commencing half 
an inch below the articulation of the knee, and extending along in the 
centre of the interval between the two heads of the gastrocnemius mus- 
cle. To tie the artery in the upper part of its course (see fig. 4), above 
the condyles of the femur, an incision four inches in length is required, 
which should begin on the lower third of the thigh, at a point opposite 
to the commencement of the artery, near the external border of the 
muscular prominence bounding the popliteal space on its inner side, 
and terminate at the centre of the space, opposite to the articulation. 
MarchaVs method.—Here the operator proposes to tie the artery in 
its lower half, but in place of getting at it through the popliteal space, 
as heretofore, the incision is made on the inner side of the limb just 
below the internal condyle of the femur. To do this, the patient should 
be placed upon his back, the limb flexed and lying on its outer side, 
and the surgeon standing on its outer side; an incision three inches in 
length is then made obliquely downwards and inwards, hugging the 
internal edge of the inner head of the gastrocnemius, and four or five 
lines distant from the inner border of the tibia. The integuments being 
incised, and the internal saphoena vein kept out of the way, the inner 
head of the gastrocnemius is separated from the deep layer of muscles 
by introducing the finger into the wound, and breaking down its cel- 
lular adhesions, and at the same time bending the leg upon the thigh 
to secure relaxation of its muscles; in this manner the artery is soon 
reached, lying on the inside of the posterior tibial nerve, and surround- 
ed by several veins ; nothing more is required but to divide the lamina 
of deep fascia which lies over it. 
Joberfs method.—Here the artery is tied in its upper part, but 
through the inner side of the thigh, just above the condyle, instead ot 
through the ham. The incision should be three inches long, and 
should correspond to the vastus internus, and the muscles which form 
the inner border of the popliteal space. PI. 16. Plate XVI. 
LIGATURE OF THE FEMORAL ARTERY. 
EIG. 1. SURGICAL ANATOMY. 
A, the femoral artery, the continuation of the external iliac, com- 
mences beneath the middle of the crural arch, formed by Poupart’s 
ligament, 1, and terminates at the tendinous opening’ in the adductor 
magnus muscle, where it takes the name of popliteal. Its course is 
oblique, winding- around the thigh in a spiral direction; at its com- 
mencement it is in front; in the middle of the thigh, on its internal 
side ; and below, in the popliteal space, on its posterior aspect. In its 
upper fourth the artery is covered only by the lymphatic glands of the 
groin, the fascia lata, and the skin; here, its superficial position renders 
it easily compressible against the horizontal ramus of the pubes, or the 
head of the femur, which lie behind it. Lower down, the sartorius 
muscle lies between it and the integuments, crossing its track very 
obliquely, in such a manner that the artery corresponds with the internal 
edge of the muscle at one part of its course, and below, at the opening 
in the adductor muscle, with its external edge. 
C, the femoral vein, accompanies the artery throughout its course ; 
on its inner side, beneath Poupart’s ligament; behind it, in the middle 
of the thigh ; and behind, and a little to its outer side, below. The 
two vessels, which are connected by an unusually dense cellular tissue 
in the lower two-thirds of their course, are contained besides in a sheath 
given off by the fascia lata. The internal saphoena vein, d, which lies 
immediately beneath the skin, skirts along the internal edge of the sar- 
torius muscle, and empties into the femoral vein of the saphoenous 
opening. 
JE, the anterial crural nerve lies on the outer side of the artery, 
and is separated from it by a layer of the iliac fascia. 
The long saphoenous nerve, F, enters the sheath of the vessels, in 
their upper fourths, and runs down in company with them from this 
point, lying on the outer side of the artery ; at the opening in the ad- 48 
ductor rnagnus it crosses in front of the artery, and still lower down 
leaves it to accompany the internal saphoena vein. Another branch of 
the anterior crural nerve, g, lies in front of the femoral sheath, and from 
this a filament is given off, h, which passes across the vessels to join the 
internal saphoenous vein which it accompanies i, i ; musculo-cutaneous 
branches. 
FIG. 2. OPERATION. 
Incision ISTo. 1. Ligature of the femoral artery in its lower fourth. 
—a, incision in the skin and subcutaneous cellular tissue; b, fascia lata; 
c, external edge of the sartorius, pushed inwards; d, long saphoenous 
nerve; e, the tendinous sheath of the femoral vessels ; A, the artery, on 
the director. 
Incision No. 2. Ligature of the femoral artery in its upper third.— 
a, incision through the integuments; h, fascia lata; c, sheath of the 
femoral vessels ; d, femoral vein; e, saphoenous nerve ; f inner edge of 
the sartorius ; A, artery upon the director. 
MODES OF OPERATING. 
§ 1. Ligature of the femoral artery in its lower fourth, or at the 
opening in the adductor muscle. (See fig. 2, incision Ho. 1.) Ist. 
The thigh being slightly flexed and rotated outwards, and the course of 
the artery being represented by a line drawn from the middle of Pou- 
part’s ligament downwards, and crossing the thigh obliquely inwards 
to the centre of the popliteal space, make an incision on this line,—or 
still better, if it can be recognised beneath the integuments, along the 
external edge of the sartorius muscle,—to the extent of three inches, 
through the skin and subcutaneous cellular tissue,—the centre of the 
incision corresponding to the union of the middle with the lower third 
of the thigh. 
2d. Recognise with the finger the position of the sartorius muscle, 
and divide the fascia lata some two lines within its outer border; this 
will allow the muscle to be pushed inwards, and the posterior layer of 
its fascial sheath to be divided to the same extent. Then, feeling with 
the finger for the separation between the vastus internus and adductor 
muscles, divide carefully on a director the fibro-cellular layer which 
lies between them ; this is the anterior wall of the canal formed for the 
passage of the artery, and after its division the vessel is brought in 
sight, with the vein behind it, and the nerve in front, and to its outer 
side. 49 
3d. Separate very cautiously the dense cellular tissue by which the 
vessels are connected, and pass the needle from without inwards. 
§ 2. Ligature of the femoral at the middle of the thigh.—lst, The 
limb being placed in the situation already described, make an incision 
on the course of the artery, at the middle of the thigh, following the 
internal edge of the sartorius muscle, and taking care not to wound the 
internal saphoena vein ; 2d, push the sartorius muscle outwards until 
the sheath of the vessel, which lies beneath it, is brought into view; 
3d, carefully lay open the sheath of the vessels upon a director; 4th, 
separate the vein from the artery, which is more easily effected at this 
point, and pass the needle from within outwards (see fig. 2, incision 
No. 2). 
§3. Ligature of the femoral in the upper third of the thigh, or 
in Scarpa’s space. In this method the object is to get at the artery 
near the apex of the triangle in which it lies in the upper third of the 
thigh, which is formed by the meeting of the sartorius and the adduc- 
tor brevis muscles, its base being Poupart’s ligament. 
Ist. At about four inches and a half below Poupart’s ligament, the 
point where the artery begins to pass beneath the sartorius muscle, and 
where its pulsations become consequently somewhat less distinct, com- 
mence an incision three inches in length and carry it downwards along 
the internal edge of the sartorius. 2d, the saphcena vein, which lies 
in the cellular tissue beneath the skin, must be pushed inwards to avoid 
its being wounded, and some of the lymphatic vessels and glands are 
almost of necessity involved in the incision, 3d, the fascia lata being 
divided on the director, we come at once upon the artery in its sheath, 
lying along the inner border of the muscle, with the saphoenous nerve 
on its outer side, and the femoral vein within and behind it. 4th, the 
artery having been carefully isolated, pass the needle, or director, be- 
neath it from within outwards. Plate XVII. 
LIGATURE OF THE FEMORAL ARTERY UNDER POUPART’S 
LIGAMENT, OF THE EXTERNAL ILIAC, 
AND EPIGASTRIC ARTERIES. 
ITG. 1 AND 2. SURGICAL ANATOMY. 
Fig. 1, 1. The external oblique, internal oblique and transversalis 
muscles with tbe integuments and aponeurotic layers which constitute 
the anterior wall of the abdomen, removed by dissection, leaving, 2, the 
peritonoeum and fascia transversalis, concealing the convolutions of the 
intestines. The fascia transversalis furnishes an investment for the sper- 
matic cord in the shape of an infundibuliform prolongation, 3 ; 6, Pou- 
part’s ligament, or crural arch ; 6, fascia lata,—its cribriform portion 
removed to show the femoral vessels. 
A, femoral artery ; B, femoral vein; between the vein and artery a 
layer of fascia is seen, 7, which is the partition by which the femoral 
canal is divided into separate compartments. C, D, internal saphoena 
vein, with lymphatic vessels and glands. 
A', the epigastric artery, arising from the inner side of the external 
iliac, beneath Poupart’s ligament. It passes beneath the spermatic 
cord, (beneath the round ligament in the female,) making a curve the 
concavity of which looks upward, and passes up obliquely from without 
inwards, between the peritonaeum and fascia transversalis to the external 
edge of the rectus muscle, beneath which it is,lost. 8, the two veins 
which accompany the artery. 
Fig, 2. 1, section of the muscles of the abdomen at their insertion 
into the crest of the ilium ; 2, anterior superior spine of the ilium ; 
3, fascia lata of the thigh; 4, psoas muscle ; 5, iliacus internus muscle. 
A, aorta; B, right primitive iliac; arising from the aorta at its 
bifurcation, opposite to the inferior border of the fourth lumbar ver- 
tebra, it descends obliquely outwards to the sacro-iliac symphysis, where 
it divides into the external iliac artery, C, and the internal iliac, D. 
The external iliac C, continues in the direction assumed by the 
primitive iliac until it arrives beneath Poupart’s ligament, so that the PI. 17. 51 
two arteries together form almost a straight line, resting above upon 
the vertebral column, and lower down upon the psoas muscle, 4 ; the 
external iliac artery, whilst passing beneath Poupart’s ligament, gives 
origin on its outer side to the circumflex iliac artery, c, and within, to 
the epigastric, c'. 
The internal iliac, or hypogastric artery, D, diverges from the pre- 
ceding at an acute angle, and passing downwards into the pelvis is dis- 
tributed to the organs contained in that cavity. 
At their point of origin at the sacro-iliac symphysis, the iliac arteries 
are crossed by the ureter, e, and the spermatic vessels, d. 
E, the iliac veins, situated at first on the inner side and behind the 
arteries, unite to the right of the bifurcation of the aorta to form the 
inferior vena cava, F. 
The left iliac vein, at first in contact with its artery, towards its ter- 
mination crosses behind the right iliac artery, in order to form a union 
with its fellow of the opposite side. 
G, anterior crural nerve. H, H, lymphatic vessels and glands. 
FIG. 3. OPERATION. 
a, incision in the skin; B, C, D, divided edges of the muscles and 
fascia of the anterior abdominal walls ; e, peritonoeum detached and 
pushed upwards ; f external iliac vein ; A, external iliac artery, with 
the needle beneath it. 
§ 1. Ligature of the femoral artery beneath Poupart's ligament.— 
Ist, beneath the centre of a straight line drawn from the anterior supe- 
rior spine of the ilium to the symphysis pubis the pulsations of the 
femoral artery can be readily felt, as it is here very superficial. 2d, 
make an incision commencing immediately over Poupart’s ligament, 
and extending two inches downwards in the course of the vessel; this 
incision will involve the skin, subcutaneous cellular tissue, and some 
lymphatic vessels and glands which it is impossible to avoid. 3d, 
divide with care, upon the director, the sheath of the vessels, beneath 
which the artery will be found, with the nerve on its outer side and 
the vein within, but separated from each by a process of fascia, (see fig. 
1-7). 4th, separate the artery from its connections, and pass the 
needle from within outwards. 
MODES OF OPERATING. 
§ 2. Ligature of the external iliac artery.—The patient lying upon 
his back with the muscles of the abdomen in a state of relaxation, make 53 
an incision three and a half inches in length, just above Poupart’s liga- 
ment, and parallel with its general direction, but in a curved line, with 
the convexity downwards. The first stroke of the knife through the 
skin and superficial fascia divides sometimes the superficial epigastric 
artery, the cut ends of which should be tied before proceeding farther. 
The aponeurotic expansion of the external oblique should then be care- 
fully divided, and afterwards the internal oblique and transversalis to 
the same extent. The finger should now be carried along the spermatic 
cord into the internal ring, and the fascia transversalis pushed upwards 
and outwards, taking great care not to injure the peritonaeum. If at 
this stage of the operation the artery cannot be recognised by the eye 
at tire bottom of the wound, the finger should be employed to ascertain 
its exact position, and then, with the point of the director, the sheath 
of the vessels furnished by the fascia iliaca should be cautiously torn 
through, and by the same means the artery should be separated from 
the vein and the nervous filament which accompanies them, and the 
needle inserted beneath it from within outwards.* 
§ 3. Ligature of the epigastric artery.—The incisions employed in 
the ligature of the preceding artery may be applied to the epigastric, 
only they should not be so extensive. When the spermatic cord is 
brought in view, let it be lifted up so as to expose the inner border of 
the internal ring, through which it is about entering the cavity of the 
abdomen. Dilate the ring by introducing the point of the finger, and 
immediately behind the layer of transversalis fascia, which constitutes 
its internal border, the pulsations of the artery will be felt. 
§ 4. Ligature of the internal iliac artery.—Stevens'1 method.—lst. 
Make an incision from four and a half to five inches in length, half an 
inch on the outer side of the epigastric artery and parallel with it. 2d. 
Having divided successively the integuments and abdominal muscles, 
detach the peritonoeum with the utmost care from the psoas and iliacus 
muscles, and push it gently inwards and upwards until the bifurcation 
of the primitive iliac can be distinguished. 3d. Feel for, and isolate the 
artery with the index finger, and pass the ligature beneath it. 
A similar process may be employed for the ligature of the primitive 
Hi ac artery.f 
* This operation was first performed by Abernethy, in 1796. 
f The primitive iliac artery may be tied by means of an incision similar to that 
employed for the ligature of the external iliac, but carried upwards aud outwards 
to the extent of from five to seven inches. The external iliac being recognised as 53 
§5. Ligature of the gluteal artery. Robert's method.—The pa- 
tient lying upon his face, ascertain in the first place the position of the 
top of the great trochanter and the posterior superior spine of the ilium, 
2d. Make an incision three inches in length, commencing an inch below 
the posterior superior spine of the ilium, and an inch to the outer side 
of the sacrum, and descending obliquely towards the top of the great 
trochanter. 3d. The incision having been carried successively through 
the skin, cellular tissue, and the fibres of the glutceus magnus muscle, 
the artery will he found lying immediately below the upper edge of the 
great sciatic notch. 4th. Separate the pyramidalis and glutceus me- 
dius muscles, which tend somewhat to conceal the artery, isolate it, 
and pass the ligature. 
above, it is followed upwards, the peritonaeum being very cautiously detached and 
raised in the same direction until the common iliac trunk is brought in view. The 
ligature is then passed beneath it, with the aid of the American artery needle, from 
within outwards, carefully avoiding the ureter. 
This operation was first successfully executed in this manner by Mott, in 1827. 
It has been performed in all, fourteen times, at least six of which were successful. 
—Eds. AMPUTATIONS 
THROUGH THE JOINTS, OR DISARTICULATIONS. 
When it becomes necessary, from ono of tbe various causes, which it 
is not required to enumerate in this place, to remove a limb, or a part 
of a limb, by amputation through one!* of its joints, it is requisite : Ist, 
to recognize accurately the situation of the articular surfaces; 2d, to 
divide the parts which unite them by cutting across the articulation; 3d, 
to manage the incisions through the soft parts surrounding the articu- 
lation in such a manner that enough of them shall be left to cover the 
stump fairly, in order that cicatrisation may take place without difficulty. 
§ 1. General rules for determining the position of a joint.—-Around 
the extremities of almost all the bones which articulate with other por- 
tions of the skeleton certain bony prominences, or tuberosities, are dis- 
tinguishable beneath the skin. These tuberosities, situated at variable 
distances from the joint, always bear to it accurate and unvarying rela- 
tions, and are therefore sure guides to the surgeon. To recognize them 
with facility, the following mode of examination should be adopted: 
Ist. Commence always with that which is the most prominent and 
well marked, and having recognized its exact position and relations, the 
other smaller and less distinct projections will be more readily made 
out. 2d. To do this to the best advantage, place the limb to be exa- 
mined in a convenient position, and from time to time, as required, give 
the joint all its natural motions in succession, and thus the bony promi- 
nences around it will be rendered more evident, and the tendons, or 
ligaments, attached to them, will be thrown more or less into relief. 
We generally find also around the articulations wrinkles, or creases in 
the skin, the position of which is sufficiently constant to serve as indica- 
tions to the surgeon of the situation of the joint. These folds in the 
skin, which are particularly well marked around the joints of the fingers, 
are sometimes found lying immediately over the articulation, at others 
again at a constant distance from it. 
It might happen, however, that an accumulation of fat, or serum, 
around a joint, should mask the bony prominences, and efface the 55 
wrinkles in the skin; or that a painful disease in its vicinity should 
render it impossible to give the joint its natural motions. In such a 
case we should endeavor to recognize the parts, as far as possible, by 
searching along the shaft of the bone towards its extremity with the 
finger, and then, if absolutely necessary, cut in the probable situation of 
the joint, making an appropriate flap, and feel in the wound for its 
exact position ; failing in this search, the heel of the knife, applied per- 
pendicularly to the bone, should be carried up and down its surface, in 
the probable situation of the joint, until its edge enters between the ar- 
ticular surfaces. 
§2. Rules for cutting through an articulation. To traverse an ar- 
ticulation without hesitation, in the midst of the blood and soft parts 
which frequently mask the articular surfaces, the operator should have the 
disposition of the joint so fixed in his mind, that he could trace it out 
exactly without having it under his eye. It is no less necessary that 
he should be familiar with the exact situation, size and attachments 
of its ligaments, in order to recognize and cut through them without 
delay. 
According to Lisfranc, knives for disarticulations should be narrow in 
the blade, in order that they may be readily turned in a joint, and 
thick in the back to ensure sufficient strength. 
These points settled, we proceed to the operation of disarticulation, 
keeping in mind the following general rules : 
Ist. The thumb and index finger of the left hand should be applied 
one on either side of the joint, for the purpose of defining its exact posi- 
tion, when ascertained, and of guiding the knife accurately. 
2d. When an articulation is to be entered from its anterior aspect, it 
should be held in the extended position; when on the contrary, the 
knife is applied to its posterior surface, the limb should be semi-flexed, 
in order to increase the distance between the articular surfaces. 
3d. The principal ligaments of the joint should be divided at first 
The lateral and dorsal ligaments being severed, the knife can generally 
be carried between the articular surfaces. But if the joint present 
several irregular surfaces for articulation, what are denominated inter- 
osseous ligaments may exist, passing from one bone to the other, 
within the joint; those require to be divided with the point of the 
knife before it can be fairly entered. 
4th. When the articulation has been thus opened, it is in general 
sufficient to make gentle traction on the distal portion of the limb, in 56 
the direction of its axis, in order to separate the articular surfaces 
enough to allow the knife to be passed between them. If the joint is 
too close and tight for this manoeuvre to succeed, the articular surfaces 
must he partially dislocated, always, however, employing great care that 
no violence be done to the neighboring soft parts. Finally, if any liga- 
ments should prove to be ossified, they must be divided by the saw. 
sth. When the knife has fairly entered the articulation, its heel and 
point should act in the same plane, and if, whilst it is being carried 
around the articular surfaces to the opposite side of the limb, the in- 
teguments from which the flap is to be formed should be in danger of 
being cut irregularly, they should be drawn out of the way by the 
thumb and index finger of the hand which supports the articulation. 
§ 3. Of the mode of operating.—The manner of making the inci- 
sions in the soft parts to provide a covering for the stump, depends upon 
the kind of operation selected. For all amputations of the limbs there 
are three principal forms given to the wound. In the first, the soft 
parts are all divided by a circular incision around the limb, and the 
cut surface is afterwards covered by the integuments only, which, be- 
fore the section of the muscles, are turned up like the cuff of a sleeve. 
In the second, the part to be removed is circumscribed by an elliptic 
incision, which, after the operation is finished, leaves a wound, the 
edges of which are easily brought in contact, and whose shape gives 
the name to this style of amputation of the oval method. Finally, in 
the third mode, one or more flaps are fashioned out of the soft parts in 
its vicinity for the purpose of covering the extremity of the amputated 
limb; and to this process the name of flap operation is applied. To 
each of these general methods belongs a variety of operative procedures; 
all of which result, however, in the production of a stump bearing the 
characteristics either of the circular, oval, or flap operation. Thus, then, 
the general method indicates the character of the result aimed at, and 
the modes of operating, the different means by which this result is 
attained. 
§ 4. On the formation of flaps.—Ist. One, or several flaps may be 
made, according to circumstances. In the latter case, the least im- 
portant flap should be made first, and that containing the larger vessels 
should be left until after the separation of the bones is completed, in 
order that, if necessary, they may be seized and compressed by an as- 
sistant before their final section. 
2d. The flap should terminate by a curved line, and not by a point, 57 
and to effect this, the knife must he carried along freely and without 
hesitation, parallel with the bone, until, by bringing it in contact with 
the surface it is intended to cover, it is found to be of sufficient length, 
when turning the edge of the knife directly outwards, the tissues are cut 
through square and clear. If the tendons project beyond the skin, they 
should be cut off with the scissors. 
3d. Healthy tissues should be selected as much as possible for the 
formation of flaps; nevertheless, if necessary, they may be made from 
inflamed or infiltrated parts, as by judicious management this swelling 
will diminish under the suppurative process without much danger of 
gangrene. Finally, according to Lisfranc, a disarticulation may be un- 
dertaken where there are no soft parts from which to form a stump, 
experience having proved that a sound cicatrix will be formed over the 
articular surfaces. Plate XYIIL 
DISARTICULATION OF THE LAST TWO PHALANGES OF 
THE FINGERS, AND OF THE WHOLE FINGER. 
SURGICAL ANATOMY. 
Fig. 1. Bones of a finger in their natural relation, seen on their 
■palmar aspect.—a, inferior extremity of the metacarpal bone ; h, first 
phalanx; c, head of the first phalanx; d, second phalanx; e, third 
phalanx. 
The phalangeal articulations are all perfect ginglymoid joints, that is 
to say, they allow but of two motions, flexion and extension. The 
head of the first phalanx presents two condyles separated by a groove; 
these fit into the two corresponding cavities in the second phalanx, 
which have a ridge between them. Each phalanx presents, also, near 
its articular surfaces, decided bony projections, both on its palmar and 
dorsal aspect, (Fig. 1, c, c; fig. 2, e.); two lateral ligaments give the 
articulations almost all their firmness. The extensor tendon behind, 
and a ligament in front, of little strength, complete the ligamentous ap- 
paratus of each joint. The interarticular line, the direction of which is 
almost transverse, of the articulation of the first with the second phalanx, 
is exactly opposite the fold of the skin on its palmar surface, and in 
the articulation of the second with the third, it is a line and a half be- 
low its corresponding fold. 
Fig, 2. Vertical section of the hones of a finger, showing the rela- 
tions which the lines of the articulations hear to the folds of the skin.— 
a, inferior extremity of the metacarpal bone; hh, line of the metacarpo- 
phalangeal point, to be found, in the normal state, about twelve or 
thirteen lines above the commissure of the fingers, c ; dd, inter-articular 
line between the first and second phalanges, situated exactly opposite the 
fold of the skin; fi] inter-articular line between the second and third 
phalanges, situated a line and a half below the fold of skin on the palmar 
surface of the finger. 
Fig. 3. Relation of the flexor tendons to the bones of the finger.— PI. 18. a, a, a, dorsal aspect of the articulations ; h, tendon of the flexor digi- 
torum sublimis perforatus ; c, tendon of the flexor profundus 
perforans. 
Fig. 4. View of a finger in a state of flexion, showing the relation 
of the articular surfaces of the phalanges to each other when flexed. 
OPERATIONS. 
Fig. 5. Disarticulation of the second phalanx (finger); from the 
dorsal aspect of the joint. Ist, Li franc’s method.—lst, the edge 
of the bistoury a, a, about to enter the articulation. 
Fig. 6. Same operation. 2d, after having cut through the articu- 
lation, the bistoury is brought beneath the second phalanx, for the pur- 
pose of cutting out a flap from its palmar surface. 
Fig. 7. Operation finished; flap brought up into its place, and re- 
tained there by a strip of adhesive plaster. 
Fig. 8. A modification of the preceding method. (See modes of 
operating). 
Fig. 9. Disarticulation of the second phalanx ; from the palmar 
aspect of the joint. Lisfranc’s second method.—a, h, c, shape to be 
given to the palmar flap. 
Fig. 10. Operation completed. 
Fig. 11. Same'operation after the bistoury h b has entered the joint, 
the flap being turned upwards. 
Fig. 12, Disarticulation of the entire finger.—a, b, c, wound left 
after the operation with two flaps ; a' h1 c 1 d', wound left after the ope- 
ration by the oval method. 
MODES OE OPERATING-, 
§ 1. Amputation of the finger between the first and second pha- 
langes. Circular method.—The hand being placed in the state of 
pronation, an assistant should confine all the fingers in a flexed position 
except the one about to be operated on. Then the operator, holding 
the finger in an extended position with the thumb, index and middle 
finger of his left hand, makes a circular incision around it with the bis- 
O 7 
toury held in the first position, one-third of an inch below the articula- 
tion for the second phalanx, and one-fourth of an inch for the last 
phalanx. This incision being carried through the skin and cellular 
tissue, the assistant, by a suitable amount of traction, drags up the in- 60 
teguments as far as the articulation, so that the surgeon can cut through 
it by dividing its ligaments, entering his knife on its dorsal aspect. 
Flap Operations.—Ledran’s method by two lateral flaps, and Ga- 
rangeot’s operation, with a dorsal and a palmar flap, are at present out 
of use, the operation with a single flap having been almost entirely sub- 
stituted for them. 
Lisfranc1 s first method, or disarticulation from the dorsal aspect 
of the joint.—An assistant supports the hand well pronated, and con- 
fines the sound fingers, keeping them as far as possible out of the way 
of the operator. The surgeon then takes the phalanx to be removed 
between the thumb and index finger of his left hand, (fig. 5,) and 
bends it to an angle of 45° ; then, with a straight bistoury held in the 
first position, (pi. 1, fig. 1,) he enters the articulation on its dorsal as- 
pect, cutting perpendicularly, a line and a half from the top of the in- 
clined plane formed by the semi-flexed phalanx, or on a level with the 
fold in the skin on the palmar aspect of the joint for the second phalanx, 
and a line and a half below the corresponding fold for the first phalanx. 
At the same time that it penetrates the joint, the bistoury, carried from 
heel to point, should form a little semi-circular flap on its right and 
left sides, and the lateral ligaments should be divided as the blade en- 
ters between the articular surfaces, (fig. 6.) The phalanx should now 
be grasped by its sides, and the knife carried around its head to its 
palmar surface, along which it should be carried towards the operator, 
to a distance of four lines, in order to make a semi-circular flap of suita- 
ble size to cover the stump. 
Fig. 7. In cutting the lateral ligaments of the articulation, care must 
be taken not to nick the base of the flap. The condyles of the first 
phalanx sometimes project on either side through the wound. To ob- 
viate this, the dorsal incision should be made as much of a curve as 
possible, with its concavity looking downwards, especially towards its 
lateral extremities. 
Fig. 8. Lisfranc1 s second method, or disarticulation from the 
palmar aspect of the joint.—The hand is to be held in the position 
of forced supination by an assistant, who confines all the fingers in a 
flexed position, except the one about to be operated upon. The sur- 
geon grasps the phalanx to be removed with the thumb and finger of 
his left hand, and in order to avoid wounding himself with the point of 
the bistoury, he should grasp it in such a manner that his thumb is 
applied upon the palmar surface of the phalanx at its distal end, and 61 
the second phalanx of his index finger should cross its dorsal surface at 
right angles. The operator, then, holding a sharp-pointed bistoury in 
his right hand, in the first position, (pi. 1, fig. 2), with its blade flat- 
wise, and its edge towards him, enters its point a line and a half below 
the fold of skin opposite the joint for the third phalanx, and exactly in 
a line with it for the second phalanx. It is then carried through the 
finger directly from one side to the other, in front of the articulation, 
and in contact with the bone, so as to take up as much upon the blade 
as possible, (fig. 9.) In this manner, the blade is introduced up to its 
heel, and then, by alternate motions, its edge being kept close to the 
bone, it is carried down along its palmar surface to a distance of half an 
inch, and then made to cut its way out, forming in this manner a semi- 
circular flap, which is immediately carried upwards by the assistant. 
The edge of the bistoury is then applied perpendicularly to the joint 
and carried directly through it, dividing its ligaments and the integu- 
ments on the opposite side of the joint without making any posterior 
flap. Nevertheless, if it is feared that the posterior integuments should 
retract to too great an extent, their section can be effected a lino or two 
below the articulation. 
After the description of these two modes of operating, it can readily 
be understood, without any further details, how, in varying cases, arising 
from injuries or otherwise, two flaps of the same size could be made, 
one from the dorsal and the other from the palmar aspect of the finger; 
or, a dorsal flap, somewhat shorter than the palmar one; or, even 
lateral flaps of varying proportions. The rules already laid down for 
the disarticulation of the phalanges of the fingers are also applicable to 
the removal of the second phalanx of the thumb, which corresponds 
with the third phalanx of a finger—(Lisfranc.) 
§2. Disarticulation of an entire finger, (fig. 12.) Method by 
double flaps. Lisfranc's mode of operating.—The hand being held 
in a state of pronation, and the fingers, except the one about to be ope- 
rated upon, confined on either side by an assistant, the surgeon, before 
commencing the operation, should endeavor to recognize as accurately as 
possible the situation of the metacarpo-phalangeal articulation. To do 
this, it is to be borne in mind that the joint usually lies about an inch 
above the commissure between the fingers. Another method recom- 
mended by Malgaigne, and to which the operator can have recourse, 
especially when the parts are deformed by injury or otherwise, consists 
in applying strong traction to the finger whilst the metacarpus is held 62 
£rmly, by which means the articular surfaces are drawn apart one or 
two lines, and a depression, manifest to both sight and touch, is the re- 
sult of the separation, indicating with exactness the situation of the 
joint. This being ascertained, the operation is to be effected in the 
following manner : 
Ist. The first phalanx of the finger to be removed, is to be grasped 
by its dorsal and palmar surfaces, and flexed to an angle of 45°. With 
a straight bistoury, having a prominent heel to its blade, the surgeon 
commences an incision over the articulation above the head of the meta- 
carpal bone, starting from the union of the internal two-thirds of the 
inter articular line W'ith its external third, if he is operating upon the 
left hand, and vice versa for the right hand, and carrying it down to 
the end of the commissure between the fingers. This incision, made by 
drawing the bistoury towards himself, and from heel to point, should 
divide at once all the soft parts down to the bone. Having attained 
the end of the web between the fingers, the blade of the bistoury should 
be brought to a perpendicular position, lying flatwise against the side 
of the phalanx, and then, at the same time that the hand of the patient 
is elevated so that the operator’s eye shall precede the edge of the bis- 
toury, he depresses its handle towards the palm of the patient’s hand, 
whilst the heel of the knife is making an oblique incision on the palmar 
aspect of the joint similar to that on its dorsal surface. 
2d. By the process just described, a lateral semi-circular flap has 
been circumscribed, which is to be detached from the phalanx. Then 
the bistoury, still held in the first position, is carried to the bottom of 
the wound, its blade lying flatwise against the phalanx, and by a gently 
sawing motion, upwards towards the articulation, until an obstacle is 
encountered which arrests its progress. This is the head of the pha- 
lanx ; the blade of the bistoury must be carefully carried around it 
without allowing it to slip or move irregularly, and as soon as it ar- 
rives at the articulation, the diminished resistance will allow it to enter 
with facility. 
3d. The joint is to be cut through with the narrowest portion of the 
blade of the bistoury, that nearest its point, and in order to effect this 
part of the operation more readily, the surgeon should make traction 
upon the fingers, so as to separate the articular surfaces, at the same 
time that the integuments of the opposite side of the joint are kept out 
of the way of the edges of the bistoury. The knife having traversed 
the articulation, it is brought back hugging the opposite side of the 63 
head of the phalanx, and a second semi-circular flap is made like the 
first, as it cuts its way out through the commissure. 
When the double flap amputation is made use of for the index or 
little fingers, there is but one flap, of course, made from the commissure 
of the fingers ; the other flap, taken from the outer or inner border of 
the hand, has generally more tendency to contraction, and hence, should 
be made somewhat larger on this account. 
Oval method. Scoutetten's operation.—The surgeon, having grasped 
the finger as in the preceding description, commences, with the heel of 
the bistoury held in his light hand, an incision, which, commencing on 
its dorsal aspect, and a quarter of an inch beyond the articulation, is 
carried down to the end of the commissure, and thence across the base 
of the finger on its palmar surface, following exactly in the fold of the 
skin which lies between the finger and the hand. To facilitate the in- 
cision on its palmar surface, the surgeon should carry the finger back 
into a state of forced extension, but as soon as the knife reaches the 
commissure on the opposite side, he should flex it again, and resume 
the same form of incision with which he commenced, carrying it back 
to join the first near its origin. Each border of the wound should then 
be detached from the head of the phalanx, and the joint entered from 
its dorsal aspect, dividing first the extensor tendon, and then the lateral 
ligaments. By increasing the flexion slightly, and an effort as if to 
luxate the joint, the division of the flexor tendons is facilitated, and the 
remaining soft parts being detached, the amputation is finished. 
The circular method is hardly used at present for the disarticulation 
of the fingers. Plate XIX. 
DISARTICULATION OF THE FOUR FINGERS; OF THE META- 
CARPAL BONES. 
OPERATIONS. 
Fig. 1. Disarticulation of the four fingers at once, a, b, c, incision 
over the metacarpo-phalangeal articulations from their dorsal aspect; 
the knife is about passing beneath the phalanges to cut out a palmar 
flap. 
Fig. 2. Wound resulting from the operation, a, b, c, form of the 
palmar flap. 
Fig. 3. Disarticulation of the first metacarpal bone, by a modifica- 
tion of the oval method ; a, b, c, outline of the external incision. 
Fig. 4. The thumb is carried across the hand, and the knife about 
completing the disarticulation of the head a, of its metacarpal bone. 
Fig. 5. Edges of the wound brought together, shewing the appear- 
ance of the cicatrix when healed. 
Fig. 6. Disarticulation of the metacarpal bone of the little finger, 
by a variety of the oval method; a, b, c, outline and extent of the ex- 
ternal incision. 
Fig. 7. The preceding operation completed; shape of the cicatrix. 
§l. Disarticulation of the four fingers together.— Operation ivith 
one flap,—Lisfranc’s method (fig. 1), The hand being pronated, the 
surgeon grasps the four fingers in the palm of his left hand, whilst his 
thumb, placed on the dorsal aspect of the fingers, flexes them mode- 
rately. An assistant supports the hand, and retracts the skin as much 
as possible. Then, with a straight narrow knife, the operator makes 
a curved incision with its convexity looking downwards, from six to 
eight lines below the heads of the metacarpal bones, from the index 
towards the little finger if he is operating on the left hand, and in the 
opposite direction for the right. The extensor tendons being exposed 
MODES OF OPERATING. 
by the retraction of the integuments, which the operator assists by a PI. 19. 65 
few strokes of the knife, each of the metacarpo-phalangeal articulations 
is then successively opened, the extensor tendon being first divided, 
then the lateral, and finally the palmar ligamentous attachments. It 
remains to carry the knife through the articulations to the palmar as- 
pect of the phalanges, and cut out a flap, which is limited anteriorly 
by the folds in the skin at the base of the fingers on their palmar 
surface. 
§2. Disarticulation of the metacarpal hone of the thumb.— Oval 
operation.—Scoutetten’s method modified hy Malgaigne (fig. 3, 4, 5). 
The hand being held in a position between supination and pronation, 
make an incision along the dorsal surface of the metacarpal bone of the 
thumb, commencing six lines above its articulation with the trapezium, 
and extending through all the tissues down to the bone, to the inner 
side of the head of the first phalanx of the thumb, on a level with the 
commissure between the thumb and index finger. Then, carrying the 
hand into a state of pronation, continue the incision around the palmar 
surface of the phalanx to its outside, and thence to the dorsum of the 
metacarpal bone, to meet the first incision about at its middle (fig. 3). 
Detach the muscles and integuments from either side of the bone, and 
open the articulation from its dorsal aspect; then, endeavoring to dis- 
locate the bone outwards, complete the division of its remaining attach- 
ments. 
§ 3. Disarticulation of the metacarpal hone of the little finger.— 
Oval Tj^thod.—Scoutetten’s operation modified hy Malgaigne (fig. 6, V), 
The hand being held in a state of forced pronation, commence an in- 
cision six lines above the carpo-metacarpal joint, which should be carried 
down in a straight line to the inner border of the first phalanx of the 
little finger, until it meets the depression at the base of the finger on 
its palmar surface, and brought around the base of the finger, following 
this depression exactly. Then the operator, lifting up the little finger, 
continues the incision around to its inside, and upwards to join its first 
portion about opposite to the centre of the metacarpal bone. The in- 
teguments and muscles are then detached from the bone, and its articu- 
lar connections divided with the point of the bistoury in the manner 
already described. Plate XX, 
AMPUTATION THROUGH THE CARPO-METACARPAL, AND 
RADIO-CARPAL ARTICULATIONS. 
Fig, 1. a, inferior extremity of the ulna; h, that of the radius; c, dy 
e,f g, h, i, bones of the carpus ; 1, 2, 3, 4, 5, first, second, third, fourth 
and fifth, metacarpal bones. 
SURGICAL ANATOMY, 
The carpo-rnetacarpal articulation is represented by an irregular 
line, the two extremities of which are easily recognised. Externally, 
it corresponds with the upper extremity of the first metacarpal bone; 
this can be made to start out from its articulation with the trapezium 
i, to which it is connected by rather lax ligamentous attachments, by 
carrying the thumb across the palm in a state of forced adduction. 
Internally, the carpo-metacarpal joint is marked by the articulation of 
the fifth metacarpal with the unciform bone, /, The long projection 
at the upper end of the fifth metacarpal serves as a guide to this point, 
and it can be readily recognised by carrying the finger along the bone 
from before backwards ; the joint lies a line or so above it. The hook- 
like process of the unciform bone might also be of some assistance as a 
landmark; the articulation lies immediately below it. 
The radio-carpal articulation is formed by the inferior extremities of 
the radius and ulna, which being- slightly concave receive the convexity 
formed by the scaphoid d 1 the semi-lunar c, and the cuneiform, e. The 
pisiform bone, situated farther in front and below the line of the articu- 
lation, forms a projection on the front of the wrist over which the knife 
passes necessarily in cutting out the palmar flap. The two styloid 
processes, that of the radius externally, and of the ulna internally, mark 
the situation of the joint with accuracy. The styloid process of the 
radius projects downwards two lines farther than that of the ulna ; and 
the articulation lies about two lines and a half above a line passing 
through the extremities of the two processes. The second fold in the 
skin on the palmar surface of the wrist, reckoning from the palm, lies 
immediately over the articulation, and would also answer as a guide to 
it in case the position of the styloid processes could not be distinguished. PI. 20. 67 
OPERATIONS. 
Fig. 2. Disarticulation of all the metacarpal hones, preserving 
that of the thumb. Maingault’s operation, a, b, c, form of tlie pal- 
mar flap. 
Fig. 3. Same operation, a, b, c, incision in the integuments on 
the back of the hand ; the joint is about being opened. 
Fig. 4. Amputation through the wrist-joint. Circular operation. 
a, b, fold of integuments turned up like the cuff of a sleeve ; c c, knife 
dividing circularly the tendinous tissues around the joint. 
Fig. 5. Denonvilliers’ method. Flap operation, a, b, c, semi- 
circular incision on the back of the wrist. The knife is cutting out 
the palmar flap. 
Fig. 6. Stump, showing shape of wound, a, b, c, palmar flap. 
MODES OF OPERATING. 
§ 1. Disarticulation of the four metacarpal bones of the fingers. 
Operation with a single flap. Maingault’s method, (fig. 2 and 3.) 
Ist. The hand being held in the position of forced supination, recog- 
nise at its outer border the articulation of the first metacarpal bone 
with the trapezium, and, at its internal side, the articulation of the un- 
ciform bone with the fifth metacarpal. 2nd. Introduce a small, 
straight knife between the bones and the soft parts, carrying it a little 
below the projections formed by the unciform and the trapezium, so 
as to bring out its point below the thumb. 3d. Carry the blade of 
the knife along the anterior surfaces of the metacarpal bones, and cut 
out a large flap of an elliptical outline. 4th. Then turn the hand in 
the prone position, and make a semi-circular incision across its back, 
two thirds of an inch below the line of the articulations, and carrying 
the knife through the tissues connecting the thumb with the index 
finger, join the first incision. Whilst an assistant is drawing the integu- 
ments upwards, the surgeon, holding the metacarpus in his left hand, 
proceeds with the disarticulation from the front of the hand, commenc- 
ing with the metacarpal bone of the index or the little finger, accord- 
ing as he is operating upon the right or left hand. 
§2. Amputation through the wrist-joint. Ist. Circular opera- 
tion. Ordinary method, (fig. 4.) Ist. One assistant forcibly re- 
tracts the skin of the forearm, whilst a second holds the hand to be re- 
moved. 2d. The surgeon, holding the knife in his right hand, makes 68 
a circular incision through the integuments, just grazing the thenar and 
hypothenar eminences at the root of the palm. 3d. He then dissects 
up the skin as far as the line of the articulation, and reflects it upwards, 
like the cuff of a coat sleeve. 4th. Second circular incision is then car- 
ried through the tendons, and the joint is cut through from its dorsal 
towards its palmar aspect. 
2d. Operation with a single flap. Denonvilliers’ method.—The 
hand being held conveniently in a state of pronation, and the integu- 
ment strongly retracted by an assistant, the operator satisfies himself 
of the position of the styloid processes of the radius and ulna, grasps 
them with the thumb and index finger of his left hand, and makes a 
semi-circular incision with its concavity looking downwards across 
the back of the wrist, its two extremities falling a little below the 
styloid projections of the two bones. After this first incision through 
the skin and cellular tissue, the retraction of the integuments upwards 
and downwards leaves the wrist joint entirely exposed. A second in- 
cision then, in the same direction as the first, across the articulation, di- 
vides the extensor tendons and the posterior radio-carpal ligaments. 
The lateral ligaments are now cut through, and the knife carried 
through the joint in front of the carpal bones in order to cut out an an- 
terior or palmar flap, which should be at least two-thirds of an inch in 
length. In order to complete this flap without difficulty, the edge of 
the knife should be turned sufficiently away from the bones of the carpus 
so as not to be arrested by their projections, and especial care should 
be taken that the pisiform bone is not cut away with the flap. After 
disarticulation by the process just described, there is no danger of the 
protrusion of the styloid apophyses through the angles of the wound; 
if the tendons are too long, they may be cut shorter before the wound 
is dressed. PI. 21. Plate XXI. 
AMPUTATION AT THE ELBOW-JOINT. 
SURGICAL ANATOMY. 
Fig. 1. The elbow joint is composed of the inferior extremity of the 
humerus, A, and the superior extremities of the radius, B, on the out- 
side, and the ulna, C, on the inside. 
Fig. 2. The radius is merely in juxtaposition with the humerus, 
whilst the ulna receives its trochlea in a corresponding depression of 
considerable depth, formed by the olecranon, 6, behind, and the coro- 
noid process, c, in front; this arrangement prevents the articulation 
from being opened directly, except from its outer side. The articular 
surfaces are retained in contact by anterior, posterior, and lateral 
ligaments. 
Fig. 3. To recognize the exact position of the articulation, its relation 
to the neighboring bony projections is to be determined ; the internal 
condyle, or epitrochlea, b, is prominent and easily detected; the exter- 
nal condyle, or epicondyle, a, is less prominent, and blends insensibly 
with the external aspect of the humerus. The two condyles, situated 
almost exactly on a horizontal line to which the axis of the humerus is 
perpendicular, lie just above the inter-articular line, c, d, e, whose two 
extremities are unequally distant from the horizontal line a, b. In 
fact, its external end, c, is but three and a half lines below the most in- 
ferior point of the external condyle, a, whilst its internal extremity is at 
least double that distance below the most inferior point of the internal 
condyle, Z», (.Malgaigne.) 
OPERATIONS. 
Fig. 4. Flap operation.—<z, b, c, form of the anterior flap. 
Fig. 5. a, b, c, anterior flap turned upwards ; d, elbow joints opened; 
e, knife about to complete the division of the anterior ligament of the 
joint. 
Fig. 6. Circular operation. Velpeau's method.—a, b7 fold of in 
teguments reflected. 70 
Fig. 7. Wound which is left after the circular operation; a, lower 
end of the humerus; 6, section of the humeral artery. 
MODES OE OPERATING. 
§ 1. Method with a single flap.—(Fig. 4 and 5.)—The forearm 
should be supinated as completely as possible, and held in a slightly 
flexed position. The surgeon, then, standing on the inner side of the 
limb, grasps the soft parts lying immediately in front of the articulation, 
and raises them from the bones of the forearm. He passes in a straight 
knife, from the inner side of the joint, about an inch below the promi- 
nence of the internal condyle, and keeping its point well in contact 
with the bones of the forearm, bring it out half an inch below the pro- 
minence of the external condyle, and cuts out a semi-circular anterior 
flap three inches in length. This flap being at once carried backwards 
by an assistant, who also retracts the skin of the arm so as to draw the 
angles of the wound as far upwards as possible, the surgeon carries his 
knife to the outside of the limb at the base of the flap, and at once en- 
ters its heel between the articulation of the radius with the humerus; 
he then continues his transverse incision across the back part of the 
forearm through all the tissues, until he reaches the inner angle of the 
wound. Nothing remains then but to divide the anterior and lateral 
ligaments of the joint with the point of the knife, and, by luxating the 
bones forward, to cut through the insertion of the triceps, which is still 
attached to the olecranon process.* 
§2. Circular operation. Velpeau’s method.—(Fig. 6 and 7.)— 
The arm being held in the same position as in the preceding operation, 
but the surgeon standing on the outside of the limb, a circular incision 
is made around the forearm three fingers’ breadth below the elbow 
joint; the integuments are dissected up as far as the joint, and reflected 
upwards, and then the muscles in front of the joint are cut through, 
with the lateral ligaments, the joint entered in front, and the operation 
terminated by the division of the triceps behind. 
In this mode of operating, the brachial artery is divided above its 
bifurcation, and the form of the wound is supposed to favor its union by 
the first intention. 
* Some surgeons prefer to saw across the olecranon, and thus to leave the inser- 
tion of the triceps muscle untouched. The result is not materially different.—Eds. PL 22. Plate XXII. 
AMPUTATION AT THE SHOULDER JOINT, 
SURGICAL ANATOMY. 
Fig. 1. a, head of the humerus ; its shape is that of an almost per- 
fect hemisphere ; b, clavicle ; c, acromion; d, infra-spinous fossa of the 
scapula; e, head of the humerus, connected with the glenoid cavity hy 
the capsular ligament of the joint. 
Fig. 2. a, glenoid cavity ; it presents an elongated concave articular 
surface which receives hut about one-third of the articular surface of the 
head of the humerus ; b, acromion ; c, coracoid process. 
The head of the humerus is connected with the glenoid cavity by a 
loose capsular ligament, which would allow a considerable amount of 
separation between the articular surfaces, if they were not also retained 
in contact by the muscles arising from the scapula. The supraspi- 
natus, the infraspinatus, the teres major and minor behind, and the 
subscapularis in front contribute to strengthen the joint, as well as the 
ligamentous fibres extending from the acromion to the capsule of the 
joint, and the deltoid muscle. 
The acromion and coracoid processes form an arch which protects 
the articulation above. The acromion is situated nearly half an inch 
above the glenoid cavity, and projects an inch beyond it. The coracoid 
process situated within and lower down, is more nearly in contact with 
the head of the humerus. 
OPERATIONS. 
Fig. 3. Lisfrands operation.—a, b, c, shape to be given to the 
posterior flap. 
Fig. 4. a, b, c, posterior flap raised upwards ; d, head of the hume- 
rus disarticulated. 
Fig. 5. Larrefs operation.—ab, first incision, vertical; cd, posterior 
incision talcing its origin from the first; ce, anterior incision starting 
also from the same point. 72 
Fig. 6. a, 6, c, d, wound which is left after the preceding operation ; 
c, glenoid cavity and remains of the capsular ligament; ffl axillary 
vessels. 
MODES OP OPERATING. 
§l. Disarticulation of the shoulder.— Operation with two flaps.— 
Lisfranc's method (fig. 3, 4). 
Ist. The patient is supported in a convenient position upon a chair, 
and the arm kept close to the trunk, the head of the humerus at the 
same time being pushed upwards and outwards as much as possible. 
The surgeon then, being provided with a long straight knife cutting 
on both edges, assures himself of the exact position of the acromion 
and coracoid processes. If it is the left shoulder upon which he is 
about to operate, the point of the knife should be entered in a direction 
almost parallel with the humerus at the outer side of the posterior bor- 
der of the axilla, in front of the tendons of the latissimus dor si and 
teres major muscles. As the knife passes in, the plane of its blade 
should form an angle of 35° with the axis of the shoulder, and its 
point should graze the posterior’and external surface of the humerus, 
until it reaches the under surface of the acromion ; at this point the 
handle of the knife should be raised, and its point lowered, so that it is 
brought out below and in front of the clavicle, in the triangular space 
between the acromion and coracoid processes, which is bounded pos- 
teriorly by the clavicle. The knife should then be made to cut its way 
outwards around the head of the humerus, and as soon as it becomes 
disengaged from beneath the acromion, the arm is carried a little dis- 
tance away from the trunk, and the surgeon grasps with his left hand 
the deltoid muscle, raising it as much as possible from the bone, and 
carries the knife directly downwards, grazing the bone, and cutting out 
a posterior semicircular flap about three inches in length. In making 
this flap the upper part of the capsule of the joint should be divided, 
as well as the tendons of latissimus dorsi, the teres major and minor, 
and a part of the deltoid. 
2d. The head of the humerus being readily separated from the gle- 
noid cavity after the division of the parts just mentioned, the operator 
passes the blade of the knife behind it, and carries it downwards and 
forwards, grazing the humerus, to cut out the internal flap, and at this 
moment the artery contained in the substance of this flap should be 
compressed by an assistant. In operating upon the shoulder of the right side the Same rules are followed, except that the knife should ho 
entered in the infra-clavicular triangle described above, to be brought 
out at the posterior border of the axilla, thus reversing the direction of 
the knife in transfixing the articulation to cut out the posterior flap. 
§ 2. Oval operation.—Larrey's method (fig. 5, 6).—Make a vertical 
incision on the outer surface of the shoulder through the skin and sub- 
jacent tissues down to the bone, and extending from the edge of the 
acromion process to a point one inch below the top of the humerus; 
2d, make then two oblique incisions starting from the centre of the ver- 
tical one, one on the anterior, and the other on the posterior aspect of 
the joint, carrying them through the tissues composing the anterior 
and posterior walls of the axilla, to the lower border of each, and 
dividing their attachments to the humerus; 3d, push the edges of the 
wound on either side to expose the joint, and open it, making traction 
on the bone to put its ligament on the stretch; 4th, luxate the bone, 
pass the knife behind it, and finish the operation by cutting directly 
through the tissues in the axilla, which intervene between the extremi- 
ties of the incisions already made, recollecting that the artery is con- 
tained in them, and requires to be compressed by an assistant. The 
wound which results from this operation is almost perfectly oval in 
shape (fig. 6). Plate XXIII. 
DISARTICULATION OF THE TOES. 
SURGICAL ANATOMY. 
Fig. 1. Bones of the foot.—Dorsal aspect.—a and h, inferior ex- 
tremities of the tibia and fibula ;c, astragalus; d, os calcis ;e, scaphoid; 
f cuboid; g, internal cuneiform ; h, middle cuneiform; i, external cu- 
neiform ; 1, 2, 3, 4 and 5, first, second, third, fourth and fifth metatar- 
sal bones ; k, k, k, k, k, phalanges of the toes. 
Fig. 2. Articular ligaments of the dorsum of the foot.—a, a, ante- 
rior tibio-tarsal ligaments ; h, anterior fasciculus of the internal lateral 
ligament; c, internal calcaneo-scaphoid ligament; d, external calcaneo- 
astragaloid ligament; e, superior astragalo-scaphoid ligament; f the 
superior calcaneo-cuboid ligament; g, g, g, scaphoido-cuneiform liga- 
ments ;h, cuboido-metatarsal ligament; i, t, i, cuneo-metatarsal liga- 
ments ; k, k, k, k, k, articulations of the metatarsal bones between 
themselves, and of the phalanges with the metatarsal bones ; I, I, I, I, I, 
lateral ligaments of the phalanges. 
Fig. 3. Horizontal section of the hones of the tarsus, showing the 
inter-articular ligaments. 
OPERATIONS. 
Fig, 4. Disarticulation of the third, and of the great toe.—a, b, c, 
d, wound resulting from the oval operation ; e, head of the first meta- 
tarsal bone ;fg, h, wound resulting from the flap operation; i, head 
of the third metatarsal bone. 
Fig. 5. Disarticulation of the five toes together.—a, b, c, form and 
direction of the incision across the heads of the metatarsal bones. 
Fig. 6. The integuments a, h, c, are retracted, and the knife is car- 
ried behind the heads of the phalanges in order to make a flap from 
the plantar surface of the foot. 
Fig. 7. Wound which results from the preceding operation.—a, b, c, 
shape of the plantar flap. PI. 23. 75 
Fig. 8. Disarticulation of the first metatarsal hone.—a, h, c, d, 
outline of the incision. 
Fig. 9. a, 6, c, incision employed in disarticulation of the first meta- 
tarsal bone, without removing the great toe, (see “ exsections.”) 
§ 1. Disarticulation of a single toe (fig. 4.)—The rules laid down 
for the disarticulation of the fingers are entirely applicable to the cor- 
responding operations upon the toes; we will only remark, that the 
oval operation is most generally preferable, as it is very rare that less 
than an entire toe is removed; the small size of the phalanges, and 
their unimportance, renders the preservation of a single phalanx a mat- 
ter of much less moment than in the hand. 
MODES 0E OPERATING. 
It has been proposed by many surgeons, that in aisarticulation of the 
great toe, (fig. 8,) the head of its metatarsal bone should be removed 
at the same time, on account of the unsightly projection, which, more- 
over, is a source of constant irritation from the friction of the shoe in 
walking. (See “ exsection ” for further remarks on this subject, and 
for amputation of the metatarsal bones.) 
§2. Disarticulation of all the toes at the same time. Flap opera- 
tion. Lisfranc’s method (fig. 6 and 7,)—Ist. The operator, grasping 
all the toes in his left hand, makes, with a narrow knife, a semi-circular 
incision, extending (for the left foot, and vice versa) from the internal 
border of the first metatarsal bone, to the external border of the fifth, 
in front of the articulations of the toes with the metatarsus, (fig, 5); 
2d, the articulations are opened in succession with the point of the 
knife, and their ligaments divided; 3d, the knife is then carried behind 
the phalanges for the purpose of cutting out a semi-circular flap from 
the plantar surface of the foot, (see fig. 6.) Plate XXIV. 
AMPUTATION THROUGH THE TARSO-METATARSAL ARTI- 
CULATION. 
SURGICAL ANATOMY. 
Fig. 1. The tarso-metatarsal articulation, formed posteriorly by the 
cuboid, a, and the three cuneiform bones, 6, c, d, and in front of the 
five metatarsal bones, presents an irregularly curved line, the general 
direction of which, with its irregularities, require attention. Externally, 
the cuboid, a, articulates with the fourth and fifth metatarsal bones, 
making a line somewhat oblique from without inwards, ai d from be- 
hind forwards. This line presents a very obtuse angle about its middle, 
the articulation of the fourth being less oblique than that of the fifth me- 
tatarsal bone. About the twelfth of an inch farther forwards is the ar- 
ticulation of the third metatarsal with the internal cuneiform, h ; at least 
two lines behind this articulation lies that of the second metatarsal with 
the middle cuneiform, c; and, finally, nearly the third of an inch in 
front of the last we find the line of articulation of the first metatarsal 
with the internal cuneiform, d. 
This arrangement presents two especial points for the consideration 
of the operator: Ist, the internal extremity of the articulation lies at 
least seven lines anterior to a transverse line e, /, drawn directly through 
its external extremity ; 2d, the proximal extremity of the second meta- 
tarsal bone is enclosed in a mortise formed by the three cuneiform 
bones, b, c, d, which is at least one-third of an inch deep antero- 
posteriorly. 
The dorsal ligaments connecting the tarsal and metatarsal bones are 
inserted several lines behind and in front of the inter-articular line, and 
hence the articular surfaces can always be partially separated, even 
when these are cut across not exactly upon the inter-articular line. The 
interosseous ligaments, which are stronger towards the plantar aspect 
of the foot, are generally easily divided; nevertheless, those situated 
on the inner side of the mortise, which connect the second metatarsal 
with the first and second cuneifoim bones, the real key to the articula- PL 24. 77 
tion, require for their ready division a particular manoeuvre to be here- 
after described. 
To recognize the articulation.—lst. On the inner side of the foot, 
carry the finger backwards along the inner border of ihe first metatar- 
sal bone until a projection is encountered, g ; one or two lines beyond 
this is the articulation, situated in a depression between the two pro- 
jections marked g and h, the internal cuneiform. The articulation may 
also be found just one inch anterior to the prominence of the scaphoid 
bon"1, i. 
2d. On the outer side : Follow the external border of the fifth meta- 
tarsal bone until the prominence at its proximal extremity is recog- 
nized, h ; the articulation lies immediately behind it; in some instances, 
the head of the metatarsal bone projects a trifle beyond the articulation. 
OPERATIONS. 
Fig. 1 bis. Lisfranc’s method.—a, b, c, form and direction of the 
incision to be made across the metatarsus. 
Fig, 2. a, b, c, dorsal ligaments of the tarsus, d'vided. 
Fig. 3. Manner of opening the mortise formed by the head of the 
second metatarsal hone.—a, b, c, are of the circle to be described by 
the knife; d, second metatarsal; e, first metatarsal bone. 
Fig. 4. a, dorsalis pedis artery. The knife, 6, is in the act of cut- 
ting out the plantar flap. 
Fig. 5. a, b, c, cZ, wound left after the operation; a, b, c, shape of 
the plantar flap. 
MODES OF OPERATING. 
Ist, The patient is placed upon his back, and the foot rotated mode- 
rately inwards. The surgeon recognizes the exact situation of the ar- 
ticulation by the rules already laid down, and then grasps, with the 
palm of his left hand, the sole of the foot, his thumb being placed on 
the outer side of the proximal end of the fifth metatarsal bone, and the 
index finger at the internal extremity of the articulation. He then 
makes a semi-lunar incision with its convexity looking downwards, 
from withoutiinwards,wrards, across the dorsum of the foot, passing about 
half an inch below the articulation, and extending from one of its ex- 
tremities to the other down to the bones. 
2d. The surgeon divides, with the point of his knife, the dorsal liga- 
ments, carrying it along the fine of the articulation from without in- 78 
wards, as already indicated, and recollecting that the articulation of the 
second metatarsal lies a third of an inch posterior to the others, (fig. 2.) 
3d. The mortise in which the head of the second metatarsal is en- 
closed remains to be opened. This is effected by introducing the point 
of the knife between the internal cuneiform and the head of the first 
metatarsal bone, its edge being turned upwards, and making an angle 
of 45° with the axis of the foot. The knife is then carried up to a 
right angle, its point traversing the whole of the inner surface of the 
mortise, in order to insure the division of the interosseous ligament; 
it is then withdrawn, and applied to the external surface of the mortise. 
4th. When this has been accomplished, pressure is made upon the 
metatarsus to separate the articular surfaces, and their remaining liga- 
mentous attachments are successively divided, especially those on the 
plantar aspect of the articulation, so that the knife may be carried readily 
beneath the heads of the metatarsal bones, and the operation is then 
finished by cutting out a flap from the sole of the foot, which should be 
somewhat larger at its internal than at its external part.* 
* The operation above described is generally known in this country as Lisfranc's 
operation on the foot, and it is distinguished by this title from Hey's operation 
through the metatarsus, in which the bones are divided with the saw, and Cho. 
part's operation through the tarsus, as next described.—E»s. PI. 25. AMPUTATION THROUGH THE TARSUS, OR CHOPART’S 
OPERATION. 
SURGICAL ANATOMY. 
Fig. 1. The articulation at the middle of the tarsus is formed by the 
astragalus, a, and the os calcis, b, behind, and by the cuboid, c, and 
scaphoid, d, in front, and the inter-articular line, which crosses the foot 
transversly, resembles the i ; lie <* , of which the anterior convexity is 
internal, and its posterior convexity, external. 
The internal extremity of the articulation is just one inch in front of 
the internal malleolus, y, and two lines and a half behind the tuberosity, 
A, of the scaphoid. 
The external extremity, i, is half an inch behind the projection formed 
by the head of the fifth metatarsal bone, j. It corresponds with a 
prominence on the external surface of the cuboid bone, which is situated 
just one inch in front of the external malleolus, Jc. 
The centre of the articulation lies immediately in front of the head 
of the astragalus, which can be made to project by forcibly extending 
the foot. On the outside of this prominence is a depression, sensible 
to the touch, lying between the astragalus, the cuboid, and the os calcis; 
the articulation is immediately in front of this (Malgaigne). 
In order to cut through the joint readily, it is necessary to be familiar 
with the different directions which are assumed by its articular surfaces. 
The pin, l: introduced between the astragalus and scap oid, indicates 
the direction to be given to the knife in opening the articulation from 
its internal side. 
The pin, m, introduced between the os calcis and cuboid, just in front 
of the prominence on the cuboid mentioned above, indicates : Iso the 
direction to be given to the knife in entering the joint from its external 
side. 
Fig. 2. When it has once entered the articulation by its inner side, 
the blade of the knife should follow the different decrees of obliquity 
assumed by the articular surfaces, of t! e astragalus, a, and the os calcis, 
b ; at first directed obliquely backwards as at c, it becomes almost per- 
pendicular at d. 80 
Fig. 3. In operating upon the right foot, the blade, slightly oblique 
at c, will become more nearly perpendicular at d, between the os calcis, 
a, and the cuboid, h, when the joint is entered from its external side. 
The interosseous ligament which is found about in the centre of the 
articulation, and which connects the four bones together, should always 
be cut through with the point of the knife as soon as the bones can be 
sufficiently separated. In aged subjects it is sometimes ossified; in 
this case it must be divided with the saw. The other ligaments require 
no particular remark. 
OPERATIONS, 
Fig. 4. Ordinary method.—«, 6, c, form and direction of the inci- 
sion to be made across the joint. 
Fig, 5. The joint being cut through, the knife is about making the 
flap from the sole ; a, dorsalis pedis artery. 
Fig. 6. a, 6, c, form of the plantar flap; d and d\ the dorsal and 
plantar arteries. 
Fig. Y. Sedillofs method.—a, h, c, form of the incision on the dor- 
sum of the foot. 
MODES OE OPERATING. 
§ 1. Chopart's operation through the middle of the tarsus (fig. 4 
and 5).— Ordinary method.—Ist, the exact position of the articulation 
having been recognized by the means already indicated, the surgeon 
grasps the foot with his left hand, its sole being placed in his palm, 
his thumb upon the external extremity of the articulation, and the 
index finger upon the tuberosity of the scaphoid bone ; 2d, the knife is 
then to be carried across the dorsum of the foot, from the thumb towards 
the index finger (fig. 4), making a semi-circular incision which descends 
about half an inch below the line of the articulation ; 3d, after the re- 
traction of the integuments, divide the tendons which remain uncut, 
and open the articulation, bearing in mind the varying obliquity of the 
articular surfaces as already indicated, and also to divide thoroughly 
the fibrous bands connecting the scaphoid and astragalus before at- 
tempting to enter the joint, as the thin edge of the scaphoid juts over 
the latter in some degree ; 4th, the articulation being entirely laid open, 
and all its ligaments freely divided, pass the flat of the blade behind 
the bones, and having brought up the end of the foot into its natural 
position, cut out a flap from its plantar surface, which should extend bo- 81 
yond the sesamoid bones in order to possess sufficient length; the 
knife should graze the bones in making the flap, care being taken to 
avoid the projections of the scaphoid, cuboid and first and fifth meta- 
tarsals. 
§ 2. Scdillot's method (fig. 6 and 7).—After determining the posi- 
tion of the articulation, and the foot being properly supported, a trans- 
verse incision is made, commencing a few lines in advance of the cal- 
caneo-cuboid articulation, and terminating about the middle of the dor- 
sum of the foot, on the outer side of the tendon of the tibialis anticus. 
From this same point a curved incision, with its convexity downwards, 
is then carried around the inner border of the foot, extending down- 
wards to within two fingers’ breadths of the metatarso-phalangeal articu- 
lation of the great toe, and thence across the sole to the commencement 
of the first incision. The plantar integuments should be cut as much 
as possible in a slanting direction to rid their edges of the subcutaneous 
fat, the protrusion of which tends to prevent the union by the first in- 
tention. It remains now to dissect up the internal flap to just beyond 
the tuberosity of the scaphoid bone, where the joint is to bo entered. 
The disarticulation is then completed as usual, and the remaining soft 
parts divided transversely.* 
* Amputation through the ankle-joint, although not an operation in general 
use at the present day, is highly praised by Baudens, amongst the French surgeons, 
and also by Mr. Syme of Edinburgh, who has lately reintroduced it with much 
success. Each of these surgeons has a mode of operating peculiar to himself. 
(See Malgaigue, Eng. ed., p. 255, and Lend, and Ed. Monthly Journal, Feb., 
1843, p. 93.)— Eos. Plate XXVI. 
AMPUTATION AT THE KNEE-JOINT, 
SURGICAL ANATOMY. 
Fig. 1.—Anterior view of the knee-joint.—a, femur; h, patella; 
c, tibia; e, fibula; g, external lateral ligament; f internal lateral liga- 
ment ; d, ligament of the patella. 
Fig. 2. A vertical antero-posterior section exhibiting the crucial 
ligaments, d, and the popliteal artery, e. a, femur; 6, tibia; c, 
patella. 
This articulation possesses some anatomical peculiarities worthy of 
the attention of the operator. The internal condyle descends lower 
than the external, nearly half an inch. They are both received into 
concave articular surfaces on the head of the tibia, which are rendered 
deeper by the semi-lunar cartilages attached to their edges. The popli- 
teal artery, (fig. 2, e) lies in the depression between the two condyles, 
posteriorly, and in immediate contact with the joint. 
In addition to the patella and its tendinous connections, the articular 
surfaces are held together by an internal and external lateral ligament, 
a posterior ligament, and two very strong interosseous ligaments, called 
crucial, which also tend to prevent displacement in an antero-posterior 
direction. 
To determine the exact position of the joint, find out the head of the 
fibula, and three-fourths of an inch above it is the inner side of the ar- 
ticulation. On the external aspect of each of the condyles of the femur 
is a prominence of bone which can generally be felt beneath the integu- 
ments ; the articulation lies three-fourths of an inch below these. The 
lower border of the patella, also, is exactly on a line with the joint. PI. 26. 83 
OPERATIONS. 
Fig. 3. Amputation through the knee-joint.—Flap operation.— 
!, b, c, form to be given to the anterior incision. 
Fig. 4. Same operation.—The articulation having been opened, the 
knife is cutting out the posterior flap; a, 6, c, shape to be given to 
this flap. 
Fig. 5. Same operation by the circular method.—a, b, c, section of 
the skin; (?, e, integuments reflected; the knife is just entering the 
joint in front. 
Fig. 6. Same operation by the oval method.—Bauden's process. 
a, b, c, oblique section of the skin; d, e, integuments turned upwards ; 
the knife is opening the articulation from before backwards. 
MODES OP OPERATING. 
§ 1. Amputation through the knee-joint.—lst. Flap operation.— 
Horn's method.—lst, the limb being extended make a semi-circular 
incision across the front of the articulation immediately below the pa- 
tella, and extending from one condyle of the femur to the other ; 2d, 
by a second incision, in the same direction, bending the knee slightly, 
open the joint freely, and dividing all its ligamentous connections, pass 
the knife flatwise behind the head of the tibia, and cut out a flap from 
the calf of sufficient size to cover well the condyles of the femur. 
§2. Circular operation.— Velpeau's method.—Ist, make a circular 
incision around the limb, from three to four fingers’ breadths below the 
patella, through the integuments only ; 2d, dissect them up and reflect 
them backwards, preserving as much of the subcutaneous fat with the 
skin, as possible ; 3d, the reflected integuments being held back by an 
assistant, and the knee flexed, carry the knife through the articulation, 
dividing all its ligamentous attachments, and cut through the nerves, 
vessels and muscles behind the joint at one stroke, perpendicular to the 
axis of the limb, and on a line with the reflected integuments. 
§ 3. Oval operation.—Bauden's method.—Ist, draw with a pen 
and ink an oblique line starting from the crest of the tibia three fingers’ 
breadths below the patella and running backwards and upwards to the 
popliteal space, and terminating two fingers’ breadths below the line of 
the articulation, and thence down the opposite side of the limb to the 84 
point from which it started; 2d, follow this line with the knife, dividing 
the integuments only, which should be dissected up as far as the line 
of the articulation and reflected upwards. The disarticulation is then 
effected as in the circular operation, the joint being opened from the 
front. CJ TJi L O G UE 
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$lO. Or half bound in calf in Paris, $12.50. SURGICAL INSTRUMENTS 
MANUFACTURED BY CHARRIERE, PARIS. 
In issuing the following list, H. B ailliere begs to call the attention of Practitioners and Students to the great superi- 
ority of Charriere’s instruments, approved of and used by Dr. Willard Parker, Dr. W. H. Van Buren, Dr. 
Carnochan, and others. H. B. has now an excellent stock on hand, and those not on hand can Be supplied on a 
short notice. - • 
Amputating' Instruments. 
Amputating knives, different sizes, each, $1 75 
Interosseous knife, 1 75 
Bone Forceps, 3,50 a 4 25 
Cha/riere’s Tourniquet, . 3 00 
‘A mputating Saw, two blades, 6 00 
Chain “ 7 00 
Sutdre Needles, each. 12>£ 
Ciiarriere’s Forceps, for continued pressure, 125 
Amussat’s Torsion Forceps 1 75 
Tenaculum, * 75 • 
ARTERIES, Ligature.of. 
Ciiarriere’s Forceps, for pressure, 1 25 
Gra’fj’s Spring Artery Forceps, 1 25 
Uiiarnere’s Curved Forceps, for continued pressure, 1 50 
Amussat.’s Torsion Forceps, 1 75 
Tenaculum, 75 
Desohamps’ Artery Needle, 1 00 
Director, with an eye in its extremity, 1 25 
Cooper's Artery Needle, 75 
Eyed Probe, 23 
Sottot’s Knot-tightener, 1 00 
RONES, Exsection of. 
Moveable back Saw, 1 73 
Small Semicircular Saw, two sizes. 3 50 
Larrey Straight Saw, 125 
Martin’s Saw, 24 00 
Dupuytreu’s Perforator. 
Liston’s Bone Forceps, 2 50 
Strong Forceps, ’ 1 50 
Forceps for extracting Sequestra, 
Chisel. Ebony handle, 75 
Gouge, “ “ 75 
Leaden Mallet, 2 25 
Rasp, 100 
Olive shaped cautery iron and handle, 2 75 
Hatchet shaped, “ “ 2 75 
Nummular “ ,2 75 
* EAR, Operations on the. 
Itard’s Speculum, 1 75 
Bnnnafond’s Speculum,. 
Fahrizi’s Forceps, for extraction of Foreign Bodies. 
Dili-uylron’s Forceps, for removal of polypi. 
Curette, for the extraction of Foreign Bodies. 
Delean’s Speculum, 1 00 
Fabrizi’s Double Catheter. 
Jtard’s Catheter, 1 25 
Blanohet’s Catheter. 
Bianchet’s Caustic Holder. 
Dclleau's Flexible Catheter & Stylet, 175 
Fabrizi’s Trepan, for perforating the membrana tym- 
pani. 3 25 
Bonnafond’s Forceps for carrying Lint. 
Bonnafond’s Instrument, for perforating the mom- 
hrana tympani. •-. 
Bdloc’s Sound, 280 
Del lean’s Instrument for perforating the membrana 
tympani. 
Caoutchouc bottle with stop-cock, for injections of 
air, fcc. 3 50 
EYE, Operations on flie. 
Eye Instrument, or the Adams’s Forceps, modified 
by Cbarriere. 
Desmarres’ Ring Forceps. 
Dcsmarres’ Forceps with bifurcated extremities. 
Charriere’s Straight Forceps, for . ontinnons pressure. 
Bistoury, for opening Lacfrrvn’ weeps, 
Gensoul’s Catheters 6 .yntal passages, 250 
Mejean’s Probe 6 - .a iaprymalia, 30 
Caustic Holder, ' 6 50 
Ariel’s Syringe, er. ' 6 50 
--■’s Xrocar, J 50 
j.a, silver, 30 
“ leal, \2V% 
, “ ivor" , 25 
Cloquet’o T- Stylet, for extracting canulas, 75 
DiHsamt s Gaaiuld,' 
Pellier’s instrumeu for elevating the eye-lid, 
■ Cprneft Knives, ditferent shape,, 75 
Needles. 75 
Scissors it? (, straight, 75 
-} curved, 100 
lloox -i... 
Eve ‘T(ShX. 
1' anted, blunt, &c. 75 
levating the eyelid. 
..») lust* u« "au for making-. 
. ...gilt Bistoury, ’ 1 25 
Curved 1 25 
Probe pointed Bistoury. 1 25 
Dissecting Forceps, 75 
Director, steel, 50c., silver, 1 25 
Straight Scissors, y • 75 
Curved “ - . ' 1 0(J 
Lvynx & Pharynx. 
Fonftps, % 255 
Probang witl*jilver 1.50 
Catheter, for artificial respiration, 1 50 
Syringe, complete, lead, 7 00 
german silver, 14 50 
Larpngotomy Sc Tracheotomy. 
Cannlas, 3 sizes, single, each. 1 50 
“ “ dotfhle “ 350 
Sponges on wlialebone handles for cleansing canulas I*oo 
Trousseau’s dilating Forceps, 125 
Trocars, with canulas, different sizes, ,150 
POLYPI, Ligature of. 
Polypus Forceps, straight and curved, 1 50 
Charrierc’s ligature carrier, 3 50 
Grade’s Knot-tyer, 2 00 
Mayor’s beaded Knot-tyer, 2 50 
Dessanlt’s Knot-tyer, 1,50 
TONSILS, Soft Palate, &c. 
Miiseux’s Forceps, 
Vclpean’s Arnygdalatorae, 1 ' 7 00l 
Ronx's angular Scissors, 150 
Depierris’ Porte.Sntipe, 6 00 
THE PHINING Instruments. * 
Charriere’a Rowel Saw, 45 00 
Trephine, complete, 10 50 
Hand, 3 50 
Raspatory, l 00 
Lenticular Knife, 1 (XI 
Double Elevator, 1 00 
Screw, for extracting pieces of bone, * 150 
. FEtl ALES, Diseases of. 
Speculum, 2 blades, german silver, 3,50 to 4 00 
“ 3 blades, “ “ 400 
“ 4 blades “ “ 5,50 to 6 00 
lead, 4 sizes, each 75 
Long Scissors, straight and curved, each 2,50 
Long Tenaculum Forceps, each ' 200 
Dressing Forceps. 1 50 
Silver Catheters, Sic.,., * sj 00 
I H INARY ORGANS, Oiscases*of. 
Silver Catheters, 1,50 to 2 50 
First quality elastic Bougies, per doz. 3 00 
“ “ wax “ 150 
, “ “ elastic Catheters, “ ‘ 350 
“ “ gutta percha “ T 200 
Lalleraand’s porte-caustic, straighi, * 425 
curved„ 5 25 
Ricord’s Scarifier, " • 300 
Civ'le’s U retro tome, ’ 7 00 
“ ** for the Urinary Passage, .5 50 
Benique’s metallic Bougies, in boxes of 30, 21 00 
HUPPING Instruments. 
Glasses with stop cocks, each. 1 00 
Elastic Intermediary Tube, 75 
Air Pump, brass, 2 50 
Scarifier, 8 blades, 3 75 
12 “ 450 
Pocket Cases. 
Cases, morocco leather, from 175 to 500 
Bistouries, shell handles, 1 25 
“ Probe, pointed, straight. 1,25 
“ curved, sharp, and probe-pointed. 3,00 
Double Bistouries, spring backs, 2 50 
Scissors, straight, . 75 
“ curved, -* 100. 
Dressing Forceps, . 7a 
Double Catheters, silver, ** 3 00 
Caustic Holders, frtjrti , 75c. to 500 
Spatulas Si Directors, silver, 1 25 
Selon Needles, 1 75 
Exploring “ to IjOJ 
Dissecting Cases. 
Containing ! Dissecting Forceps, 1 Chain Hook, 
6 Scalpels, 1 pair straight Scissors. 1 pair curved 
Scissors, 1 Chisel, 1 Blow Pipe, 1 Grooved Probe, 
.1 Exploring Stylet, 1 Morocco Case, . _ 6,50 
Case or box containing besides the above, 1 pairde- 
■/ Jicate dissecting Forceps, 1 Tenaculum, small, 2 
small Scalpels, 1 Saw, moveable back, 1 Ham- 
mer, 10,50 
Case for Post-mortem Examination and Dissect- _ , 
iug, in one, $24 to 45 00 
Cases for Microscopic Anatomy, from 4 50 to 12 00 
Mercury Syringes 10 50 
Robin’s small Syringe, , 7 50'